Nursing Care of Individuals with Genitourinary Disorders: Renal Trauma Renal Vascular Problems Acute Kidney Injury

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Nursing Care of Individualswith Genitourinary
DisordersRenal TraumaRenal Vascular
ProblemsAcute Kidney Injury
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The 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

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Kidney- macrostructure

• kidney anatomy

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Kidney- microstructure

• nephron

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The Nephron

• Why is it called the functional unit of the
  kidney?

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Glomerular 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

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Glomerular 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

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GFR

• 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

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The 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

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Functions of the Kidneys

• Regulates acid-base balance
• HCO3 and H
• Controls Blood Pressure
• Renin Release

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RAAS

• 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

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Functions of the Kidneys

• Erythropoietin Release
• If a patient has chronic kidney disease or
  chronic renal failure, what condition will occur
  and why?

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Functions 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

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Functions 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?

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Functions 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?

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Review- Functions of the Kidney

• Regulate
• Volume composition of extracellular fluid
• FE balance
• Acid/Base balance
• Blood pressure regulation
• Erythropoetin release
• Vitamin D activation

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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

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Acute 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

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Acute 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

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Acute 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

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Acute 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
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Acute Kidney InjuryIntra-renal

• Acute Tubular Necrosis (ATN)
• Nephrotoxic drugs/chemicals (ATN)
• Aminoglycosides
• Radiographic contrast agents
• Arsenic, lead, carbon tetrachloride

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Acute Kidney InjuryIntra-renal

• Hemolytic blood transfusion (ATN)
• Trauma
• crushing injuries which release myoglobin
• damaged muscle tissue and blocks tubules
  (rhabdomyolysis)(ATN)
• What is Rhabdomyolysis?

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Compare Contrast

• Healthy

• ATN

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• Lupus Nephritis
• Flea bite look

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Acute Kidney InjuryPost-renal

• Mechanical obstruction of urinary outflow
• urine backs up into renal pelvis
• BPH
• Calculi
• Trauma
• Prostate cancer

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Stages 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

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• Urine output in AKI varies widely does NOT
  provide clinical correlation to the degree of
  injury!!!!!
• Must look at GRF

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Oliguric 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

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Oliguric 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

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Treatment 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?

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Treatment 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?

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Diuretic 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?

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Recovery 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?

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Diagnostic 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?

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Diagnostic 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

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Diagnostic 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

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24 hour urine

• What is the nurses role in the collection of a 24
  hour urine?
• What if they have a foley cath?

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Diagnostic 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

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Diagnostic tests in AKI

• Serum Electrolytes
• Serum Sodium
• Normal 135-145
• May be high, low, or normal
• When would it be high/low?

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Diagnostic 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.

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Diagnostic 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?

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Diagnostic 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?

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Diagnostic 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

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Management of AKI

• Treat the primary disease/condition
• Prevention
• Frequent monitoring for early signs of AKI in at
  risk patients
• What are these signs?

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Management of AKI

• Assess for FVD vs FVE
• VS
• Strict IO
• Daily weights
• Monitor labs- which ones?
• Metabolic acidosis
• Administer NaHCO3 IV as ordered

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Management 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

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Management of AKI

• Calcium imbalance
• Calcium Gluconate
• Phosphorus imbalance
• Calcium supplements, Phosphate binders
• Hypertension
• Lasix, Amlodipine, Metoprolol

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Management 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

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Renal Trauma

• Etiology
• Men under age 30
• Blunt force from falls
• MVA
• Sports injuries
• Knife/gunshot wounds
• Impalement injury, rib fractures

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Renal 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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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)

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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

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Renal Trauma-Interventions

• Nursing Management
• Bedrest
• Prevent complications
• Close Observation for s/sx shock
• HH
• IO
• Daily weights
• VS

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Renal Surgery-Nephrectomy

• Indications for Nephrectomy
• Renal tumor
• Massive Trauma
• Polycystic Kidney Disease
• Donating a Healthy kidney

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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

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Renal 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?

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Patho 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

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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?
  

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Renal Artery Stenosis

• Treatment/Collaborative Care
• Anti-hypertensive Medications
• Dilation of renal artery by Percutaneous
  Transluminal Angioplasy
• Bypass Graft of Renal Artery
• Nephrectomy

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Renal 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

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Renal 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

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Renal Vein Thrombosis/Occlusion

• Treatment/Collaborative Care
• Diagnosis
• Renal venography
• Management
• Thrombolytic drugs
• Anticoagulant therapy
• Surgical thrombectomy
• Corticosteroids

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Your 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

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Your 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

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Clinical 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?

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The 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

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Activity

• 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?

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A 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

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Which urinary symptom is the most common initial
manifestation of AKI?

• a-dysuria
• b-anuria
• c-hematuria
• d-oliguria