Kidney A & P -excellent site for kidney pathophysiology

1. Nursing Care of Individual Experiencing a Kidney Disorder:Vascular DisordersKidney TraumaAcute Kidney Injurymodified by Kelle Howard RN, MSN, CNErevised Fall 2012 Kidney A & P -excellent site for kidney pathophysiology

2. I. A&P 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 acute kidney injury, 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 acute kidney injury, what will happen to the patient’s serum calcium level? __________________

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

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

11. Identify the Nephron’s Parts • Glomerulus • Bowman’s capsule • Proximal tubule • Loop of Henle • Distal tubule • Collecting duct

12. Kidney 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 over the flank area - aka: ____________ • Signs/Symptoms depend upon severity injury • *Severe blood loss/signs shock

13. Kidney Trauma

14. Kidney Trauma • What are common diagnostic tests used in kidney 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. Kidney Trauma:Interventions • Minor Trauma • Conservative • Bedrest and close observation • Monitor for S & S of what?

16. Kidney 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 ____________ • Fluid mgt • Prevent complications/monitor I & O • Manage drainage tubes • Daily weights****

17. Kidney Surgery:Nephrectomy • Indications for Nephrectomy: • kidney tumor • massive trauma • polycystic kidney disease • donating a healthy kidney • What are the different types and approaches?

18. Kidney 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 • Medicate for pain as ordered

19. Vascular Disorders of the Kidney: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 _____

20. Vascular Disorders of the Kidney:Renal Artery Stenosis • Definition: • narrowing of one or both renal arteries due to atherosclerosis or structural abnormalities. • Common Manifestation: • uncontrollable HTN • medications do not work

21. Vascular Disorders of the Kidney:Renal Artery Stenosis • Treatment/Collaborative Care • Diagnostic Tests • Renal arteriogram-most definitive • Management • Conservative-antihypertensive meds • Percutaneous Transluminal Angioplasty • Surgical re-vacularization (Graft) • Nephrectomy

22. Vascular Disorders of the Kidney:Renal 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/Occlusion • 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 Kidney:Renal Vein Thrombosis/Occlusion • Pathophysiology/etiology • Cause unclear: thrombus forms in renal vein • Associated with trauma, nephrotic syndrome gradual deterioration of kidney function • Common Manifestations/Complications • Decreased GFR • Signs of kidney failure • **Complication ---*_______________

25. Vascular Disorders of the KidneyRenal Vein Thrombosis/Occlusion • Treatment/Collaborative Care • Diagnosis- renal venography • Management • Thrombolytic drugs • Anticoagulant therapy • Surgical thrombectomy • Cortiocosteroids

26. Acute Kidney Injury(AKI)(previously known as 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 Kidney Injury Etiology of AKI: • Pre-renal • Intra-renal • Post renal

28. Etiology of Acute Kidney InjuryPre-renal Most common cause of pre-renal AKI • Causes of “pre-renal” AKI • Hypovolemia: dehydration, shock, burns, N&V, diarrhea • Decreased cardiac output: CHF, MI, arrythmias • Dec. vascular resistance (septic shock, etc) • Renal vascular obstruction: renal artery stenosis, thrombus

29. Etiology of Acute Kidney Injury:Intra-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 • Most common cause of Intra-renal AKI

30. Etiology of Acute Kidney Injury:Intra-renal • Hemolytic blood transfusion (ATN) • Trauma(crush injuries > release myoglobin>damage muscle tissue > blocks tubules) (rhabdomylosis) (ATN) • Nephrotoxic drugs/chemicals (ATN) • Aminoglycosides* • Radiographic contrast agents • Arsenic, lead, carbons • Drug overdose • Acute glomerulonephritis/pyelonephritis • Systemic Lupus

31. Etiology of Acute Kidney Injury:Intra-renal (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 Kidney Injury: 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:Acute Kidney Injury • BUN (blood urea nitrogen) • Normal = 6-20 mg/dl; measurement of amt of nitrogen, in the form of urea, in blood • Serum Creatinine: • Normal = 0.6 – 1.3 mg/dl • Directly related to GFR • 2 X pts. normal = 50% nephron fx loss • 10 X pts. normal = 90% nephron fx loss • MORE ACCURATE INDICATOR of kidney function than BUN

34. Diagnostic Tests:Acute Kidney Injury • Creatinine clearance • Most accurate indicator of kidney function • Reflects GFR (glomerular filtration rate) • Involves a 24 hr urine/serum creatinine • Formula: • urine creatinine X urine volume serum creatinine • Normal= 70-135ml/minute • (+/- 120-125ml/minute)

35. Diagnostic Tests:Acute Kidney Injury • Urine Specific Gravity • Normal= 1.003-1.030 • Fixed - 1.010 usually in AKI • Can indicate ATN • Kidneys lose ability to concentrate urine • Serum Electrolyte • 1. Serum Sodium Normal= 135-145meq/L • May be high, low, or normal

36. Diagnostic Tests:Acute Kidney Injury • Serum Electrolytes 2. Serum K+ Normal= 3.5-5.0 meq/dL • Almost always increased in kidney failure • Why?

37. Diagnostic Tests:Acute Kidney Injury • Serum Electrolytes 3. Serum Calcium Normal= 8.6-10.2mg/dL Almost always decreased Why?

38. Diagnostic Tests:Acute Kidney Injury • Serum Electrolytes 4. Serum Phosphorus Normal= 2.4 - 4.4mg/dL Almost always increased Why?

39. Diagnostic Tests:Acute Kidney Injury • 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 & ____________

40. Stages of Acute Kidney Injury • 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

41. Acute Kidney Injury: Oliguric Phase • Onset: 1-7 days • Duration: 10-14 days • Urine output: Less than 400 ml/24 hours in 50% of patients • Can have non-oliguric AKI • 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

42. Acute Kidney Injury: 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 > elevated BUN, serum creatinine

43. Acute Kidney Injury: Oliguric Phase • Treatment • Fluid Challenge/Diuretics • Why do you think it is done? • Process: • 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????

44. Acute Kidney Injury: Oliguric Phase Treatment • 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

45. Acute Kidney Injury: Diuretic Phase • Onset: days to weeks • Duration: about 10 days (1-3 weeks) • Urine output: 1-3 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?

46. Acute Kidney Injury: Recovery Phase • Onset: • When BUN and Creatinine are stabilized • Duration: • 4-12 months • Urine output: • Normal • Signs and Symptoms to anticipate? • Monitor for signs and symptoms of F & E imbalances • All body systems for effects of fluid volume changes

47. Acute Kidney InjuryManagement/Interventions • 1- Treat primary disease/condition whether it is pre-intra-post renal problem. • 2- Prevention: • Frequent monitoring for early signs of AKI in at risk patients

48. Acute Kidney InjuryManagement/Interventions • 3- Assess for Fluid V deficit vs Fluid V overload • Vital signs – HR, BP, RR • Strict I & O • Daily weights 500ml =1lb. (1kg = approx 1000ml) • Monitor lab value • 4- Metabolic Acidosis • Administer NaHCO3 I.V. as ordered

49. Acute Kidney Injury Management/Interventions • 5- Hyperkalemia • Give insulin & glucose I.V. or • Sodium bicarbonate I.V. or • Calcium gluconate or • Dialysis or • Kayexalate po/enema or • Dietary restrictions (not necessarily in this order)

50. Acute Kidney InjuryManagement/Interventions • 6- Calcium Imbalance • Administer calcium supplements as ordered • 7- Treat Hypertension (HTN) • 8- Phosphorus Imbalance • Administer phosphate binders • *Amphogel *Basaljel, Renagel • Oscal Phoslo *Cautious use of aluminum-based phosphate binders can cause encephalopathy