Nursing Care of Individual with Genitourinary Disorders:

Renal Trauma Renal Vascular Problems Acute 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 patients serum calcium level? __________________ III. The Nephron Why is it called the functional unit of the Kidney??? Label the Nephrons Parts a. Glomerulus b. Bowmans 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 Turners 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 Kidney Renal 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 Failure Pre-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 Failure Intra-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 clients 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 Creatinine 1.6 1.2

BUN 16 12

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 Normal= 135-145

1- Serum Sodium sodium 2

May be high, low, or normal High in Volume deficit (dehydration) Low due to damaged tubules not conserving

Diagnostic Tests in Acute Renal Failure:

Serum Electrolytes 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: 3 Serum Electrolytes 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 phosphorus??? __________________ Diagnostic Tests in Acute Renal Failure: Serum Electrolytes increase serum

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 excrete acid metabolites ability of kidneys to

(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 RBCs; WBCs 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 patients 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 patients 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