nursing care of individuals with genitourinary disorders: renal trauma renal vascular problems acute...
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Nursing Care of Individualswith Genitourinary Disorders:
Renal TraumaRenal Vascular ProblemsAcute Kidney Injury
04/19/23 1
The KidneyPrimary function
◦Regulate volume and composition of ECF (extracellular fluid)
◦Excrete waste productsOther functions
◦Regulate acid-base balance◦Control BP◦Produce Erthyropoietin◦Activate Vitamin D
04/19/23 2
The NephronWhy is it called the functional unit of
the kidney?
04/19/23 5
Glomerular Filtration RateGlomerular filtration rateUsed to assess how well the kidneys
are working
Estimates how much blood passes through the glomeruli each minute
The amount of filtrate formed per minute by the two kidneys combined
04/19/23 6
Glomerular Filtration RateFor average male GFR is 125ml/min
◦That would create180 L/d!
More than 99% of the filtrate is reabsorbed◦Average 1mL/min of urine excreted◦1-2 L/day
Older people will have lower normal GFR levels, because GFR decreases with age
04/19/23 7
GFRGFR too high
◦ increased urine output ◦threat of dehydration and electrolyte
depletionGFR too low
◦ insufficient excretion of wastes
GFR of 60 or higher is in the normal rangeGFR below 60 may mean kidney disease
GFR of 15 or lower may mean kidney failure
04/19/23 8
The KidneyPrimary function
◦Regulate volume and composition of ECF (extracellular fluid)
◦Excrete waste productsOther functions
◦Regulate acid-base balance◦Control BP◦Produce Erthyropoietin◦Activate Vitamin D
04/19/23 9
Functions of the KidneysRegulates acid-base balance
◦HCO3 and H+Controls Blood Pressure:
◦Renin Release
04/19/23 10
RAASKidney senses low perfusionRenin released by kidney
Angiotensinogen (from liver) acivated into angiotensin I
Converted to Angiotensin II by ACE
Angiotensin II stimulates release of aldosterone
Na+ and H2O retained04/19/23 11
04/19/23 12
Functions of the Kidneys Erythropoietin Release
◦If a patient has chronic kidney disease or chronic renal failure, what condition will occur and why?
04/19/23 13
Functions of the Kidneys
Erythropoietin promotes the formation of RBC’s in response to decreased O2 carrying capacity
Anemia from impaired erythropoietin
production and platelet abnormalities >
bleeding risk
04/19/23 14
Functions of the Kidneys
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 patient’s serum calcium level?
04/19/23 15
Functions of the Kidneys
Inability of kidneys to activate vitamin D- hypocalcemia > parathyroid gland > secretes PTH > stimulates bone demineralization > release calcium from bones
Low serum calcium level/elevated phosphate
Why do you have a elevated serum phosphate?
04/19/23 16
Review- Functions of the KidneyRegulate
◦Volume & composition of extracellular fluid
◦F&E balance
Acid/Base balanceBlood pressure regulationErythropoetin releaseVitamin D activation
04/19/23 17
Acute Kidney Injury
Rapid decline in renal function that leads to accumulation of nitrogenous wastes in the blood (azotemia)
Etiology of AKI:◦Pre-renal◦Intra-renal◦Post renal
04/19/23 18
Acute Kidney InjuryPre-renalHypovolemia
dehydration, shock, burnsDecreased cardiac output
CHF, MI, arrhythmiasDecreased vascular resistance
septic shockRenal vascular obstruction
renal artery stenosis, thrombusCauses related to decreased blood flow to the kidneys
04/19/23 19
Acute Kidney InjuryIntra-renalConditions causing direct damage to renal tissue causing damage to nephrons
Result from ischemiaNephrotoxinsHemoglobin released from hemolysis
of red blood cellsMyoglobin released from necrotic
muscle cells
04/19/23 20
Acute Kidney InjuryIntra-renalPrimary Renal Disease
◦Acute glomerulonephritis/pyelonephritis
◦Systemic lupus
Acute Tubular Necrosis (ATN)◦Necrosis of tubular cells which slough
and plug tubules ◦Potentially reversible◦Most common cause of intra-renal AKI
04/19/23 21
Acute Tubular Necrosis(ATN)
◦ 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
04/19/23 22
Renal ischemia
Nephrotoxic agents
Acute Kidney InjuryIntra-renal
Acute Tubular Necrosis (ATN)
Nephrotoxic drugs/chemicals (ATN)◦Aminoglycosides*◦Radiographic contrast agents◦Arsenic, lead, carbon tetrachloride
04/19/23 23
Acute Kidney InjuryIntra-renalHemolytic blood transfusion (ATN)
Trauma ◦crushing injuries which release
myoglobin◦damaged muscle tissue and blocks
tubules (rhabdomyolysis)(ATN)
What is Rhabdomyolysis?
04/19/23 24
Compare & ContrastCompare & Contrast
Healthy ATN
04/19/23 25
Lupus Nephritis‘Flea bite’ look
04/19/23 26
Acute Kidney InjuryPost-renalMechanical
obstruction of urinary outflow
urine backs up into renal pelvis
BPH CalculiTraumaProstate cancer
04/19/23 27
Stages of Acute Kidney InjuryInitiating 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
04/19/23 28
Urine output in AKI varies widely & does NOT provide clinical correlation to the degree of injury!!!!!
Must look at GRF
04/19/23 29
Oliguric PhaseOnset- 1-7 daysDuration- 10-14 daysUrine Output- Less than 400 ml/24 hours in 50%
of patients (Can have non-oliguric AKI)
Signs & Symptoms to anticipate-Specific gravity fixed at 1.010 in oliguria in intra
renal failure – may be elevated in pre & postFluid overloadUrine with RBCs, casts, WBCs, protein (if
glomerulus damaged)K+ likely elevated
04/19/23 30
Oliguric PhaseMetabolic acidosis
kidneys unable to synthesize HCO3, cannot excrete H+ and acid metabolites, serum bicarbonate decreased because used to buffer H+
Kussmaul breathing
Calcium deficit & phosphate excessdecreased GI absorption of Ca (Vit D) increase in Calcium secretion
Nitrogenous product accumulation◦ unable to eliminate urea and creatinine >
elevated BUN, serum creatinine
04/19/23 31
Treatment – Oliguric phaseFluid 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?04/19/23 32
Treatment – Oliguric phaseIf fluid challenge fails- intake limitedFluid restriction
◦600ml + u.o. past 24 hours
Patient’s u.o. yesterday was 300ml. What will be the allowed fluid intake today?
04/19/23 33
Diuretic PhaseOnset- days to weeksDuration- 1-3 weeksUrine Output- 1-3 liters/day
Signs & Symptoms to anticipateElevated BUN and Serum CreatinineWhat happens to intravascular volume?What happens to BP?Urine Na?K+ elevated or decreased?
04/19/23 34
Recovery PhaseOnset- When BUN and Creatinine stabilizedDuration- 4-12 monthsUrine Output- Normal
Signs & Symptoms◦ Continue to monitor for signs and
symptoms of F & E imbalances◦ All body systems for effects of fluid volume
changes◦ What are some key nursing interventions?
04/19/23 35
Diagnostic tests in AKIBUN (blood urea nitrogen) Measurement of amount of urea in
bloodNormal -6-20 mg/dl
What is urea?BUN fluctuates
BUN elevated when?BUN decreased when?
04/19/23 36
Diagnostic tests in AKISerum Creatinine
◦End product of muscle and protein metabolism
◦Excreted by the kidneys at a constant rate◦Normal = 0.6 – 1.3 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= 12:1 to 20:104/19/23 37
Diagnostic tests in AKICreatinine clearance
Normal= 120-125ml/minute◦Most accurate indicator of Renal
Function◦Reflects GFR◦Involves a 24 hr urine/serum creatinine
◦Formula:urine creatinine X urine Volume serum creatinine
04/19/23 38
24 hour urineWhat is the nurses role in the
collection of a 24 hour urine?What if they have a foley cath?
04/19/23 39
Diagnostic tests in AKIUrine Specific GravityNormal= 1.003-1.030Will be fixed a 1.010 usually in AKI due to
kidneys losing ability to concentrate urine
Serum ElectrolytesSodiumPotassiumCalciumPhosphorus
04/19/23 40
Diagnostic tests in AKISerum ElectrolytesSerum Sodium Normal= 135-145
May be high, low, or normalWhen would it be high/low?
04/19/23 41
Diagnostic tests in AKISerum ElectrolytesSerum Potassium Normal= 3.5-5 meq/L
Almost always increased in renal failure
Why? Two major reasons
If > 6.0 treatment to prevent….04/19/23 42
Diagnostic tests in AKISerum ElectrolytesSerum Phosphorus Normal=2.8-4.5mg/dl
Almost always increased. Why?
What other process is occurring to increase serum phosphorus?
04/19/23 43
Diagnostic tests in AKISerum ElectrolytesSerum Calcium Normal=9.0-11.0 mg/dl
Almost always decreased, why?
What other process is occurring to decrease serum calcium?
04/19/23 44
Diagnostic tests in AKIABGsMetabolic acidosis-due to decreased
ability of kidneys to excrete acid metabolite (uric acid)
So the pH will be high or low?
Bicarb- decreased due to bicarb being used up to buffer excess H+ ions
04/19/23 45
Management of AKITreat the primary disease/condition
Prevention ◦Frequent monitoring for early signs
of AKI in at risk patients
◦What are these signs?
04/19/23 46
Management of AKIAssess for FVD vs FVE
◦VS◦Strict I&O◦Daily weights◦Monitor labs- which ones?
Metabolic acidosis◦Administer NaHCO3 IV as ordered
04/19/23 47
Management of AKIHyperkalemia
◦Insulin and glucose K+ moves back into the cells when insulin is
given. Glucose to prevent hypoglycemia
◦Sodium Bicarbonate Correct acidosis and shifts K+ into cells
◦Kayexalate Pulls K+ out through GI tract
◦Dietary restrictions Bananas, avocado, apricots, potatoes, white
beans
04/19/23 48
Management of AKICalcium imbalance
◦Calcium Gluconate
Phosphorus imbalance◦Calcium supplements, Phosphate
binders
Hypertension◦Lasix, Amlodipine, Metoprolol
04/19/23 49
Management of AKIAnemia
◦Administer epogen/procrit as ordered◦PRBC’s
Diet◦Fluid restriction◦Low K+, low Na◦Low protein- why?
Emergency dialysis◦K+>6.0, FVE, uremia, metabolic
acidosis
04/19/23 50
Renal Trauma
Etiology:Men under age 30
Blunt force from fallsMVA Sports injuries Knife/gunshot woundsImpalement injury, rib fractures
04/19/23 51
Renal TraumaCommon Manifestations:
◦Hematuria-microscopic to gross ◦Pain- Flank or abdominal ◦Decreased Urine Output- oliguria or
anuria◦Localized swelling, tenderness◦Turner’s sign
04/19/23 52
renal trauma
04/19/23 53
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Renal Trauma
What are some diagnostic tests used in renal trauma?◦CT scan, MRI, renal ultrasound, renal
arteriogram, IVP with cystography
What serum levels can be useful?UA (hematuria),H & H (decreasing values)
04/19/23 54
Renal Trauma-Interventions
Minor Trauma◦Bedrest and close observation.◦Monitor for S & S of what?
Moderate/Major Trauma◦Embolization or open surgery to stop
bleeding or repair◦Partial or total Nephrectomy
04/19/23 55
Renal Trauma-InterventionsNursing ManagementBedrestPrevent complicationsClose Observation for s/sx shock
◦H&H◦I&O◦Daily weights◦VS
04/19/23 56
Renal Surgery-Nephrectomy
Indications for Nephrectomy:◦Renal tumor◦Massive Trauma◦Polycystic
Kidney Disease◦Donating a
Healthy kidney
04/19/23 57
Renal Surgery-Nephrectomy
Post Op Nursing Management◦Strict I & O Urine output should be at least _____. What should output be if patient had
bilateral nephrectomy? ______.◦Observe ACC of urine◦TCDB & incentive spirometery Incision in flank area, 12th rib
removed◦Medicate for pain as ordered
04/19/23 58
Renal Vascular ProblemsNephrosclerosis
Caused by chronic or malignant HTN
Renal dysfunction and renal failure are two major complications of HTN
Sustained elevation of the systemic blood pressure can result from or cause kidney disease---How?
04/19/23 59
Patho of 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
04/19/23 60
Renal Vascular Problems Renal Artery Stenosis
Narrowing of one or both renal arteries due to atherosclerosis or structural abnormalities
Uncontrollable HTN
How could a renal artery stenosis result in HTN? 04/19/23 61
Treatment/Collaborative CareAnti-hypertensive MedicationsDilation of renal artery by Percutaneous
Transluminal AngioplasyBypass Graft of Renal ArteryNephrectomy
Renal Artery Stenosis
04/19/23 62
Renal Vein Thrombosis/Occlusion
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
04/19/23 63
Renal Vein Thrombosis/OcclusionPathophysiology/etiology
◦Thrombus forms in renal vein◦Cause unclear◦Trauma, nephrotic syndrome◦Gradual loss of kidney function
Common manifestations/complications◦Decreased GFR◦Signs of renal failure◦Pulmonary embolus
04/19/23 64
Renal Vein Thrombosis/OcclusionTreatment/Collaborative CareDiagnosis
◦Renal venography
Management◦Thrombolytic drugs◦Anticoagulant therapy◦Surgical thrombectomy◦Corticosteroids
04/19/23 65
Your patient develops AKI after being on Amphotericin for 1 week:
The patient’s AKI 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
04/19/23 66
Your patient’s K+ level is elevated. The physician orders Kayexalate because it:
A. increases sodium excretion from the colon
B. releases hydrogen ions for sodium ionsC. increases calcium absorption in the
colonD. exchanges sodium for potassium in
the colon
04/19/23 67
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?
04/19/23 68
The client’s BUN is elevated in AKI. 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
04/19/23 69
ActivityThe 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?
04/19/23 70
A 24 hours urine for creatinine clearance is ordered. Which task is appropriate to delegate to the the clinical assistant??
a) instruct patient 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 urine for color, odor, sediment
04/19/23 71
Which urinary symptom is the most common initial manifestation of AKI?
a-dysuriab-anuriac-hematuriad-oliguria
04/19/23 72
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