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Nursing Care of Individual with Genitourinary Disorders: Renal Trauma Renal Vascular Problems Acute Renal Failure

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Title: Nursing Care of Individual with Genitourinary Disorders: Renal Trauma Renal Vascular Problems Acute Renal Failure


1
Nursing Care of Individual with Genitourinary
DisordersRenal TraumaRenal Vascular
ProblemsAcute Renal Failure
2
I. AP of the Kidney
  • a. Fibrous capsule
  • b. Renal cortex
  • c. Renal medulla
  • d. Pyramids
  • e. Papillae
  • f. Minor calyx
  • g. Major calyx
  • h. Renal pelvis
  • i. Ureter

3
Review
  • Renal A P

4
II. Functions of the Kidneys
  • Elimination of _______ _________
  • Can you name some of these substances?
    __________________________
  • Regulates fluid electrolyte balance thru
  • processes of __________, _________, and
    _____________.

5
Functions of the Kidneys (continued)
  • Name a few of these Fluid and Electrolyes
    regulated by kidneys
  • __________________
  • __________________
  • __________________

6
Functions of the Kidneys (cont)
  • Regulates acid-base balance
  • HCO3 and H
  • Hormonal (endocrine) functions
  • Renin Release

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

8
Functions of the Kidneys (cont)
  • 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?
    __________________

9
III. The Nephron
  • Why is it called the functional unit of the
    Kidney???

10
Label the Nephrons Parts
  • a. Glomerulus
  • b. Bowmans
  • capsule
  • c. Proximal tubule
  • d. Loop of Henle
  • e. Distal tubule
  • f. Collecting duct

11
Renal Trauma

12
Renal Trauma
  • Etiology
  • Blunt force from falls, MVA, sports injuries,
    knife/gunshot wounds, impalement injury, rib
    fractures

13
Renal Trauma
  • Common Manifestations
  • Microscopic to gross hematuria
  • Flank or abdominal pain
  • Oliguria or anuria
  • Localized swelling, tenderness, ecchymosis flank
    area
  • Turners signbluish discoloration flank area due
    to
  • retroperitoneal bleeding

14
Renal Trauma
  • What are some diagnostic tests used in renal
    trauma?
  • IVP, renal ultrasound, CT scan, renal arteriogram
  • What serum levels can be useful?
  • _________________________

15
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?

16
Renal Trauma-Interventions
  • Bedrest and close observation.
  • Monitor for S S of what???
  • ____________________
  • Embolization or open surgery to
  • stop bleeding or repair
  • Partial or total Nephrectomy

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 u.o. be if patient had bilateral
    nephrectomy? ______.
  • Observe ACC of urine.
  • TCDB incentive spirometry
  • Incision in flank area, 12th rib removed
  • Medicate for pain as ordered

19
Renal Vascular Problems
  • I. Hypertension Nephrosclerosis
  • Sustained elevation of the systemic blood
    pressure can result from or cause kidney
    disease---How?

20
Patho 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 GFR

21
Renal Vascular Problems II. Renal Artery Stenosis
  • Definition Narrowing of one or both renal
    arteries due to atherosclerosis or structural
    abnormalities.
  • Common Manifestations
  • Uncontrollable HTN

22
Critical thinking question
  • How could a renal artery stenosis result in HTN?

23
Renal Artery Stenosis
  • Treatment/Collaborative Care
  • Anti-hypertensive Medications
  • Dilation of renal artery by Percutaneous
    Transluminal Angioplasy
  • Bypass Graft of Renal Artery

24
Renal Artery Stenosis
  • Treatment/Collaborative Care

25
Acute Renal Failure
  • Definition rapid decline in renal
  • function that leads to accumulation
  • of nitrogenous wastes (azotemia)
  • Etiology of ARF
  • Pre-renal
  • Intra-renal
  • Post renal

26
Compare Contrast
  • What is missing from the ARF definition?
  • What is the difference between uremia and
    azotemia???
  • ____________________________

27
Etiology of Acute Renal FailurePre-renal
  • List causes of pre-renal ARF failure-all
    related to decreased blood flow to the kidneys
  • Hypovolemia dehydration, shock, burns
  • Decreased cardiac output CHF, MI, arrythmias
  • Renal vascular obstruction renal artery
  • stenosis, or renal artery blockage.

28
Etiology of Acute Renal FailureIntra-renal
  • Direct injury to the kidneys
  • Conditions causing direct insult to renal tissue
    causing damage to nephrons
  • List causes of intra renal ARF failure

29
Causes of Intrarenal Failure
  • Primary renal disease
  • acute glomeulonephritis and acute
    pyelonephritis
  • ATN (Acute tubular necrosis) most common causes
  • Result from ischemia, nephrotoxins, (such as
    antibiotics), hemoglobin released from hemolyzed
    red blood cells, or myoglobin released from
    necrotic muscle cells

30
Frequent causes of intra-renal failure
  • ATN acute tubular necrosis of tubular cells
    which slough and plug tubules (nephrotoxicity,
    ischemia) potentially reversible
  • Hemolytic blood transfusion (ATN)
  • Trauma (crushing injuries which release
    myoglobin damaged muscle tissue and blocks
    tubules (rhabdomylosis)(ATN)
  • What is Rhabdomylosis?

31
  • Nephrotoxic drugs/chemicals (ATN)
  • Aminoglycosides
  • Radiographic contrast agents
  • Arsenic, lead, carbon tetachloride
  • Acute glomerulonephritis/pyelonephritis
  • Systemic lupus

32
Causes of Acute Renal Failure (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
33
Etiology of Acute Renal Failure Post-renal
  • Identify three causes of post-renal failure
    (mechanical obstruction of urinary outflow urine
    backs up into renal pelvis)
  • BPH (Benign Prostatic Hypertrophy)
  • Calculi
  • Trauma
  • Prostate cancer

34
Diagnostic Tests in Acute Renal Failure
  • BUN (blood urea nitrogen)
  • Normal please change to 6-20 mg/dl measurement
    of amount of urea in blood
  • What is urea?_____
  • BUN fluctuates
  • BUN elevated in______ decreased in_________.

35
Question
  • Which of the following urinary symptoms is the
    most common initial manifestations of ARF?
  • a-dysuria
  • b-anuria
  • c-hematuria
  • d-oliguria

36
Question
  • The clients BUN is elevated in ARF. 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

37
CLINICAL SCENARIO
  • Another client is scheduled to get a CT with
    contrast of their abdomen and is at risk for ARF.
    The physician has prescribed acetylcysteine
    (Mucomyst) 5 20ml po prior to CT scan.
  • The nurse proceeds to look up the medication and
    sees that the drug is a mucolytic. The patient
    has no history of respiratory disease. Why is
    this patient receiving this medication?

38
Clinical scenario
  • You are the Level 4 nursing student assigned to
    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?

39
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?

40
Diagnostic Tests in Acute Renal Failure
  • Serum Creatinine end product of muscle and
    protein metabolism excreted by the kidneys at a
    constant rate
  • Normal 0.6-1.3 mg/dl please change this value
    on your ppt
  • Directly related to GFR
  • 2 X normal (2.6) 50 nephron fx loss
  • 10 X normal (13) 90 nephron fx loss
  • MORE ACCURATE INDICATOR of RENAL FUNCTION THAN
    BUN
  • BUN Creatinine ratio Normal 101
  • BUN Creatinine
  • 16 1.6
  • 12 1.2

41
Diagnostic Tests in Acute Renal Failure
  • Creatinine clearance
  • Most accurate indicator of Renal Function
  • Reflects GFR
  • Involves a 24 hr urine/serum creatinine
  • Formula
  • Amount of urine creatinine X urine V
  • serum creatinine
  • Normal 100-135ml/minute

42
Question..
  • A 24 hours urine for creatinine clearance is
    ordered for Ms. J. Which task is appropriate to
    delegate to the the clinical assistant?
  • a) instruct Ms. J 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 Ms. Js urine for color, odor, sediment

43
Diagnostic Tests in Acute Renal Failure
  • Urine Specific Gravity
  • Normal 1.003-1.030
  • Will be fixed a 1.010 usually in ARF due to
  • kidneys losing ability to concentrate urine
  • Serum Electrolytes
  • 1- Serum Sodium Normal 135-145
  • May be high, low, or normal
  • High in Volume deficit (dehydration)
  • Low due to damaged tubules not conserving
  • sodium

44
Diagnostic Tests in Acute Renal Failure
  • Serum Electrolytes
  • 2- ? Serum K Normal 3.5-5.0 meq/l
  • Almost always increased
  • WHY?
  • Kidneys excrete 80-90 of our K
  • If Kgt 6.0 treatment initiated to prevent
  • ______________________

45
Diagnostic Tests in Acute Renal Failure
  • Serum Electrolytes
  • 3- ? Serum Phosphorus
  • Normal 2.8-4.5mg/dl
  • Phosphorus is a product of protein
  • breakdown excreted by the
  • kidneys
  • What other process is occurring to
    increase serum phosphorus???
    __________________

46
Diagnostic Tests in Acute Renal Failure
  • Serum Electrolytes
  • 4 - ? Serum Calcium
  • Normal 9.0-11.0 mg/dl
  • due to ? production of activated Vitamin D
  • Vitamin D needed to absorb calcium from
    GI
  • tract
  • What other process is occurring to decrease
  • serum calcium??? __________________

47
Diagnostic Tests in Acute Renal Failure
  • ABGs
  • pH
  • Metabolic acidosis due to ability
    of kidneys to excrete acid metabolites
  • (uric acid) so the pH will be __________.
  • Also, bicarb levels due to bicarb being
  • used up to buffer excess H ions.

48
Treatment During Oliguric/Non-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????

49
Treatment During Oliguric/Non-Oliguric Phase
  • If fluid challenge fails, fluid intake is
    usually limited and client is placed on fluid
    restriction
  • Restriction is limited to 600ml u.o. past 24
    hours
  • Physician will specify in the orders how much.
  • Question
  • Patients u.o. on Tuesday300ml, what will be his
    fluid intake allowed on Wednesday? ________

50
Acute Renal Failure Management of.
  • 1- Treat primary disease/condition whether
  • it is pre-intra-or post renal problem.
  • 2-Prevention
  • Frequent monitoring for early signs of ARF in at
    risk patients
  • What can the nurse assess for at this point?
  • 3-Assess for Fluid V deficit vs Fluid V overload
  • Strict I O
  • Daily weights 500ml-1 lb.
  • Monitor lab valueswhich ones? _______

51
Acute Renal Failure Management of.
  • 4- Metabolic Acidosis
  • Administer NaHCO3 I.V. as ordered
  • 5-Hyperkalemia
  • What are the S S of hyperkalemia?
  • ___________________________________
  • Treatment for hyperkalemia
  • Give insulin glucose I.V. Why?
  • K moves out of serum back into cells with the
    glucose in the presence of insulin

52
Acute Renal Failure Management of Potassium
Levels
  • Sodium Bicarbonate I.V.
  • Correct acidosis get potassium into cells
  • Kayexalate po or enema
  • Sodium exchanged for potassium in the GI tract
    produced osmotic diarrhea
  • Dietary Restrictions Potassium
  • Avoid foods high in K
  • Name some of those foods ________________

53
Acute Renal Failure Management of.
  • 6- Calcium Imbalance
  • Administer calcium supplements as ordered
  • (Phoslo or calcium acetate, Oscal or calcium
    carbonate)
  • 7-Phosphorus Imbalance
  • Administer phosphate binders Renagel or
    sevelamer hydrochloride, Nephrox
  • 8- Treat Hypertension (HTN)
  • Lasix, Norvasc (amilodipine), Lopressor
    (metoprolol) as ordered

54
Acute Renal Failure Management of.
  • 9- Assess for anemia
  • Administer Epogen/Procrit as ordered
  • PRBCs as ordered
  • 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

55
Your patient develops acute renal failure after
being on Amphotericin for 1 week
  • The patients ARF 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

56
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

57
Case study Ms.J 63 yo admitted with sob and
swelling in ankles. Hx of DM, htn, cad, r/o
Chronic renal disease
  • What other information do we need?
  • What labs do we need?
  • What meds do we think she is taking currently?
  • What interventions would be included in her POC?

58
Question
  • Ms. Js POC includes nsg dx of Fluid volume
    excess. Which interventions are appropriate?
  • a) Daily weights
  • b) Record intake and output
  • c) Restrict sodium intake with meals
  • d) Restrict fluid to 1500ml urine output
  • e) Assess for crackles and edema every shift
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