Nursing Care of Individual Experiencing a Renal Disorder: Vascular Disorders Renal Trauma Acute Renal Failure modified by Kelle Howard RN, MSN - PowerPoint PPT Presentation

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Nursing Care of Individual Experiencing a Renal Disorder: Vascular Disorders Renal Trauma Acute Renal Failure modified by Kelle Howard RN, MSN

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Title: Nursing Care of Individual Experiencing a Renal Disorder: Vascular Disorders Renal Trauma Acute Renal Failure modified by Kelle Howard RN, MSN


1
Nursing Care of Individual Experiencing a Renal
DisorderVascular DisordersRenal TraumaAcute
Renal Failuremodified by Kelle Howard RN, MSN
Renal A P -excellent site for renal
pathophysiology
2
I. AP of the Kidney- (locate structures)
  • Fibrous capsule
  • Renal cortex
  • Renal medulla
  • Pyramids
  • Papillae
  • Minor calyx
  • Major calyx
  • Renal pelvis
  • Ureter

3
II. 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
    __________________

4
Functions of the Kidneys (cont)
  • Regulates acid-base balance through _________
  • Hormonal functions (BP control), multisytem
    effect.
  • Renin Release

RAAS
5
How the RAAS Pathway Works
Valerie Kolmer 2006
6
Quick 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

7
Functions of the Kidneys (cont)
  • Erythropoietin Release
  • If a patient has chronic renal failure, what
    condition will occur
  • WHY???

8
Functions 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?
    __________________

9
Review Functions of the Kidneys
  • Regulate
  • 1.___________
  • 2.___________
  • 3.___________
  • 4.___________
  • Release of ________________
  • Activation of _______________

10
III. Nephron- functional unit of the Kidney!
  • How the Nephron Works! Click-watch YouTube video!

11
Identify 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

13
Renal Trauma


14
Renal 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
15
Renal Trauma-Interventions
  • Minor Trauma
  • Conservative
  • Bedrest and close observation
  • Monitor for S S of what?

16
Renal 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

17
Renal Surgery-Nephrectomy
  • Indications for Nephrectomy
  • Renal tumor
  • Massive Trauma
  • Polycystic Kidney Disease
  • Donating a healthy kidney

18
Renal 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

19
Renal 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 _____

20
Vascular 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?

21
Vascular 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

22
Vascular Disorders of the KidneyRenal Artery
Stenosis
  • Treatment/Collaborative Care

What type of procedure is this? What are some
post procedure nursing care interventions?
23
Vascular 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

24
Vascular 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

25
Vascular 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

26
Acute 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)

27
Acute Renal Failure
  • Etiology of ARF
  • Pre-renal
  • Intra-renal
  • Post renal

28
Etiology 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.

29
Etiology 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

30
Causes 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

31
Causes 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
32
Etiology 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

33
Diagnostic 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

34
Diagnostic Tests in Acute Renal Failure
  • BUN/Creatinine ratio
  • Normal 101
  • BUN Creatinine
  • 16 1.6
  • 12 1.2
  • 8 0.8

35
Diagnostic 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

36
Diagnostic 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

37
Diagnostic Tests in Acute Renal Failure
  • Serum Electrolytes
  • 2. Serum K
  • Normal 3.5-5.0 meq/dL
  • Almost always increased in renal failure
  • Why?

38
Diagnostic Tests in Acute Renal Failure
  • Serum Electrolytes
  • 3. Serum Calcium
  • Normal 9-11mg/dL
  • Almost always decreased
  • Why?

39
Diagnostic Tests in Acute Renal Failure
  • Serum Electrolytes
  • 4. Serum Phosphorus
  • Normal 2.8 - 4.5mg/dL
  • Almost always increased
  • Why?

40
Diagnostic 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.

41
Stages 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

42
Acute 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

44
Diuretic 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?

45
Recovery 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
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