Title: Nursing Care of Individuals with Genitourinary Disorders: Renal Trauma Renal Vascular Problems Acute Kidney Injury
1Nursing Care of Individualswith Genitourinary
DisordersRenal TraumaRenal Vascular
ProblemsAcute Kidney Injury
2The Kidney
- Primary function
- Regulate volume and composition of ECF
(extracellular fluid) - Excrete waste products
- Other functions
- Regulate acid-base balance
- Control BP
- Produce Erthyropoietin
- Activate Vitamin D
3Kidney- macrostructure
4Kidney- microstructure
5The Nephron
- Why is it called the functional unit of the
kidney?
6Glomerular Filtration Rate
- Glomerular filtration rate
- Used to assess how well the kidneys are working
- Estimates how much blood passes through the
glomeruli each minute - The amount of filtrate formed per minute by the
two kidneys combined
7Glomerular Filtration Rate
- For average male GFR is 125ml/min
- That would create180 L/d!
- More than 99 of the filtrate is reabsorbed
- Average 1mL/min of urine excreted
- 1-2 L/day
- Older people will have lower normal GFR levels,
because GFR decreases with age
8GFR
- GFR too high
- increased urine output
- threat of dehydration and electrolyte depletion
- GFR too low
- insufficient excretion of wastes
- GFR of 60 or higher is in the normal range
- GFR below 60 may mean kidney disease
- GFR of 15 or lower may mean kidney failure
9The Kidney
- Primary function
- Regulate volume and composition of ECF
(extracellular fluid) - Excrete waste products
- Other functions
- Regulate acid-base balance
- Control BP
- Produce Erthyropoietin
- Activate Vitamin D
10Functions of the Kidneys
- Regulates acid-base balance
- HCO3 and H
- Controls Blood Pressure
- Renin Release
11RAAS
- Kidney senses low perfusion
- Renin released by kidney
- Angiotensinogen (from liver) acivated into
angiotensin I - Converted to Angiotensin II by ACE
- Angiotensin II stimulates release of aldosterone
- Na and H2O retained
12(No Transcript)
13Functions of the Kidneys
- Erythropoietin Release
- If a patient has chronic kidney disease or
chronic renal failure, what condition will occur
and why?
14Functions of the Kidneys
- Erythropoietin promotes the formation of RBCs ?
in response to decreased O2 carrying capacity - Anemia from impaired erythropoietin
- production and platelet abnormalities gt
- bleeding risk
15Functions of the Kidneys
- Activated Vitamin D
- Necessary to absorb Calcium in the GI tract.
There is decrease in synthesis of D3, the active
metabolite of Vitamin D - If a patient has renal failure, what will happen
to the patients serum calcium level? -
16Functions of the Kidneys
- Inability of kidneys to activate vitamin D-
hypocalcemia gt parathyroid gland gt secretes PTH
gt stimulates bone demineralization gt release
calcium from bones - Low serum calcium level/elevated phosphate
- Why do you have a elevated serum phosphate?
17Review- Functions of the Kidney
- Regulate
- Volume composition of extracellular fluid
- FE balance
- Acid/Base balance
- Blood pressure regulation
- Erythropoetin release
- Vitamin D activation
18 Acute Kidney Injury
- Rapid decline in renal function that leads to
accumulation of nitrogenous wastes in the blood
(azotemia) - Etiology of AKI
- Pre-renal
- Intra-renal
- Post renal
19Acute Kidney InjuryPre-renal
- Hypovolemia
- dehydration, shock, burns
- Decreased cardiac output
- CHF, MI, arrhythmias
- Decreased vascular resistance
- septic shock
- Renal vascular obstruction
- renal artery stenosis, thrombus
- Causes related to decreased blood flow to the
kidneys
20Acute Kidney InjuryIntra-renal
- Conditions causing direct damage to renal tissue
causing damage to nephrons - Result from ischemia
- Nephrotoxins
- Hemoglobin released from hemolysis of red blood
cells - Myoglobin released from necrotic muscle cells
21Acute Kidney InjuryIntra-renal
- Primary Renal Disease
- Acute glomerulonephritis/pyelonephritis
- Systemic lupus
- Acute Tubular Necrosis (ATN)
- Necrosis of tubular cells which slough and plug
tubules - Potentially reversible
- Most common cause of intra-renal AKI
22Acute Tubular Necrosis(ATN)
- Renal ischemia
- Disruption basement membranedestruction tubular
epithelium - Nephrotoxic agents
- Necrosis tubular epithelium plug tubules
basement membrane intact. - Potentially reversible IF
- Basement not destroyed and tubular epithelium
regenerates
Renal ischemia
Nephrotoxic agents
23Acute Kidney InjuryIntra-renal
- Acute Tubular Necrosis (ATN)
- Nephrotoxic drugs/chemicals (ATN)
- Aminoglycosides
- Radiographic contrast agents
- Arsenic, lead, carbon tetrachloride
24Acute Kidney InjuryIntra-renal
- Hemolytic blood transfusion (ATN)
- Trauma
- crushing injuries which release myoglobin
- damaged muscle tissue and blocks tubules
(rhabdomyolysis)(ATN) - What is Rhabdomyolysis?
25Compare Contrast
26- Lupus Nephritis
- Flea bite look
27Acute Kidney InjuryPost-renal
- Mechanical obstruction of urinary outflow
- urine backs up into renal pelvis
- BPH
- Calculi
- Trauma
- Prostate cancer
28Stages of Acute Kidney Injury
- Initiating Phase
- Time of insult until signs and symptoms become
apparent - Oliguric Phase
- Usually appears 1-7 days of initiating event
- Diuretic Phase
- Start varies, usually within10-12 days of onset
oliguric phase - Recovery
- Usually within a month, recovery takes up to 12
months
29- Urine output in AKI varies widely does NOT
provide clinical correlation to the degree of
injury!!!!! - Must look at GRF
30Oliguric Phase
- Onset- 1-7 days
- Duration- 10-14 days
- Urine Output- Less than 400 ml/24 hours in 50 of
patients (Can have non-oliguric AKI) - Signs Symptoms to anticipate-
- Specific gravity fixed at 1.010 in oliguria in
intra renal failure may be elevated in pre
post - Fluid overload
- Urine with RBCs, casts, WBCs, protein (if
glomerulus damaged) - K likely elevated
31Oliguric Phase
- Metabolic acidosis
- kidneys unable to synthesize HCO3, cannot excrete
H and acid metabolites, serum bicarbonate
decreased because used to buffer H - Kussmaul breathing
- Calcium deficit phosphate excess
- decreased GI absorption of Ca (Vit D)
- increase in Calcium secretion
- Nitrogenous product accumulation
- unable to eliminate urea and creatinine gt
elevated BUN, serum creatinine
32Treatment Oliguric phase
- Fluid Challenge/Diuretics
- Done to r/o dehydration as cause of ARF and to
blast out tubules if ATN - 250-500cc NS given I.V. over 15 minutes
- Mannitol (osmotic diuretic) 25gm I.V. given
- Lasix 80mg I.V. given
- Should see what within 1-2 hours?
33Treatment Oliguric phase
- If fluid challenge fails- intake limited
- Fluid restriction
- 600ml u.o. past 24 hours
- Patients u.o. yesterday was 300ml. What will be
the allowed fluid intake today?
34Diuretic Phase
- Onset- days to weeks
- Duration- 1-3 weeks
- Urine Output- 1-3 liters/day
- Signs Symptoms to anticipate
- Elevated BUN and Serum Creatinine
- What happens to intravascular volume?
- What happens to BP?
- Urine Na?
- K elevated or decreased?
35Recovery Phase
- Onset- When BUN and Creatinine stabilized
- Duration- 4-12 months
- Urine Output- Normal
- Signs Symptoms
- Continue to monitor for signs and symptoms of F
E imbalances - All body systems for effects of fluid volume
changes - What are some key nursing interventions?
36Diagnostic tests in AKI
- BUN (blood urea nitrogen)
- Measurement of amount of urea in blood
- Normal -6-20 mg/dl
- What is urea?
- BUN fluctuates
- BUN elevated when?
- BUN decreased when?
37Diagnostic tests in AKI
- Serum Creatinine
- End product of muscle and protein metabolism
- Excreted by the kidneys at a constant rate
- Normal 0.6 1.3 mg/dl
- Directly related to GFR
- 2 X normal (2.4) 50 nephron fx loss
- 10 X normal (12) 90 nephron fx loss
- More accurate indicator of renal function than
BUN - BUNCreatinine ratio Normal 121 to 201
38Diagnostic tests in AKI
- Creatinine clearance
- Normal 120-125ml/minute
- Most accurate indicator of Renal Function
- Reflects GFR
- Involves a 24 hr urine/serum creatinine
- Formula
- urine creatinine X urine Volume
- serum creatinine
3924 hour urine
- What is the nurses role in the collection of a 24
hour urine? - What if they have a foley cath?
40Diagnostic tests in AKI
- Urine Specific Gravity
- Normal 1.003-1.030
- Will be fixed a 1.010 usually in AKI due to
kidneys losing ability to concentrate urine - Serum Electrolytes
- Sodium
- Potassium
- Calcium
- Phosphorus
41Diagnostic tests in AKI
- Serum Electrolytes
- Serum Sodium
- Normal 135-145
- May be high, low, or normal
- When would it be high/low?
42Diagnostic tests in AKI
- Serum Electrolytes
- Serum Potassium
- Normal 3.5-5 meq/L
- Almost always increased in renal failure
- Why? Two major reasons
- If gt 6.0 treatment to prevent.
43Diagnostic tests in AKI
- Serum Electrolytes
- Serum Phosphorus
- Normal2.8-4.5mg/dl
- Almost always increased. Why?
- What other process is occurring to increase serum
phosphorus?
44Diagnostic tests in AKI
- Serum Electrolytes
- Serum Calcium
- Normal9.0-11.0 mg/dl
- Almost always decreased, why?
- What other process is occurring to decrease serum
calcium?
45Diagnostic tests in AKI
- ABGs
- Metabolic acidosis-due to decreased
ability of kidneys to excrete acid metabolite
(uric acid) - So the pH will be high or low?
- Bicarb- decreased due to bicarb being used up to
buffer excess H ions
46Management of AKI
- Treat the primary disease/condition
- Prevention
- Frequent monitoring for early signs of AKI in at
risk patients - What are these signs?
47Management of AKI
- Assess for FVD vs FVE
- VS
- Strict IO
- Daily weights
- Monitor labs- which ones?
- Metabolic acidosis
- Administer NaHCO3 IV as ordered
48Management of AKI
- Hyperkalemia
- Insulin and glucose
- K moves back into the cells when insulin is
given. - Glucose to prevent hypoglycemia
- Sodium Bicarbonate
- Correct acidosis and shifts K into cells
- Kayexalate
- Pulls K out through GI tract
- Dietary restrictions
- Bananas, avocado, apricots, potatoes, white beans
49Management of AKI
- Calcium imbalance
- Calcium Gluconate
- Phosphorus imbalance
- Calcium supplements, Phosphate binders
- Hypertension
- Lasix, Amlodipine, Metoprolol
50Management of AKI
- Anemia
- Administer epogen/procrit as ordered
- PRBCs
- Diet
- Fluid restriction
- Low K, low Na
- Low protein- why?
- Emergency dialysis
- Kgt6.0, FVE, uremia, metabolic acidosis
51 Renal Trauma
- Etiology
- Men under age 30
- Blunt force from falls
- MVA
- Sports injuries
- Knife/gunshot wounds
- Impalement injury, rib fractures
52Renal Trauma
- Common Manifestations
- Hematuria-microscopic to gross
- Pain- Flank or abdominal
- Decreased Urine Output- oliguria or anuria
- Localized swelling, tenderness
- Turners sign
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54 Renal Trauma
- What are some diagnostic tests used in renal
trauma? - CT scan, MRI, renal ultrasound, renal
arteriogram, IVP with cystography - What serum levels can be useful?
- UA (hematuria),
- H H (decreasing values)
55 Renal Trauma-Interventions
- Minor Trauma
- Bedrest and close observation.
- Monitor for S S of what?
- Moderate/Major Trauma
- Embolization or open surgery to stop bleeding or
repair - Partial or total Nephrectomy
56Renal Trauma-Interventions
- Nursing Management
- Bedrest
- Prevent complications
- Close Observation for s/sx shock
- HH
- IO
- Daily weights
- VS
57 Renal Surgery-Nephrectomy
- Indications for Nephrectomy
- Renal tumor
- Massive Trauma
- Polycystic Kidney Disease
- Donating a Healthy kidney
58 Renal Surgery-Nephrectomy
- Post Op Nursing Management
- Strict I O
- Urine output should be at least _____.
- What should output be if patient had bilateral
nephrectomy? ______. - Observe ACC of urine
- TCDB incentive spirometery
- Incision in flank area, 12th rib removed
- Medicate for pain as ordered
59Renal Vascular ProblemsNephrosclerosis
- Caused by chronic or malignant HTN
- Renal dysfunction and renal failure are two major
complications of HTN - Sustained elevation of the systemic blood
pressure can result from or cause kidney
disease---How?
60Patho of Nephrosclerosis
- Development of arterio sclerotic lesions in the
arterioles and glomerular capillaries - ?
- Decreased blood flow which leads to ischemia and
patchy necrosis - ?
- Destruction of glomeruli
- ?
- Decrease in GFR
61 Renal Vascular Problems Renal Artery
Stenosis
- Narrowing of one or both renal arteries due to
atherosclerosis or structural abnormalities - Uncontrollable HTN
- How could a renal artery stenosis result in HTN?
62Renal Artery Stenosis
- Treatment/Collaborative Care
- Anti-hypertensive Medications
- Dilation of renal artery by Percutaneous
Transluminal Angioplasy - Bypass Graft of Renal Artery
- Nephrectomy
63Renal Vein Thrombosis/Occlusion
- Partial occlusion in one or both renal veins due
to atherosclerosis or structural abnormalities in
vein by a thrombus - Risk Factors
- Nephrotic syndrome
- Use of birth control pills
- Certain malignancies
64Renal Vein Thrombosis/Occlusion
- Pathophysiology/etiology
- Thrombus forms in renal vein
- Cause unclear
- Trauma, nephrotic syndrome
- Gradual loss of kidney function
- Common manifestations/complications
- Decreased GFR
- Signs of renal failure
- Pulmonary embolus
65Renal Vein Thrombosis/Occlusion
- Treatment/Collaborative Care
- Diagnosis
- Renal venography
- Management
- Thrombolytic drugs
- Anticoagulant therapy
- Surgical thrombectomy
- Corticosteroids
66Your patient develops AKI after being on
Amphotericin for 1 week
- The patients AKI is primarily related to
- A. spasms of the renal arteries
- B. blood clots in the loops of Henle
- C. low cardiac output
- D. acute tubular necrosis
67Your patients K level is elevated. The
physician orders Kayexalate because it
- A. increases sodium excretion from the colon
- B. releases hydrogen ions for sodium ions
- C. increases calcium absorption in the colon
- D. exchanges sodium for potassium in the colon
68Clinical scenario
- You are a student nurse on day shift and you hear
in report that your patient is scheduled to have
an IVP this am. - What do you know about an IVP?
- What do you teach the patient about preparing for
this procedure? - What nursing interventions or orders should you
anticipate?
69The clients BUN is elevated in AKI. What is the
likely cause of this finding?
- a-fluid retention
- b-hemolysis of red blood cells
- c-below normal protein intake
- d-reduced renal blood flow
70Activity
- The RN is taking care of a group of patients.
One of the patients is taking glucophage 500mg
orally every morning. What does the RN need to
know prior to administration of this medication? - Another client is scheduled to get a CT with
contrast of their abdomen and is at risk for ARF,
what does the RN need to know?
71A 24 hours urine for creatinine clearance is
ordered. Which task is appropriate to delegate
to the the clinical assistant?
- a) instruct patient to collect all urine with
each voiding - b) explain the purpose of collecting a 24 hour
urine - c) ensure that the 24 hour urine collection is
kept on ice - d) assess urine for color, odor, sediment
72Which urinary symptom is the most common initial
manifestation of AKI?
- a-dysuria
- b-anuria
- c-hematuria
- d-oliguria