nursing care of individual with genitourinary disorders
TRANSCRIPT
• Nursing Care of Individual with Genitourinary Disorders:
Renal TraumaRenal Vascular ProblemsAcute Renal Failure
• 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
• Review:
• Renal A & P
• 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 __________________
• Functions of the Kidneys (continued)
• Name a few of these Fluid and Electrolyes regulated by kidneys
• __________________
• __________________
• __________________
• Functions of the Kidneys (cont)
• Regulates acid-base balance
• HCO3 and H+
• Hormonal (endocrine) functions:
• Renin Release
• Functions of the Kidneys (cont)
• Erythropoietin Release
• If a patient has chronic kidney disease or chronic renal failure, what condition will occur and WHY???
• 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? __________________
• III. The Nephron
• Why is it called the functional unit of the Kidney???
• Label the Nephron’s Parts
• a. Glomerulus
• b. Bowman’s
capsule
• c. Proximal tubule
• d. Loop of Henle
• e. Distal tubule
• f. Collecting duct
• How the Kidney Works
• http://www.youtube.com/watch?v=glu0dzK4dbU
• Renal Trauma
• Renal Trauma
• Etiology:
• Blunt force from falls, MVA, sports injuries, knife/gunshot wounds, impalement injury, rib fractures
• 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
• Renal Trauma
• What are some diagnostic tests used in renal trauma?
• IVP, renal ultrasound, CT scan, renal arteriogram
• What serum levels can be useful?
• _________________________
• 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
• Renal Surgery-Nephrectomy
• Indications for Nephrectomy:
• Renal tumor
• Massive Trauma
• Polycystic Kidney Disease
• Donating a Healthy kidney
• 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
• Renal Vascular Problems
• I. Hypertension & Nephrosclerosis
• Sustained elevation of the systemic blood pressure can result from or cause kidney disease---How?
• 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 GFR
• Renal Vascular Problems II. Renal Artery Stenosis
• Definition: Narrowing of one or both renal arteries due to atherosclerosis or structural abnormalities.
• Common Manifestations:
• Uncontrollable HTN
• Critical thinking question…
• How could a renal artery stenosis result in HTN?
• Renal Artery Stenosis
• Treatment/Collaborative Care
• Anti-hypertensive Medications
• Dilation of renal artery by Percutaneous Transluminal Angioplasy
• Bypass Graft of Renal Artery
• Renal Artery Stenosis
• Treatment/Collaborative Care
• Renal Vascular Problems:III. Renal Vein Thrombosis
• Renal Vein Occlusion
• Definition: Blockage or obstruction of Renal Vein by a thrombus.
• Risk Factors:
• Nephrotic syndrome
• Use of Birth control pills
• Certain Malignancies
• Vascular Disorders of the KidneyRenal Vein Occlusion
• Treatment/Collaborative Care
• Thrombolytic drugs such as streptokinase or tPA
• Anticoagulant therapy to prevent
further clot formation
• 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
• Compare & Contrast…
• What is missing from the ARF definition?
• What is the difference between uremia and azotemia???
• ____________________________
• Etiology of Acute Renal FailurePre-renal
• 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, or renal artery blockage.
• Etiology of Acute Renal FailureIntra-renal
• Direct injury to the kidneys
• Conditions causing direct insult to renal tissue causing damage to nephrons
• List causes of “intra renal” ARF failure:
• Causes of Intrarenal Failure
• 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
• 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
• Causes of Acute Renal Failure (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
• 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
• Diagnostic Tests in Acute Renal Failure:
• BUN (blood urea nitrogen)
• Normal = 10-30 mg/dl; measurement of amount of urea in blood
• What is urea?_____
• BUN fluctuates
• BUN elevated in______; decreased in_________.
• Question…
• Which of the following urinary symptoms is the most common initial manifestations of ARF?
a-dysuria
b-anuria
c-hematuria
d-oliguria
• 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
• Diagnostic Tests in Acute Renal Failure:
• Serum Creatinine: end product of muscle and protein metabolism; excreted by the kidneys at a constant rate
• Normal = 0.5-1.5 mg/dl
• Directly related to GFR
• 2 X normal (3.0) = 50% nephron fx loss
• 10 X normal (15) = 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
• Diagnostic Tests in Acute Renal Failure:
• 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:
• 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:
• Serum Electrolytes
2- ↑ Serum K+ Normal= 3.5-5.0 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:
• Serum Electrolytes
3- ↑ Serum Phosphorus
Normal= 2.8-4.5mg/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:
• Serum Electrolytes
4 - ↓ Serum Calcium
Normal= 9.0-11.0 mg/dl
due to ↓ production of activated Vitamin D;
Vitamin D needed to absorb calcium from GI
tract
What other process is occurring to decrease
serum calcium??? __________________
• Diagnostic Tests in Acute Renal Failure:
• 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.
• Initiating Phase of ARF:
• What stage?
• Initiating Phase
• Onset: begins at time of insult
• Duration: hours to days
• Urine output: <20ml/h or 100-400 ml/24 hours or
• CAN HAVE NORMAL URINE OUTPUT!
• What Signs and Symptoms to Anticipate?
• Urine less that 400 ml in 24 hours
• Urine possibly with RBC’s; WBC’s depending on the causative agent
• Oliguric Phase of ARF:
• What stage?
• Oliguric Phase
• Onset: 1-7 days
• Duration: 10-14 days
• Urine output: Less than 400 ml/24 hours in 50% of patients
• What Signs and Symptoms to Anticipate?
• Urine less that 400 ml in 24 hours
• Specific gravity fixed at 1.010 in oliguria in intra renal failure
• Fluid overload
• Urine with RBCs, casts, WBCs
• Elevated BUN and serum creatinine
• K likely to be elevated
• Ca deficit, PO4 excess
• Diuretic Phase of ARF:
• What stage?
• Diuretic Phase
• Onset: days to weeks
• Duration: 10 days (1-3 weeks)
• Urine output:1-3 liters/day
• What Signs and Symptoms to Anticipate?
• Fluid Volume Overload or Fluid Volume Deficit???
• Elevated BUN and serum creatinine
• K likely to be elevated or decreased???
• Hyponatremia and hypotension
• Recovery Phase of ARF:
• What stage?
• Recovery Phase
• Onset: When BUN and Creatinine are stablized
• Duration: 4-12 months
• Urine output: Normal
• What 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
• Treatment During: Oliguric/Non-Oliguric Phase
• Treatment During: Oliguric/Non-Oliguric Phase
• Acute Renal Failure: Management of….
• Acute Renal Failure: Management of….
• Acute Renal Failure: Management of Potassium Levels
• Acute Renal Failure: Management of….
• Acute Renal Failure: Management of….
• Your patient develops acute renal failure after being on Amphotericin for 1 week:
• The patient’s ARF 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
• 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 ions
• C. increases calcium absorption in the colon
• D. exchanges sodium for potassium in the colon