Title: Nursing Care of Individual Experiencing a Renal Disorder: Vascular Disorders Renal Trauma Acute Renal Failure modified by Kelle Howard RN, MSN
1Nursing Care of Individual Experiencing a Renal
DisorderVascular DisordersRenal TraumaAcute
Renal Failuremodified by Kelle Howard RN, MSN
Renal A P -excellent site for renal
pathophysiology
2I. AP of the Kidney- (locate structures)
- Fibrous capsule
- Renal cortex
- Renal medulla
- Pyramids
- Papillae
- Minor calyx
- Major calyx
- Renal pelvis
- Ureter
3II. Functions of the Kidneys
- Regulates ______ _________ of extracellular
fluid - Regulates fluid electrolyte balance thru
- processes of glomerular__________,
tubular _________, and tubular _____________. - Name some of the F Es regulated by kidneys
__________________
4Functions of the Kidneys (cont)
- Regulates acid-base balance through _________
- Hormonal functions (BP control), multisytem
effect. - Renin Release
RAAS
5How the RAAS Pathway Works
Valerie Kolmer 2006
6Quick Quiz
- Pick the correct pathway of the RAAS
- 1. Renin Angiotensin II ACE ADH
Aldosterone - 2. Renin Angiotensin I Aldosterone ADH ACE
- 3. Renin-Angiotensin I-ACE-Angiotensin
II-Aldosterone
7Functions of the Kidneys (cont)
- Erythropoietin Release
- If a patient has chronic renal failure, what
condition will occur - WHY???
8Functions of the Kidneys (cont)
- Activated Vitamin D
- Necessary to absorb Calcium in the GI
- tract.
- If a patient has renal failure, what will happen
to the patients serum calcium level?
__________________
9Review Functions of the Kidneys
- Regulate
- 1.___________
- 2.___________
- 3.___________
- 4.___________
- Release of ________________
- Activation of _______________
10III. Nephron- functional unit of the Kidney!
- How the Nephron Works! Click-watch YouTube video!
11Identify the Nephrons Parts
- Glomerulus
- Bowmans capsule
- Proximal tubule
- Loop of Henle
- Distal tubule
- Collecting duct
Click here for Nephron AP Games too!
12 Renal Trauma
- Etiology
- Blunt force from falls, MVA, sports injuries,
knife/gunshot wounds, impalement, rib fractures - Common Manifestations
- Microscopic to gross hematuria
- Flank or abdominal pain
- Oliguria or anuria
- Localized swelling, tenderness, ecchymosis flank
- area - Turners Sign
- Signs/Symptoms depend upon severity injury
- Severe blood loss/signs shock
-
13Renal Trauma
14Renal Trauma
- What are common diagnostic tests used in renal
trauma?
CT-determine if peritoneal violation and predict
need for laparotomy-here initially see
extravasation and fluid in paracolic gutters
(peritoneal violation) and also a hematoma in
perirenal space
15Renal Trauma-Interventions
- Minor Trauma
- Conservative
- Bedrest and close observation
- Monitor for S S of what?
16Renal Trauma-Interventions
- Moderate to Major Trauma
- Surgical
- Surgical repair, maybe nephrectomy
- Percutaneous arterial embolization during
angiography - Nursing management
- Accurate assessment
- Monitor H H levels
- Bedrest close observation evaluate S S of
shock - Fluid mgt
- Prevent complications/monitor I O
- Manage drainage tubes
- Daily weights
17Renal Surgery-Nephrectomy
- Indications for Nephrectomy
- Renal tumor
- Massive Trauma
- Polycystic Kidney Disease
- Donating a healthy kidney
18Renal Surgery-Nephrectomy
- Post Op Nursing Management
- Strict I O
- Urine output should be at least _____.
- What should the UO be if patient had bilateral
nephrectomy? ______. - Observe urine
- Daily weights
- TCDB IS
- Incision in flank area, 12th rib removed
- Medicate for pain as ordered
19Renal Vascular ProblemsPatho of
HTN-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 _____
20Vascular Disorders of the KidneyRenal Artery
Stenosis
- Definition Narrowing of one or both renal
arteries due to atherosclerosis or structural
abnormalities. - Common Manifestation!
- uncontrollable HTN- medications do
not work - Why?
-
21Vascular Disorders of the KidneyRenal Artery
Stenosis
- Treatment/Collaborative Care
- Diagnostic Tests
- Renal arteriogram-most definitive
- Management
- Conservative-antihypertensive meds
- Percutaneous Transluminal Angioplasy
- Surgical re-vacularization (Graft)
- ?Nephrectomy
22Vascular Disorders of the KidneyRenal Artery
Stenosis
- Treatment/Collaborative Care
What type of procedure is this? What are some
post procedure nursing care interventions?
23Vascular Disorders of the Kidney
- Renal Vein Thrombosis
- Definition 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
24Vascular Disorders of the KidneyRenal Vein
Thrombosis/Occlusion
- Pathophysiology/etiology
- Cause unclear-thrombus forms in renal vein
- Associated with trauma, nephrotic syndrome
gradual - deterioration of renal function
- Common Manifestations/Complications
- Decreased GFR
- Signs of Renal Failure
- Complication ---Pulmonary Embolus
25Vascular Disorders of the KidneyRenal Vein
Thrombus/Occlusion
- Treatment/Collaborative Care
- Diagnosis- renal venography
- Management
- Thrombolytic drugs
- streptokinase or tPA
- Anticoagulant therapy to prevent
- further clot formation
26Acute Renal Failure
- Definition
- Rapid decline in renal function- leads to
accumulation of nitrogenous wastes (azotemia) - Kidneys unable to remove urea from blood-become
uremic -- aka uremia - (multiple body symptoms affected)
27Acute Renal Failure
- Etiology of ARF
- Pre-renal
- Intra-renal
- Post renal
28Etiology of Acute Renal FailurePre-renal (most
common cause ARF!)
- Causes of pre-renal ARF
- -What do all of these causes have in common?
-
- Hypovolemia dehydration, shock, burns
- Decreased cardiac output CHF, MI, arrythmias
- Dec. vascular resistance (septic shock, etc)
- Renal vascular obstruction renal artery
- stenosis, thrombus.
29Etiology of Acute Renal FailureIntra-renal
- Direct injury to the kidneys/nephrons
- causing damage to renal tissue (parenchyma)
- ATN (acute tubular necrosis)
- Destruction of tubular epithelial cells, slough,
plug tubules- abrupt decline in renal
function-recovery possible if basement membrane
remains intact tubular epithelium regenerates
30Causes of Intrarenal Failure
- Hemolytic blood transfusion (ATN)
- Trauma (crush injuries gt release myoglobin
damage - muscle tissue gt blocks tubules
(rhabdomylosis) - (ATN)
- Nephrotoxic drugs/chemicals (ATN)
- Aminoglycosides
- Radiographic contrast agents
- Arsenic, lead, carbons
- Drug overdose
- Acute glomerulonephritis/pyelonephritis
- Systemic Lupus
31Causes of Acute Tubular Necrosis (ATN)
- Renal ischemia
- Destruction tubular epithelium
- Nephrotoxic agents
- Necrosis tubular epithelium plug tubules.
- Potentially reversible IF
- Basement not destroyed and tubular epithelium
regenerates
Renal ischemia
Nephrotoxic agents
32Etiology of Acute Renal Failure Post-renal
- Causes of post-renal failure
- mechanical obstruction of urinary outflow
- urine backs up into renal pelvis
- BPH (Benign Prostatic Hypertrophy)
- Calculi
- Trauma
- Prostate cancer
33Diagnostic Tests in Acute Renal Failure
- BUN (blood urea nitrogen)
- Normal 10-30 mg/dl measurement of
- amt of urea in blood
- Serum Creatinine
- Normal 0.5 1.5 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
34Diagnostic Tests in Acute Renal Failure
- BUN/Creatinine ratio
- Normal 101
- BUN Creatinine
- 16 1.6
- 12 1.2
- 8 0.8
35Diagnostic Tests in Acute Renal Failure
- Creatinine clearance
- Most accurate indicator of Renal Function
- Reflects GFR
- Involves a 24 hr urine/serum creatinine
- Formula
- urine creatinine X urine volume
- serum creatinine
- Normal /- 120-125ml/minute
36Diagnostic Tests in Acute Renal Failure
- Urine Specific Gravity
- Normal 1.003-1.030
- Fixed sp. Gravity- 1.010 usually in ARF
- kidneys lose ability to concentrate urine
- Serum Electrolytes
- 1. Serum Sodium Normal 135-145meq/L
- May be high, low, or normal
37Diagnostic Tests in Acute Renal Failure
- Serum Electrolytes
- 2. Serum K
- Normal 3.5-5.0 meq/dL
- Almost always increased in renal failure
- Why?
-
38Diagnostic Tests in Acute Renal Failure
- Serum Electrolytes
- 3. Serum Calcium
-
- Normal 9-11mg/dL
-
- Almost always decreased
- Why?
39Diagnostic Tests in Acute Renal Failure
- Serum Electrolytes
- 4. Serum Phosphorus
-
- Normal 2.8 - 4.5mg/dL
-
- Almost always increased
- Why?
-
40Diagnostic Tests in Acute Renal Failure
- ABGs
- pH
- Metabolic acidosis due to ability of
- kidneys to excrete acid metabolites
- (uric acid, ammonia) so the pH will be
- __________.
- Also, bicarb levels due to bicarb being
- used up to buffer excess H ions.
-
41Stages of Acute Renal Failure
- 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
42Acute Renal Failure Oliguric Phase
- Signs and 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
- Onset 1-7 days
- Duration 10-14 days
- Urine output Less than 400 ml/24 hours in 50 of
patients
43 Acute Renal Failure Oliguric Phase
- Metabolic acidosis
- kidneys unable to synthesize HCO3, cannot
excrete H and acid metabolites serum
bicarbonate dec. because used to buffer H - Result Kussmaul breathing
- Ca deficit phosphate excess
- dec. GI absorption Ca (lack of active vitamin D)
- Nitrogenous product accumulation
- unable to eliminate urea and creatinine gt
elevated BUN, serum creatinine
44Diuretic Phase of ARF
- Onset days to weeks
- Duration about 10 days (1-3 weeks)
- Urine output1-3 liters/day
- Signs and Symptoms to anticipate?
- What happens to fluid volume?
- Elevated BUN and serum creatinine
- K likely to be elevated or decreased???
- What happens to Na?
- What happens to blood pressure?
45Recovery Phase of ARF
- Recovery Phase
- Onset When BUN and Creatinine are stabilized
- Duration 4-12 months
- Urine output Normal
- Signs and Symptoms to anticipate?
- Continue to monitor for signs and symptoms of
- F E imbalances
-
- All body systems for effects of fluid volume
changes, including daily weights
46 Treatment During Oliguric Phase
- Fluid Challenge/Diuretics
- Done to r/o dehydration as cause of ARF and
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????
47 Treatment During OliguricPhase
- If fluid challenge fails, fluid intake is
usually limited and client is placed on fluid
restriction - Restriction is limited to
600ml
(includes insensible loss) UO over the past 24
hours - Physician will specify in the orders how much.
- Question
- Patients UO on Tuesday300ml, what will be his
fluid intake allowed on Wednesday? ________
48 Acute Renal Failure Management of.
- 1- Treat primary disease/condition whether it is
pre-intra-post renal problem. - 2- Prevention
- Frequent monitoring for early signs of ARF in at
risk patients - 3- Assess for Fluid V deficit vs Fluid V overload
- Strict I O
- Daily weights 500ml-1 lb. (1kg approx 1000ml
fluid) - Monitor lab valueswhich ones?
49 Acute Renal Failure Management of.
- 4- Metabolic Acidosis
- Administer NaHCO3 I.V. as ordered
- 5- Hyperkalemia
- Give insulin glucose I.V.
- Sodium Bicarbonate I.V.
- Kayexalate po or enema
- Dietary Restrictions Potassium
50 Acute Renal Failure Management of.
- 6- Calcium Imbalance
- Administer calcium supplements as ordered
- 7- Treat Hypertension (HTN)
- 8- Phosphorus Imbalance
- Administer phosphate binders
- Amphogel Basaljel, Renagel
- Cautious use of aluminun-based phosphate
binders - can cause encephalopathy
51 Acute Renal Failure Management of.
- 9- Assess for anemia
- Administer Epogen/Procrit as ordered
- PRBCs as ordered what do you have to watch for?
- 10- Diet (Nutritional considerations)
- Fluid restriction as ordered
- Low K diet, Low Na diet
- Low protein diet why?
- 11- Emergency Dialysis indicated when
- K gt 6.0, Fluid V overload, uremia
- Metabolic acidosis lt15 HCO3