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Nursing Care of Individual Experiencing a Kidney Disorder:
Vascular DisordersKidney Trauma
Acute Kidney Injurymodified by Kelle Howard RN, MSN, CNE
revised Fall 2012
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Kidney A & P -excellent site for kidney pathophysiology
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I. A&P of the Kidney- (locate structures)
• Fibrous capsule• Renal cortex• Renal medulla• Pyramids• Papillae• Minor calyx• Major calyx • Renal pelvis• Ureter
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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 __________________
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Functions of the Kidneys (cont) • Regulates acid-base balance through _________• *Hormonal functions: (BP control), multisytem effect.
– Renin Release
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RAAS=
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How the RAAS Pathway Works
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Valerie KolmerValerie Kolmer
20062006
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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
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Functions of the Kidneys (cont)
• Erythropoietin Release– If a patient has acute kidney injury, what
condition will occur?– WHY???
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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? __________________
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Review: Functions of the Kidneys
• Regulate– 1.___________– 2.___________– 3.___________– 4.___________
• Release of ________________• Activation of _______________
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Nephron- functional unit of the Kidney!
• How the Nephron Works! Click-watch YouTube video!
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Identify the Nephron’s Parts
• Glomerulus• Bowman’s capsule• Proximal tubule• Loop of Henle• Distal tubule• Collecting duct
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Kidney Trauma Etiology:
Blunt force from falls, MVA, sports injuries, knife/gunshot wounds, impalement, rib fractures
Common Manifestations:Microscopic to gross hematuriaFlank or abdominal painOliguria or anuriaLocalized swelling, tenderness, ecchymosis over the
flank area - aka: ____________Signs/Symptoms depend upon severity injury*Severe blood loss/signs shock
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Kidney Trauma
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Kidney Trauma
• What are common diagnostic tests used in kidney trauma?
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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
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Kidney Trauma:Interventions
• Minor Trauma– Conservative – Bedrest and close observation– Monitor for S & S of what?
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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****
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Kidney Surgery:Nephrectomy
• Indications for Nephrectomy:
– kidney tumor– massive trauma– polycystic kidney disease– donating a healthy kidney
– What are the different types and approaches?
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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
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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 _____
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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 HTNmedications do not work
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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
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Vascular Disorders of the Kidney:Renal Artery Stenosis
– Treatment/Collaborative Care
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What type of procedure is this?
What are some post procedure nursing care interventions?
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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
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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 ---*_______________
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Vascular Disorders of the KidneyRenal Vein Thrombosis/Occlusion
• Treatment/Collaborative Care– Diagnosis- renal venography– Management
• Thrombolytic drugs• Anticoagulant therapy• Surgical thrombectomy• Cortiocosteroids
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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)
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Acute Kidney Injury
Etiology of AKI:– Pre-renal– Intra-renal– Post renal
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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
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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
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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
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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
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Renal ischemia
Nephrotoxic agents
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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
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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
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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)
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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
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Diagnostic Tests:Acute Kidney Injury
– Serum Electrolytes
2. Serum K+
Normal= 3.5-5.0 meq/dL
• Almost always increased in kidney failure• Why?
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Diagnostic Tests:Acute Kidney Injury
– Serum Electrolytes
3. Serum Calcium
Normal= 8.6-10.2mg/dL
Almost always decreased
Why?
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Diagnostic Tests:Acute Kidney Injury
– Serum Electrolytes
4. Serum Phosphorus
Normal= 2.4 - 4.4mg/dL
Almost always increased Why?
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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 & ____________
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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
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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
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Acute Kidney Injury: Oliguric Phase
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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
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Acute Kidney Injury: Oliguric Phase
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Acute Kidney Injury: Oliguric Phase
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Treatment
If fluid challenge fails, fluid intake is usually limited and client is placed on fluid restrictionRestriction is limited to 600ml (includes insensible loss) + UO over the past 24 hours
Physician will specify in the orders how much
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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?
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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
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Acute Kidney InjuryManagement/Interventions
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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
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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
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Acute Kidney Injury Management/Interventions
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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)
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Acute Kidney InjuryManagement/Interventions
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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
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Acute Kidney Injury Management/Interventions
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9- Assess for anemia
Administer Epogen/Procrit as orderedPRBCs as ordered what do you have to watch for?
10- Diet (nutritional considerations)
Fluid restriction as ordered
Low K+ diet, Low Na diet
Low protein diet why?
11- Emergency Dialysis indicated when
K+ > 6.0 with s/s, Fluid V overload, uremia
Metabolic acidosis <15 HCO3
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Acute Kidney Injury Management/Interventions
• 11a Emergency Dialysis– Intermittent hemodialysis (HD)
• Used when rapid changes are required– Continuous Renal Replacement Therapy (CRRT)
• Much slower blood flow rates than HD• CVVHD
– Continuous venovenous hemodialysis» Solute loss via convection/diffusion
• CVVH– Continuous venovenous hemofiltration
» Solute loss via convection (more like mammalian filtration)» Replacement fluid via hemodilution
• Both use double lumen catheter
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CVVH/CVVHD
• When is it indicated?– acute kidney injury– pt usually has low blood pressure or other
contraindications to hemodialysis • Not a treatment for acute hypokalemia
– slow continuous process– sessions usually last between 12 to 24hrs– usually performed daily in the ICU