Renal A & P -excellent site for renal pathophysiology

1. Nursing Care of Individual Experiencing a Renal Disorder:Vascular DisordersRenal TraumaAcute Renal Failuremodified by Kelle Howard RN, MSN Renal A & P -excellent site for renal 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 renal failure, 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 renal failure, 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. III. 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 Click here for Nephron A&P & Games too!

12. 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 • Signs/Symptoms depend upon severity injury • *Severe blood loss/signs shock

13. Renal Trauma

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

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

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 the UO be if patient had bilateral nephrectomy? ______. • Observe urine • Daily weights • TCDB & IS • Incision in flank area • Medicate for pain as ordered

19. Renal Vascular ProblemsPatho 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 KidneyRenal Artery Stenosis • Definition: Narrowing of one or both renal arteries due to atherosclerosis or structural abnormalities. • Common Manifestation! • uncontrollable HTN- medications do not work • Why?

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

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

25. Vascular Disorders of the KidneyRenal Vein Thrombus/Occlusion • Treatment/Collaborative Care Diagnosis- renal venography Management Thrombolytic drugs streptokinase or tPA Anticoagulant therapy to prevent further clot formation

26. Acute Renal Failure/ Acute Kidney Injury • 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 Renal Failure/ Acute Kidney Injury Etiology of ARF: • Pre-renal • Intra-renal • Post renal

28. Causes of “pre-renal” ARF -What do all of these causes have in common? 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 Etiology of Acute Renal Failure/Acute Kidney InjuryPre-renal (most common cause Acute Kidney Injury!)

29. 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 Etiology of Acute Renal FailureIntra-renal

30. 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 Causes of Intrarenal Failure

31. Renal ischemia Destruction tubular epithelium Nephrotoxic agents Necrosis tubular epithelium… plug tubules. Potentially reversible IF Basement not destroyed and tubular epithelium regenerates Causes of Acute Tubular Necrosis (ATN) Renal ischemia Nephrotoxic agents

32. Etiology of Acute Renal Failure 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. BUN (blood urea nitrogen) Normal = 10-30 mg/dl; measurement of amt of nitrogen in the from of urea in blood Serum Creatinine: Normal = 0.5 – 1.5 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 Diagnostic Tests in Acute Renal Failure:

34. BUN/Creatinine ratio Normal= 10:1 BUN Creatinine 16 1.6 12 1.2 8 0.8 Diagnostic Tests in Acute Renal Failure:

35. Creatinine clearance Most accurate indicator of Renal Function Reflects GFR (glomerular filtration rate) Involves a 24 hr urine/serum creatinine Formula: urine creatinine X urine volume serum creatinine Normal= +/- 120-125ml/minute Diagnostic Tests in Acute Renal Failure:

36. 5 Stages of Chronic Kidney Disease

37. Urine Specific Gravity Normal= 1.003-1.030 Fixed sp. Gravity- 1.010 usually in ARF – Can indicate ATN Kidneys lose ability to concentrate urine Serum Electrolytes 1. Serum Sodium Normal= 135-145meq/L May be high, low, or normal Diagnostic Tests in Acute Renal Failure:

38. Serum Electrolytes 2. Serum K+ Normal= 3.5-5.0 meq/dL Almost always increased in renal failure Why? Diagnostic Tests in Acute Renal Failure:

39. Serum Electrolytes 3. Serum Calcium Normal= 9-11mg/dL Almost always decreased Why? Diagnostic Tests in Acute Renal Failure:

40. Serum Electrolytes 4. Serum Phosphorus Normal= 2.8 - 4.5mg/dL Almost always increased Why? Diagnostic Tests in Acute Renal Failure:

41. 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:

42. Stages of Acute Renal Failure • 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

43. Onset: 1-7 days Duration: 10-14 days Urine output: Less than 400 ml/24 hours in 50% of patients 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 Acute Renal Failure: Oliguric Phase

44. Acute Renal Failure: 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

45. Treatment During: Oliguric Phase • Fluid Challenge/Diuretics • Done to r/o dehydration as cause of ARF and “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????

46. Treatment During: Oliguric Phase • 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. Question: Patient’s UO on Tuesday=300ml, what will be his fluid intake allowed on Wednesday? ________

47. 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? Diuretic Phase of ARF:

48. Recovery Phase Onset: When BUN and Creatinine are stabilized Duration: 4-12 months Urine output: Normal 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, including daily weights Recovery Phase of ARF:

49. Acute Renal Failure: Management of…. • 1- Treat primary disease/condition whether it is pre-intra-post renal problem. • 2- Prevention: • Frequent monitoring for early signs of ARF in at risk patients • 3- Assess for Fluid V deficit vs Fluid V overload • Vital signs – HR, BP, RR • Strict I & O • Daily weights 500ml-=1 lb. (1kg = approx 1000ml fluid) • Monitor lab values…which ones?

50. Acute Renal Failure: Management of…. • 4- Metabolic Acidosis • Administer NaHCO3 I.V. as ordered • 5- Hyperkalemia • Give insulin & glucose I.V. or • Sodium Bicarbonate I.V. or • Kayexalate po or enema or • Dietary Restrictions Potassium