2. Nursing Care of Individuals with Genitourinary Disorders: Renal Trauma Renal Vascular Problems Acute Kidney Injury 8/19/20151

3. The Kidney Primary function ◦ Regulate volume and composition of ECF (extracellular fluid) ◦ Excrete waste products Other functions ◦ Regulate acid-base balance ◦ Control BP ◦ Produce Erthyropoietin ◦ Activate Vitamin D 8/19/20152

4. Kidney- macrostructure kidney anatomy 8/19/20153

5. Kidney- microstructure nephron 8/19/20154

6. The Nephron Why is it called the functional unit of the kidney? 8/19/20155

7. Glomerular Filtration Rate Glomerular filtration rate Used 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 8/19/20156

8. Glomerular Filtration Rate For 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 8/19/20157

9. GFR GFR too high ◦ increased urine output ◦ threat of dehydration and electrolyte depletion GFR too low ◦ insufficient excretion of wastes GFR of 60 or higher is in the normal range GFR below 60 may mean kidney disease GFR of 15 or lower may mean kidney failure 8/19/20158

10. The Kidney Primary function ◦ Regulate volume and composition of ECF (extracellular fluid) ◦ Excrete waste products Other functions ◦ Regulate acid-base balance ◦ Control BP ◦ Produce Erthyropoietin ◦ Activate Vitamin D 8/19/20159

11. Functions of the Kidneys Regulates acid-base balance ◦ HCO3 and H+ Controls Blood Pressure: ◦ Renin Release 8/19/201510

12. RAAS Kidney senses low perfusion Renin 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 retained 8/19/201511

13. 8/19/201512

14. Functions of the Kidneys Erythropoietin Release ◦ If a patient has chronic kidney disease or chronic renal failure, what condition will occur and why? 8/19/201513

15. 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 8/19/201514

16. 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? 8/19/201515

17. 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? 8/19/201516

18. Review- Functions of the Kidney Regulate ◦ Volume & composition of extracellular fluid ◦ F&E balance Acid/Base balance Blood pressure regulation Erythropoetin release Vitamin D activation 8/19/201517

19. 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 8/19/201518

20. Acute Kidney Injury Pre-renal Hypovolemia dehydration, shock, burns Decreased cardiac output CHF, MI, arrhythmias Decreased vascular resistance septic shock Renal vascular obstruction renal artery stenosis, thrombus Causes related to decreased blood flow to the kidneys 8/19/201519

21. Acute Kidney Injury Intra-renal Conditions causing direct damage to renal tissue causing damage to nephrons Result from ischemia Nephrotoxins Hemoglobin released from hemolysis of red blood cells Myoglobin released from necrotic muscle cells 8/19/201520

22. Acute Kidney Injury Intra-renal Primary 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 8/19/201521

23. 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 8/19/201522 Renal ischemia Nephrotoxic agents

24. Acute Kidney Injury Intra-renal Acute Tubular Necrosis (ATN) Nephrotoxic drugs/chemicals (ATN) ◦ Aminoglycosides* ◦ Radiographic contrast agents ◦ Arsenic, lead, carbon tetrachloride 8/19/201523

25. Acute Kidney Injury Intra-renal Hemolytic blood transfusion (ATN) Trauma ◦ crushing injuries which release myoglobin ◦ damaged muscle tissue and blocks tubules (rhabdomyolysis)(ATN) What is Rhabdomyolysis? 8/19/201524

26. Compare & Contrast HealthyATN 8/19/201525

27. Lupus Nephritis ‘Flea bite’ look 8/19/201526

28. Acute Kidney Injury Post-renal Mechanical obstruction of urinary outflow urine backs up into renal pelvis BPH Calculi Trauma Prostate cancer 8/19/201527

29. 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 8/19/201528

30. Urine output in AKI varies widely & does NOT provide clinical correlation to the degree of injury!!!!! Must look at GRF 8/19/201529

31. 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 & 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 8/19/201530

32. Oliguric Phase Metabolic 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 excess decreased GI absorption of Ca (Vit D) increase in Calcium secretion Nitrogenous product accumulation ◦ unable to eliminate urea and creatinine > elevated BUN, serum creatinine 8/19/201531

33. Treatment – Oliguric phase Fluid 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? 8/19/201532

34. Treatment – Oliguric phase If fluid challenge fails- intake limited Fluid restriction ◦ 600ml + u.o. past 24 hours Patient’s u.o. yesterday was 300ml. What will be the allowed fluid intake today? 8/19/201533

35. Diuretic Phase Onset- days to weeks Duration- 1-3 weeks Urine Output- 1-3 liters/day Signs & Symptoms to anticipate Elevated BUN and Serum Creatinine What happens to intravascular volume? What happens to BP? Urine Na? K+ elevated or decreased? 8/19/201534

36. Recovery Phase Onset- When BUN and Creatinine stabilized Duration- 4-12 months Urine 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? 8/19/201535

37. Diagnostic tests in AKI BUN (blood urea nitrogen) Measurement of amount of urea in blood Normal -6-20 mg/dl What is urea? BUN fluctuates BUN elevated when? BUN decreased when? 8/19/201536

38. Diagnostic tests in AKI Serum 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 20:1 8/19/201537

39. Diagnostic tests in AKI Creatinine 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 8/19/201538

40. 24 hour urine What is the nurses role in the collection of a 24 hour urine? What if they have a foley cath? 8/19/201539

41. Diagnostic tests in AKI Urine Specific Gravity Normal= 1.003-1.030 Will be fixed a 1.010 usually in AKI due to kidneys losing ability to concentrate urine Serum Electrolytes Sodium Potassium Calcium Phosphorus 8/19/201540

42. Diagnostic tests in AKI Serum Electrolytes Serum Sodium Normal= 135-145 May be high, low, or normal When would it be high/low? 8/19/201541

43. Diagnostic tests in AKI Serum Electrolytes Serum Potassium Normal= 3.5-5 meq/L Almost always increased in renal failure Why? Two major reasons If > 6.0 treatment to prevent…. 8/19/201542

44. Diagnostic tests in AKI Serum Electrolytes Serum Phosphorus Normal=2.8-4.5mg/dl Almost always increased. Why? What other process is occurring to increase serum phosphorus? 8/19/201543

45. Diagnostic tests in AKI Serum Electrolytes Serum Calcium Normal=9.0-11.0 mg/dl Almost always decreased, why? What other process is occurring to decrease serum calcium? 8/19/201544

46. Diagnostic tests in AKI ABGs Metabolic 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 8/19/201545

47. Management of AKI Treat the primary disease/condition Prevention ◦ Frequent monitoring for early signs of AKI in at risk patients ◦ What are these signs? 8/19/201546

48. Management of AKI Assess for FVD vs FVE ◦ VS ◦ Strict I&O ◦ Daily weights ◦ Monitor labs- which ones? Metabolic acidosis ◦ Administer NaHCO3 IV as ordered 8/19/201547

49. Management of AKI Hyperkalemia ◦ 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 8/19/201548

50. Management of AKI Calcium imbalance ◦ Calcium Gluconate Phosphorus imbalance ◦ Calcium supplements, Phosphate binders Hypertension ◦ Lasix, Amlodipine, Metoprolol 8/19/201549

51. Management of AKI Anemia ◦ 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 8/19/201550

52. Renal Trauma Etiology: Men under age 30 Blunt force from falls MVA Sports injuries Knife/gunshot wounds Impalement injury, rib fractures 8/19/201551

53. Renal Trauma Common Manifestations: ◦ Hematuria-microscopic to gross ◦ Pain- Flank or abdominal ◦ Decreased Urine Output- oliguria or anuria ◦ Localized swelling, tenderness ◦ Turner’s sign 8/19/201552

54. renal trauma renal trauma 8/19/201553 http://www.google.com/imgres?hl=en&biw=1170&bih=772&tbm =isch&tbnid=RToE1hCkGbRJ_M:&imgrefurl=http://www.radiolog yassistant.nl/en/466181ff61073&docid=cXNEYO0bGQ3ABM&im gurl=http://www.radiologyassistant.nl/images/4ae4ca443ec2dT EK-renal- trauma.jpg&w=800&h=976&ei=bCYpUOzUFeSc2QWZwID4Bg&z oom=1&iact=hc&vpx=114&vpy=96&dur=2596&hovh=248&hovw =203&tx=100&ty=154&sig=113972578980002860388&page=1& tbnh=141&tbnw=116&start=0&ndsp=26&ved=1t:429,r:0,s:0,i:73

55. 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) 8/19/201554

56. 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 8/19/201555

57. Renal Trauma-Interventions Nursing Management Bedrest Prevent complications Close Observation for s/sx shock ◦ H&H ◦ I&O ◦ Daily weights ◦ VS 8/19/201556

58. Renal Surgery-Nephrectomy Indications for Nephrectomy: ◦ Renal tumor ◦ Massive Trauma ◦ Polycystic Kidney Disease ◦ Donating a Healthy kidney 8/19/201557

59. 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, 12 th rib removed ◦ Medicate for pain as ordered 8/19/201558

60. Renal Vascular Problems Nephrosclerosis 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? 8/19/201559

61. 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 8/19/201560

62. 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? 8/19/201561

63. Treatment/Collaborative Care Anti-hypertensive Medications Dilation of renal artery by Percutaneous Transluminal Angioplasy Bypass Graft of Renal Artery Nephrectomy Renal Artery Stenosis 8/19/201562

64. 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 8/19/201563

65. Renal Vein Thrombosis/Occlusion Pathophysiology/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 8/19/201564

66. Renal Vein Thrombosis/Occlusion Treatment/Collaborative Care Diagnosis ◦ Renal venography Management ◦ Thrombolytic drugs ◦ Anticoagulant therapy ◦ Surgical thrombectomy ◦ Corticosteroids 8/19/201565

67. 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 8/19/201566

68. 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 8/19/201567

69. 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? 8/19/201568

70. 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 8/19/201569

71. Activity The 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? 8/19/201570

72. ? 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 8/19/201571

73. Which urinary symptom is the most common initial manifestation of AKI? a-dysuria b-anuria c-hematuria d-oliguria 8/19/201572