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

1. Nursing Care of Individual with Genitourinary Disorders:Vascular DisordersRenal TraumaAcute 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. 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 __________________

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

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

6. 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? __________________

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

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

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

10. Vascular Disorders of the Kidney • Renal Vein Occlusion • Definition: Blockage or obstruction of Renal Vein by a thrombus. • Risk Factors: • Nephrotic syndrome • Use of Birth control pills • Certain Malignancies

11. Vascular Disorders of the KidneyRenal Vein Occlusion • Common Manifestations/Complications • Decreased GFR • Signs of Renal Failure • Complication ---Pulmonary Embolus if clot breaks loose.

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

13. Vascular Disorders of the KidneyRenal Artery Stenosis • Definition: Narrowing of one or both renal arteries due to atherosclerosis or structural abnormalities. • Common Manifestations: • Uncontrollable HTN

14. Vascular Disorders of the KidneyRenal Artery Stenosis • Treatment/Collaborative Care • Anti-hypertensive Medications • Dilation of renal artery by Percutaneous Transluminal Angioplasy • Bypass Graft of Renal Artery

15. Vascular Disorders of the KidneyRenal Artery Stenosis • Treatment/Collaborative Care

16. Renal 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 flank area • Turner’s sign=bluish discoloration flank area due to retroperitoneal bleeding

17. 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

18. Renal Trauma

19. Renal Trauma • What are some diagnostic tests used in renal trauma? • IVP, renal ultrasound, CT scan, renal arteriogram • What serum levels can be useful? • What other test(s)?

20. 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

21. Renal Surgery-Nephrectomy • Indications for Nephrectomy: • Renal tumor • Massive Trauma • Polycystic Kidney Disease • Donating a Healthy kidney

22. 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

23. 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

24. 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, thrombus. Etiology of Acute Renal FailurePre-renal

25. 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

26. 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

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

28. 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

29. 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

30. BUN (blood urea nitrogen) Normal = 8-20 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:

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

32. 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

33. Serum Creatinine:end product of muscle and protein metabolism; excreted by the kidneys at a constant rate Normal = 0.6-1.2 mg/dl Directly related to GFR 2 X normal (2.4) = 50% nephron fx loss 10 X normal (12) = 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 8 0.8 Diagnostic Tests in Acute Renal Failure:

34. 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:

35. 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:

36. Serum Electrolytes 2- Serum K+ Normal= 3.5-5.5 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:

37. Serum Electrolytes 3- Serum Calcium Normal= 8.5-10.5mg/dl due to production of activated Vitamin D; needed to absorb calcium from GI tract What other process is occurring to decrease serum calcium??? __________________ Diagnostic Tests in Acute Renal Failure:

38. Serum Electrolytes 4- Serum Phosphorus Normal= 2.0-4.5mg/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:

39. 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:

40. What stage? Oliguric___________ What data to support? Onset: 1-7 days of causative agent Duration: 3 days-3 weeks Urine output: <20cc/h or 100-400 cc/24 hours CAN HAVE NORMAL URINE OUTPUT! What Signs and Symptoms to Anticipate? Urine less that 400 cc in 24 hours Urine with RBC’s; WBC’s Maybe fixed sp.gravity Proteinuria maybe Fluid overload Metabolic acidosis May have dilutional hyponatremia K likely to be elevated Ca deficit, PO4 excess Initiation: Oliguric/Non-Oliguric Phase

41. Acute Renal Failure: Oliguric/Non-Oliguric Phase • Oliguric Phase • Urine less than 400 cc in 24 hours; will have fixed specific gravity to 1.101; urine osmolality 300 mmol/kg (cannot concentrate); perhaps proteinuria, if due to damage to glomerulus • Fluid volume excess: potential pulmonary edema • Sodium excess: overload can mask elevated sodium levels • Potassium excess: EKG changes; above 6 mEg/L immediate treatment needed!

42. Acute Renal Failure: Oliguric/Non-Oliguric Phase • Metabolic acidosis: kidneys unable to synthesize NH3, needed H excretion, or excrete acid metabolites, ; serum bicarbonate, decreases used to buffer H (Kussmaul breathing) • Ca deficit; phosphate excess; decreased GI absorption Ca (lack of active vitamin D) • Nitrogenous product accumulation: unable to eliminate urea and creatinine: get elevated BUN, serum creatinine

43. 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????

44. 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 500ml + u.o. past 24 hours • Physician will specify in the orders how much. • Question: • Patient’s u.o. on Tuesday=300ml, what will be his fluid intake allowed on Wednesday? ________

45. Acute Renal Failure: Diuretic Phase • Diuretic Phase • Begins with gradual increase 1-3 L/day; can increase to 3-5 L/day • Due to osmotic diuresis (high urea concentration) • Uremia may still be severe • May last 1-3 weeks • Caution careful monitoring fluid and electrolytes!

46. Acute Renal Failure: Clinical Course • Recovery Phase • GRF increased: BUN and serum creatinine stabilized; eventually decreased to normal levels • May take up to 12 months • Failure to recover related most often to infection

47. 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 values…which ones? _______

48. 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

49. 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: ________________

50. Acute Renal Failure: Management of…. • 6- Calcium Imbalance • Administer calcium supplements as ordered • (Phoslo, Oscal) • 7-Phosphorus Imbalance • Administer phosphate binders Amphogel Basaljel, Renagel, Nephrox • 8- Treat Hypertension (HTN) • Lasix, Procardia, Vasotec as ordered