Download Powerpoint Notes-ARF

5/25/2017
NURSING CARE OF INDIVIDUAL WITH
GENITOURINARY DISORDERS:
RENAL TRAUMA
RENAL VASCULAR PROBLEMS
ACUTE RENAL FAILURE
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I. A&P OF THE KIDNEY
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a.
b.
c.
d.
e.
f.
g.
h.
i.
Fibrous capsule
Renal cortex
Renal medulla
Pyramids
Papillae
Minor calyx
Major calyx
Renal pelvis
Ureter
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REVIEW:

Renal A & P
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II. FUNCTIONS OF THE KIDNEYS

Elimination of _______ & _________


Can you name some of these substances?
__________________________
Regulates fluid & electrolyte balance thru
processes of: __________, _________,
and _____________.
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FUNCTIONS OF THE KIDNEYS (CONTINUED)
Name a few of these Fluid and Electrolyes
regulated by kidneys
 __________________
 __________________
 __________________

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FUNCTIONS OF THE KIDNEYS
(CONT)

Regulates acid-base balance
 HCO3

and H+
Hormonal (endocrine) functions:
 Renin
Release
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FUNCTIONS OF THE KIDNEYS
(CONT)

Erythropoietin Release
 If
a patient has chronic kidney disease or chronic
renal failure, what condition will occur and WHY???
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FUNCTIONS OF THE KIDNEYS
(CONT)

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?
__________________
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III. THE NEPHRON

Why is it called the functional unit of the
Kidney???
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LABEL THE NEPHRON’S PARTS
a. Glomerulus
 b. Bowman’s
capsule
 c. Proximal tubule
 d. Loop of Henle
 e. Distal tubule
 f. Collecting duct

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RENAL TRAUMA
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RENAL TRAUMA

Etiology:
 Blunt
force from falls, MVA, sports
injuries, knife/gunshot wounds,
impalement injury, rib fractures
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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

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RENAL TRAUMA

What are some diagnostic tests used in
renal trauma?
 IVP,
renal ultrasound, CT scan, renal
arteriogram
 What serum levels can be useful?
 _________________________
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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?

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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

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RENAL SURGERY-NEPHRECTOMY
 Indications
for Nephrectomy:
Renal tumor
Massive Trauma
Polycystic Kidney Disease
Donating a Healthy kidney
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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
 Medicate
in flank area, 12th rib removed
for pain as ordered
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RENAL VASCULAR PROBLEMS
 I.
Hypertension & Nephrosclerosis
Sustained
elevation of the systemic blood
pressure can result from or cause kidney
disease---How?
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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
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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
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CRITICAL THINKING QUESTION…

How could a renal artery stenosis result in
HTN?
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RENAL ARTERY STENOSIS
 Treatment/Collaborative
Care
Anti-hypertensive
Medications
Dilation of renal artery by Percutaneous
Transluminal Angioplasy
Bypass Graft of Renal Artery
Stent placement
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RENAL ARTERY STENOSIS
 Treatment/Collaborative
Care
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STENT PLACEMENT RENAL ARTERY
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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
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COMPARE & CONTRAST…

What is missing from the ARF definition?

What is the difference between uremia and
azotemia???

____________________________
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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.
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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:
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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
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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)

What is Rhabdomylosis?
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Nephrotoxic drugs/chemicals (ATN)
 Aminoglycosides*
 Radiographic contrast agents
 Arsenic, lead, carbon tetachloride
Acute glomerulonephritis/pyelonephritis
Systemic lupus
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CAUSES OF ACUTE RENAL FAILURE (ATN)

Renal ischemia


Nephrotoxic agents

Renal
ischemia

Disruption basement
membrane;destruction tubular
epithelium
Necrosis tubular epithelium… plug
tubules; basement membrane
intact.
Potentially reversible IF

Basement not destroyed and
tubular epithelium regenerates
Nephrotoxic
agents
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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
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DIAGNOSTIC TESTS IN ACUTE RENAL FAILURE:

BUN (blood urea nitrogen)
 Normal
= please change to 6-20 mg/dl;
measurement of amount of urea in
blood
 What is urea?_____
 BUN fluctuates
 BUN elevated in______; decreased
in_________.
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QUESTION…

Which of the following urinary symptoms is the
most common initial manifestations of ARF?
a-dysuria
b-anuria
c-hematuria
d-oliguria
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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
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CLINICAL SCENARIO
Another client is scheduled to get a CT with
contrast of their abdomen and is at risk for
ARF. The physician has prescribed
acetylcysteine (Mucomyst) 5% 20ml po prior to
CT scan.
 The nurse proceeds to look up the medication
and sees that the drug is a mucolytic. The
patient has no history of respiratory disease.
Why is this patient receiving this medication?

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CLINICAL SCENARIO
You are the Level 4 nursing student assigned to
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?

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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?

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DIAGNOSTIC TESTS IN ACUTE RENAL FAILURE:


Serum Creatinine: end product of muscle and protein metabolism;
excreted by the kidneys at a constant rate
 Normal = 0.6-1.3 mg/dl please change this value on your ppt
 Directly related to GFR
 2 X normal (2.6) = 50% nephron fx loss
 10 X normal (13) = 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
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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
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QUESTION…..
A 24 hours urine for creatinine clearance is
ordered for Ms. J. Which task is appropriate to
delegate to the the clinical assistant?
 a) instruct Ms. J 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 Ms. J’s urine for color, odor, sediment

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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

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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
______________________
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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???
__________________
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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??? __________________
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DIAGNOSTIC TESTS IN ACUTE RENAL FAILURE:
 ABGs

pH
 Metabolic
acidosis due to
ability of kidneys
to excrete acid metabolites
(uric acid) so the pH will be __________.
 Also, bicarb levels
due to bicarb being
used up to buffer excess H+ ions.
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TREATMENT DURING: OLIGURIC/NONOLIGURIC 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????
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TREATMENT DURING: OLIGURIC/NONOLIGURIC PHASE
If fluid challenge fails, fluid intake is usually
limited and client is placed on fluid restriction

Restriction is limited to 600ml + u.o. past 24
hours


Physician will specify in the orders how much.
Question:
Patient’s u.o. on Tuesday=300ml, what will be
his fluid intake allowed on Wednesday?
________
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ACUTE RENAL FAILURE: MANAGEMENT OF….

1- Treat primary disease/condition whether
it is pre-intra-or post renal problem.

2-Prevention:
Frequent monitoring for early signs of ARF in at risk
patients



What can the nurse assess for at this point?
3-Assess for Fluid V deficit vs Fluid V overload

Strict I & O

Daily weights 500ml-=1 lb.

Monitor lab values…which ones? _______
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ACUTE RENAL FAILURE: MANAGEMENT OF….

4- Metabolic Acidosis


Administer NaHCO3 I.V. as ordered
5-Hyperkalemia

What are the S & S of hyperkalemia?
___________________________________
Treatment for hyperkalemia:
Give insulin & glucose I.V. Why?
K+ moves out of serum back into cells with the
glucose in the presence of insulin
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ACUTE RENAL FAILURE: MANAGEMENT OF
POTASSIUM LEVELS

Sodium Bicarbonate I.V.


Correct acidosis; get potassium into cells
Kayexalate po or enema
Sodium exchanged for potassium in the GI tract;
produced osmotic diarrhea


Dietary Restrictions Potassium

Avoid foods high in K+;

Name some of those foods: ________________
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ACUTE RENAL FAILURE: MANAGEMENT OF….

6- Calcium Imbalance

Administer calcium supplements as ordered
(Phoslo or calcium acetate, Oscal or calcium carbonate)

7-Phosphorus Imbalance
Administer phosphate binders: Renagel or
sevelamer hydrochloride, Nephrox


8- Treat Hypertension (HTN)
Lasix, Norvasc (amilodipine), Lopressor
(metoprolol) as ordered

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ACUTE RENAL FAILURE: MANAGEMENT OF….



9- Assess for anemia

Administer Epogen/Procrit as ordered

PRBCs as ordered
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, Fluid V overload, uremia

Metabolic acidosis <15 HCO3
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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
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YOUR PATIENT’S K+ LEVEL IS ELEVATED.
THE PHYSICIAN ORDERS KAYEXALATE
BECAUSE IT:




A.
B.
C.
D.
increases sodium excretion from the colon
releases hydrogen ions for sodium ions
increases calcium absorption in the colon
exchanges sodium for potassium in the colon
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CASE STUDY: MS.J 63 YO ADMITTED WITH SOB
AND SWELLING IN ANKLES. HX OF DM, HTN,
CAD, R/O CHRONIC RENAL DISEASE:

What other information do we need?

What labs do we need?

What meds do we think she is taking currently?

What interventions would be included in her POC?
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QUESTION…
Ms. J’s POC includes nsg dx of Fluid volume
excess. Which interventions are appropriate?
 a) Daily weights
 b) Record intake and output
 c) Restrict sodium intake with meals
 d) Restrict fluid to 1500ml + urine output
 e) Assess for crackles and edema every shift

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