Renal Nursing Study Guide

Renal nursing encompasses a broad range of conditions — from acute, reversible kidney injuries to chronic progressive disease requiring lifelong dialysis. This guide covers the highest-yield renal nursing content for nursing school exams and the NCLEX, with clinical specifics on assessment, common conditions, dialysis management, and nursing priorities.

Renal and urinary nursing study notes — AKI, CKD, dialysis, UTI, and kidney disease management for NCLEX

Renal Assessment: What Nurses Monitor

Urine output: Normal ≥0.5 mL/kg/hr. Oliguria = <400 mL/24 hours. Anuria = <100 mL/24 hours. Both require immediate provider notification
BUN and creatinine: Rise when GFR falls. Creatinine is more specific to kidney function. BUN is also elevated by dehydration, high-protein diet, and GI bleeding
Electrolytes: Kidney disease impairs potassium excretion (hyperkalemia), phosphate excretion (hyperphosphatemia), and sodium regulation
Fluid balance: Daily weights (same time, same scale, same clothing). Weight gain >1 kg/day = fluid retention
Blood pressure: Kidneys regulate BP through the RAAS — hypertension is both a cause and complication of kidney disease

Acute Kidney Injury (AKI)

AKI is a rapid decline in kidney function over hours to days, categorized by location of the insult:

Prerenal AKI: Decreased blood flow to kidneys. Causes: hypovolemia, heart failure, sepsis. BUN:Creatinine ratio >20:1. Treatment: restore perfusion (IV fluids, vasopressors)
Intrarenal AKI: Direct kidney tissue damage. Most common: acute tubular necrosis (ATN) from ischemia or nephrotoxic agents (aminoglycosides, contrast dye, NSAIDs, vancomycin). BUN:Cr ratio ~10–15:1
Postrenal AKI: Obstruction of urine outflow. Causes: BPH, kidney stones, tumors. Treatment: relieve obstruction

AKI Phases and Nursing Priorities

Oliguric phase: Urine output <400 mL/day. Fluid restriction, monitor electrolytes — hyperkalemia is the most dangerous complication (fatal dysrhythmias). Restrict dietary potassium
Diuretic phase: Urine output increases dramatically (3–5+ L/day). Risk of dehydration and hypokalemia — replace electrolytes
Recovery phase: GFR gradually recovers over weeks to months; some patients progress to CKD

Hyperkalemia emergency sequence: Calcium gluconate IV (stabilizes cardiac membrane — first priority) → Sodium bicarbonate (shifts K+ into cells) → Insulin + dextrose (shifts K+ into cells) → Kayexalate/patiromer (removes K+ from body) → Dialysis if refractory.

Chronic Kidney Disease (CKD)

CKD is irreversible, progressive loss of kidney function over 3+ months, staged by GFR:

Stage 1–2: GFR ≥60 — mild decrease or normal GFR with kidney damage markers
Stage 3: GFR 30–59 — moderate decrease; begin preparing patient for possible future dialysis
Stage 4: GFR 15–29 — severe decrease; dialysis planning and access creation
Stage 5 (ESRD): GFR <15 — dialysis or transplant required

CKD Complications and Nursing Management

Anemia: Kidneys produce erythropoietin (EPO) — EPO deficiency → anemia. Treatment: erythropoiesis-stimulating agents (darbepoetin, epoetin alfa), iron supplementation
Hyperkalemia: Dietary potassium restriction (<2,000 mg/day). Avoid potassium-sparing diuretics and NSAIDs
Hyperphosphatemia: Phosphate binders (calcium carbonate, sevelamer) taken with meals. Low-phosphate diet. Risk of renal osteodystrophy and vascular calcification
Metabolic acidosis: Sodium bicarbonate supplementation; dialysis in advanced disease
Hypertension: ACE inhibitors or ARBs preferred (reduce intraglomerular pressure) — monitor potassium and creatinine closely

Dialysis: Hemodialysis vs Peritoneal Dialysis

Hemodialysis

Access types: AV fistula (first choice — takes 4–6 weeks to mature), AV graft (synthetic), tunneled CVC (highest infection risk)
AV fistula care: Assess bruit (auscultate) and thrill (palpate) before each session — absence = possible clot. No BP, blood draws, or IV access in that arm
During dialysis: Hypotension is most common complication (rapid fluid removal). Watch for disequilibrium syndrome (nausea, headache, confusion)
Post-dialysis: Assess access site for bleeding, monitor BP, expect fatigue

Peritoneal Dialysis

Dialysate instilled via peritoneal catheter; peritoneal membrane filters waste and fluid
Monitor drainage: Should be clear to slightly yellow. Cloudy = peritonitis (most serious complication — send for culture, start intraperitoneal antibiotics)
Monitor blood glucose: Dextrose in dialysate is absorbed systemically
Patient education: Strict sterile technique every exchange. Report fever, cloudy fluid, or abdominal pain immediately

Urinary Tract Infections (UTI)

Lower UTI (cystitis): Dysuria, frequency, urgency, suprapubic pain, hematuria. No fever in uncomplicated lower UTI
Upper UTI (pyelonephritis): All lower UTI symptoms + flank pain (CVA tenderness), fever, chills, nausea/vomiting. May require IV antibiotics
Most common cause: E. coli. More common in women (shorter urethra)
CAUTI prevention: Remove Foley ASAP, maintain closed drainage system, keep bag below bladder level, meatal care
Treatment: Antibiotics per culture/sensitivity. Push fluids (>2 L/day). Phenazopyridine for symptomatic relief (warn: turns urine orange)

Renal Calculi (Kidney Stones)

Symptoms: Sudden severe colicky flank pain radiating to the groin — patient cannot find a comfortable position. Hematuria, nausea, vomiting
Most common type: Calcium oxalate (75–80%). Also: struvite (infection), uric acid (gout), cystine
Nursing priorities: IV analgesia, IV fluids, strain all urine (save stone for analysis), monitor for obstruction
Treatment by size: <5 mm — usually passes spontaneously. 5–10 mm — tamsulosin (alpha-blocker facilitates passage). >10 mm — lithotripsy (ESWL) or ureteroscopy
Prevention: Increase hydration for all types. Calcium stones — limit sodium (not dietary calcium). Uric acid stones — low-purine diet, allopurinol

NCLEX Tips: Renal Nursing

Hyperkalemia = first give calcium gluconate IV (stabilizes the cardiac membrane before lowering K+)
AV fistula: absent bruit or thrill = notify provider immediately — do not wait
Cloudy peritoneal dialysis effluent = peritonitis. Culture first, then antibiotics
Urine output <30 mL/hr in any patient = notify provider immediately
Prerenal AKI responds to fluids; intrarenal does not (and excess fluids may worsen it)
Strain all urine after lithotripsy — send stone for analysis to guide prevention strategy

For complete, exam-ready renal nursing notes organized by condition, the Lectures Note Renal Bundle covers all major renal topics in a compact, NCLEX-focused format.

Official Resources and Further Reading

External References

National Kidney Foundation — CKD staging criteria, GFR calculators, and dialysis clinical resources
NIDDK: Kidney Disease — National Institute evidence base for AKI, CKD, and renal replacement therapy

Frequently Asked Questions: Renal Nursing

What is the most dangerous complication of AKI?

Hyperkalemia. When kidneys fail, potassium accumulates rapidly and causes fatal cardiac dysrhythmias. Calcium gluconate IV is given first because it stabilizes the cardiac membrane while other agents lower the potassium level.

Why is creatinine a better indicator of kidney function than BUN?

BUN rises with high-protein diet, GI bleeding, dehydration, and steroids — not just kidney dysfunction. Creatinine is a byproduct of muscle metabolism excreted almost entirely by the kidneys, making it more specific to GFR changes.

What is the priority nursing assessment for a patient on hemodialysis?

Assess the vascular access: auscultate for bruit and palpate for thrill. Absence of either indicates possible thrombosis — notify the provider immediately. Also assess blood pressure, fluid status, and potassium level before beginning treatment.