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

1. Nursing Care of Individual with Genitourinary Disorders:Renal TraumaRenal Vascular ProblemsAcute Renal Failure

2. I. A&P 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 _____________. Name a few of these F&Es regulated by kidneys __________________

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. If a patient has renal failure, what will happen to the patient’s serum calcium level? __________________

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

10. Label the Nephron’s Parts • a. Glomerulus • b. Bowman’s capsule • c. Proximal tubule • d. Loop of Henle • e. Distal tubule • f. Collecting duct

11. How the Kidney Works • http://www.youtube.com/watch?v=glu0dzK4dbU

12. Renal Trauma

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

14. Renal Trauma • Common Manifestations: • Microscopic to gross hematuria • Flank or abdominal pain • Oliguria or anuria • Localized swelling, tenderness, ecchymosis flank area • Turner’s sign=bluish discoloration flank area due to retroperitoneal bleeding

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

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. Renal Vascular Problems:III. 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

26. Vascular Disorders of the KidneyRenal Vein Occlusion • Treatment/Collaborative Care • Thrombolytic drugs such as streptokinase or tPA • Anticoagulant therapy to prevent further clot formation

27. 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

28. Compare & Contrast… • What is missing from the ARF definition? • What is the difference between uremia and azotemia??? • ____________________________

29. 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. Etiology of Acute Renal FailurePre-renal

30. Direct injury to the kidneys Conditions causing direct insult to renal tissue causing damage to nephrons List causes of “intra renal” ARF failure: Etiology of Acute Renal FailureIntra-renal

31. 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 Causes of Intrarenal Failure

32. 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)

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

34. Renal ischemia Disruption basement membrane;destruction tubular epithelium Nephrotoxic agents Necrosis tubular epithelium… plug tubules; basement membrane intact. Potentially reversible IF Basement not destroyed and tubular epithelium regenerates Causes of Acute Renal Failure (ATN) Renal ischemia Nephrotoxic agents

35. 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

36. BUN (blood urea nitrogen) Normal = 10-30 mg/dl; measurement of amount of urea in blood What is urea?_____ BUN fluctuates BUN elevated in______; decreased in_________. Diagnostic Tests in Acute Renal Failure:

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

38. Question… • The client’s 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

39. Serum Creatinine: end product of muscle and protein metabolism; excreted by the kidneys at a constant rate Normal = 0.5-1.5 mg/dl Directly related to GFR 2 X normal (3.0) = 50% nephron fx loss 10 X normal (15) = 90% nephron fx loss MORE ACCURATE INDICATOR of RENAL FUNCTION THAN BUN BUN; Creatinine ratio Normal= 10:1 BUN Creatinine 16 1.6 12 1.2 Diagnostic Tests in Acute Renal Failure:

40. 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 Diagnostic Tests in Acute Renal Failure:

41. 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 Diagnostic Tests in Acute Renal Failure:

42. Serum Electrolytes 2- ↑ Serum K+ Normal= 3.5-5.0 meq/l Almost always increased WHY? Kidneys excrete 80-90% of our K+ If K+> 6.0; treatment initiated to prevent ______________________ Diagnostic Tests in Acute Renal Failure:

43. 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??? __________________ Diagnostic Tests in Acute Renal Failure:

44. 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??? __________________ Diagnostic Tests in Acute Renal Failure:

45. 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. Diagnostic Tests in Acute Renal Failure:

46. What stage? Initiating Phase Onset: begins at time of insult Duration: hours to days Urine output: <20ml/h or 100-400 ml/24 hours or CAN HAVE NORMAL URINE OUTPUT! What Signs and Symptoms to Anticipate? Urine less that 400 ml in 24 hours Urine possibly with RBC’s; WBC’s depending on the causative agent Initiating Phase of ARF:

47. What stage? Oliguric Phase Onset: 1-7 days Duration: 10-14 days Urine output: Less than 400 ml/24 hours in 50% of patients 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 Oliguric Phase of ARF:

48. What stage? Diuretic Phase Onset: days to weeks Duration: 10 days (1-3 weeks) Urine output:1-3 liters/day 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 Diuretic Phase of ARF:

49. What stage? Recovery Phase Onset: When BUN and Creatinine are stablized Duration: 4-12 months Urine output: Normal 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 Recovery Phase of ARF:

50. 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????