Title: Nursing Care of Individual with Genitourinary Disorders: Renal Trauma Renal Vascular Problems Acute Renal Failure
1Nursing Care of Individual with Genitourinary
DisordersRenal TraumaRenal Vascular
ProblemsAcute Renal Failure
2I. 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
3Review
4II. Functions of the Kidneys
- Elimination of _______ _________
- Can you name some of these substances?
__________________________ - Regulates fluid electrolyte balance thru
- processes of __________, _________, and
_____________. - Name a few of these FEs regulated by
kidneys __________________
5Functions of the Kidneys (continued)
- Name a few of these Fluid and Electrolyes
regulated by kidneys - __________________
- __________________
- __________________
6Functions of the Kidneys (cont)
- Regulates acid-base balance
- HCO3 and H
- Hormonal (endocrine) functions
- Renin Release
7Functions of the Kidneys (cont)
- Erythropoietin Release
- If a patient has chronic kidney disease or
chronic renal failure, what condition will occur
and WHY???
8Functions 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?
__________________
9III. The Nephron
- Why is it called the functional unit of the
Kidney???
10Label the Nephrons Parts
- a. Glomerulus
- b. Bowmans
- capsule
- c. Proximal tubule
- d. Loop of Henle
- e. Distal tubule
- f. Collecting duct
11How the Kidney Works
- http//www.youtube.com/watch?vglu0dzK4dbU
12Renal Trauma
13Renal Trauma
- Etiology
- Blunt force from falls, MVA, sports injuries,
knife/gunshot wounds, impalement injury, rib
fractures
14Renal 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
-
15Renal Trauma
- What are some diagnostic tests used in renal
trauma? - IVP, renal ultrasound, CT scan, renal arteriogram
- What serum levels can be useful?
- _________________________
16Clinical 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?
17Renal 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
18Renal Surgery-Nephrectomy
- Indications for Nephrectomy
- Renal tumor
- Massive Trauma
- Polycystic Kidney Disease
- Donating a Healthy kidney
19Renal 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
20Renal Vascular Problems
- I. Hypertension Nephrosclerosis
- Sustained elevation of the systemic blood
pressure can result from or cause kidney
disease---How?
21Patho 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
22Renal Vascular Problems II. Renal Artery Stenosis
- Definition Narrowing of one or both renal
arteries due to atherosclerosis or structural
abnormalities. - Common Manifestations
- Uncontrollable HTN
23Critical thinking question
- How could a renal artery stenosis result in HTN?
24Renal Artery Stenosis
- Treatment/Collaborative Care
- Anti-hypertensive Medications
- Dilation of renal artery by Percutaneous
Transluminal Angioplasy - Bypass Graft of Renal Artery
25Renal Artery Stenosis
- Treatment/Collaborative Care
26Renal Vascular ProblemsIII. Renal Vein
Thrombosis
- Renal Vein Occlusion
- Definition Blockage or obstruction of Renal
Vein by a thrombus. - Risk Factors
- Nephrotic syndrome
- Use of Birth control pills
- Certain Malignancies
27Vascular Disorders of the KidneyRenal Vein
Occlusion
- Treatment/Collaborative Care
- Thrombolytic drugs such as streptokinase or tPA
- Anticoagulant therapy to prevent
- further clot formation
28Acute 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
29Compare Contrast
- What is missing from the ARF definition?
- What is the difference between uremia and
azotemia??? - ____________________________
30Etiology 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.
31Etiology 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
32Causes 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
33Frequent 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?
34- Nephrotoxic drugs/chemicals (ATN)
- Aminoglycosides
- Radiographic contrast agents
- Arsenic, lead, carbon tetachloride
- Acute glomerulonephritis/pyelonephritis
- Systemic lupus
35Causes 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
36Etiology 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
37Diagnostic 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_________.
38Question
- Which of the following urinary symptoms is the
most common initial manifestations of ARF? - a-dysuria
- b-anuria
- c-hematuria
- d-oliguria
39Question
- 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
40CLINICAL 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?
41Clinical 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?
42Activity
- 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?
43Diagnostic 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
-
44Diagnostic 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
45Question..
- 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
46Diagnostic 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
47Diagnostic 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
- ______________________
-
48Diagnostic 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???
__________________
49Diagnostic 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??? __________________
50Diagnostic 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.
-
51Initiating Phase of ARF
- What Signs and Symptoms to Anticipate?
- Urine less that 400 ml in 24 hours
- Urine possibly with RBCs WBCs depending on the
causative agent
- What stage?
- Initiating Phase
- Onset begins at time of insult
- Duration hours to days
- Urine output lt20ml/h or 100-400 ml/24 hours or
- CAN HAVE NORMAL URINE OUTPUT!
52Oliguric Phase of ARF
- What Signs and Symptoms to Anticipate?
- Urine less that 400 ml in 24 hours
- Specific gravity fixed at 1.010 in oliguria in
intra renal failure - Fluid overload
- Urine with RBCs, casts, WBCs
- Elevated BUN and serum creatinine
- K likely to be elevated
- Ca deficit, PO4 excess
- What stage?
- Oliguric Phase
- Onset 1-7 days
- Duration 10-14 days
- Urine output Less than 400 ml/24 hours in 50 of
patients
53Diuretic Phase of ARF
- What Signs and Symptoms to Anticipate?
- Fluid Volume Overload or Fluid Volume Deficit???
- Elevated BUN and serum creatinine
- K likely to be elevated or decreased???
- Hyponatremia and hypotension
- What stage?
- Diuretic Phase
- Onset days to weeks
- Duration 10 days (1-3 weeks)
- Urine output1-3 liters/day
54Recovery Phase of ARF
- What 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
- What stage?
- Recovery Phase
- Onset When BUN and Creatinine are stablized
- Duration 4-12 months
- Urine output Normal
55 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????
56 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? ________
57 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? _______
58 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
59 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 ________________
60 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
61 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
62Your 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
63Your 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
64Case 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?
65Question
- 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