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

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Nursing Care of Individual with Genitourinary
DisordersRenal TraumaRenal Vascular
ProblemsAcute Renal Failure
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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

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Review

• Renal A P

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II. Functions of the Kidneys

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

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Functions of the Kidneys (continued)

• Name a few of these Fluid and Electrolyes
  regulated by kidneys
• __________________
• __________________
• __________________

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Functions of the Kidneys (cont)

• Regulates acid-base balance
• HCO3 and H
• Hormonal (endocrine) functions
• Renin Release

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Functions of the Kidneys (cont)

• 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 (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?
  __________________

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III. The Nephron

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

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Label the Nephrons Parts

• a. Glomerulus
• b. Bowmans
• capsule
• c. Proximal tubule
• d. Loop of Henle
• e. Distal tubule
• f. Collecting duct

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Renal Trauma

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Renal Trauma

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

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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

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Renal Trauma

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

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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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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

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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 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

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Renal Vascular Problems

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

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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

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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

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Critical thinking question

• 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

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Renal Artery Stenosis

• Treatment/Collaborative Care

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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

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Compare Contrast

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

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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.

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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

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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

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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?

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

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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
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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

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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_________.

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Question

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

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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

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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?

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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?

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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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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

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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

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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

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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

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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
• ______________________

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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???
  __________________

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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??? __________________

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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.

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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????

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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? ________

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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? _______

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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

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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 ________________

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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

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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

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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

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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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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?

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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