12/5/20151 nursing care of individual experiencing a renal disorder: vascular disorders renal trauma...

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Nursing Care of Individual Experiencing a Renal Disorder:

Vascular DisordersRenal Trauma

Acute Renal Failuremodified by Kelle Howard RN, MSN

Renal A & P -excellent site for renal pathophysiology

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I. A&P of the Kidney- (locate structures)

Fibrous capsuleRenal cortexRenal medullaPyramidsPapillaeMinor calyxMajor calyx Renal pelvisUreter

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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

RAAS=

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How the RAAS Pathway Works

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 ReleaseIf a patient has chronic renal failure, what

condition will occurWHY???

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Functions of the Kidneys (cont)

Activated Vitamin DNecessary to absorb Calcium in the GI

tract.

If a patient has renal failure, what will happen to the patient’s serum calcium level? __________________

Review: Functions of the Kidneys

Regulate1.___________2.___________3.___________4.___________

Release of ________________Activation of _______________

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III. 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

Click here for Nephron A&P & Games too!

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Renal 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 flank area - Turner’s SignSigns/Symptoms depend upon severity injury*Severe blood loss/signs shock

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Renal Trauma

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Renal Trauma

What are common diagnostic tests used in renal trauma?

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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Renal Trauma-Interventions

Minor TraumaConservative Bedrest and close observationMonitor for S & S of what?

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Renal 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 shock Fluid mgt Prevent complications/monitor I & O Manage drainage tubes Daily weights****

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Renal Surgery-Nephrectomy

Indications for Nephrectomy:

Renal tumorMassive TraumaPolycystic Kidney DiseaseDonating a healthy kidney

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Renal Surgery-Nephrectomy

Post Op Nursing ManagementStrict I & O

Urine output should be at least _____.What should the UO be if patient had bilateral

nephrectomy? ______.

Observe urineDaily weightsTCDB & IS

Incision in flank area, 12th rib removed

Medicate for pain as ordered

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Renal Vascular ProblemsPatho 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 KidneyRenal Artery Stenosis

Definition: Narrowing of one or both renal arteries due to atherosclerosis or structural abnormalities.

Common Manifestation!uncontrollable HTN-

medications do not work Why?

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Treatment/Collaborative CareDiagnostic Tests

Renal arteriogram-most definitive

ManagementConservative-antihypertensive medsPercutaneous Transluminal AngioplasySurgical re-vacularization (Graft)?Nephrectomy

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Treatment/Collaborative Care

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 ThrombosisDefinition: Partial occlusion in one or both renal

veins due to atherosclerosis or structural abnormalities in vein by a thrombus.

Risk Factors:Nephrotic syndromeUse of birth control pillsCertain malignancies

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Vascular Disorders of the KidneyRenal Vein Thrombosis/Occlusion

Pathophysiology/etiologyCause unclear-thrombus forms in renal veinAssociated with trauma, nephrotic syndrome gradual

deterioration of renal function

Common Manifestations/ComplicationsDecreased GFRSigns of Renal Failure**Complication ---*Pulmonary Embolus

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Vascular Disorders of the KidneyRenal Vein Thrombus/Occlusion

Treatment/Collaborative CareDiagnosis- renal venography

Management

Thrombolytic drugs

streptokinase or tPA

Anticoagulant therapy to prevent

further clot formation

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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 Renal Failure

Etiology of ARF:Pre-renal Intra-renalPost renal

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Etiology of Acute Renal FailurePre-renal (most common cause ARF!)

Causes of “pre-renal” ARF -What do all of these causes have in common?

Hypovolemia: dehydration, shock, burns

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 Renal FailureIntra-renal

Direct injury to the kidneys/nephronscausing 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

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Causes of Intrarenal FailureHemolytic blood transfusion (ATN)Trauma (crush injuries > release myoglobin; damage muscle tissue > blocks tubules (rhabdomylosis) (ATN)Nephrotoxic drugs/chemicals (ATN)

Aminoglycosides*Radiographic contrast agentsArsenic, lead, carbonsDrug overdose

Acute glomerulonephritis/pyelonephritisSystemic Lupus

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Causes of Acute Tubular Necrosis (ATN)

Renal ischemia Destruction tubular

epithelium

Nephrotoxic agentsNecrosis tubular

epithelium… plug tubules.

Potentially reversible IFBasement not destroyed

and tubular epithelium regenerates

Renal ischemia

Nephrotoxic agents

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Etiology of Acute Renal Failure Post-renal

Causes of “post-renal failure” mechanical obstruction of urinary outflow urine backs up into renal pelvis

BPH (Benign Prostatic Hypertrophy)CalculiTraumaProstate cancer

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Diagnostic Tests in Acute Renal Failure:

BUN (blood urea nitrogen)Normal = 10-30 mg/dl; measurement of amt of urea in blood

Serum Creatinine: Normal = 0.5 – 1.5 mg/dlDirectly related to GFR

2 X normal (2.4) = 50% nephron fx loss10 X normal (12) = 90% nephron fx lossMORE ACCURATE INDICATOR of RENAL

FUNCTION THAN BUN

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BUN/Creatinine ratio Normal= 10:1

BUN Creatinine 16 1.6

12 1.2

8 0.8

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Creatinine clearanceMost accurate indicator of Renal FunctionReflects GFRInvolves a 24 hr urine/serum creatinineFormula:

urine creatinine X urine volume

serum creatinineNormal= +/- 120-125ml/minute

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Urine Specific GravityNormal= 1.003-1.030Fixed sp. Gravity- 1.010 usually in ARF

• kidneys lose ability to concentrate urine

Serum Electrolytes

1. Serum Sodium Normal= 135-145meq/LMay be high, low, or normal

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Serum Electrolytes

2. Serum K+

Normal= 3.5-5.0 meq/dL

Almost always increased in renal failureWhy?

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Serum Electrolytes

3. Serum Calcium

Normal= 9-11mg/dL

Almost always decreased

Why?

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Serum Electrolytes

4. Serum Phosphorus

Normal= 2.8 - 4.5mg/dL

Almost always increased

Why?

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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 Renal Failure

Initiating PhaseTime of insult until signs and symptoms become

apparent!

Oliguric PhaseUsually appears 1-7 days of initiating event

Diuretic PhaseStart varies, usually within10-12 days of onset oliguric

phase

RecoveryUsually within a month, recovery takes up to 12 months

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Acute Renal Failure: Oliguric Phase

Onset: 1-7 days

Duration: 10-14 days

Urine output: Less than 400 ml/24 hours in 50% of patients

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 Renal Failure: Oliguric Phase

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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Diuretic Phase of ARF:

Onset: days to weeks

Duration: about 10 days (1-3 weeks)

Urine output:1-3 liters/day


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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Recovery Phase of ARF:

Recovery Phase

Onset: When BUN and Creatinine are stabilized

Duration: 4-12 months

Urine output: Normal


Continue to monitor for signs and symptoms of

F & E imbalances

All body systems for effects of fluid volume changes, including daily weights

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Treatment During: Oliguric Phase

Fluid Challenge/Diuretics

Done to r/o dehydration as cause of ARF and “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: OliguricPhase

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.

Question:

Patient’s UO 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-post renal problem.

2- Prevention: Frequent monitoring for early signs of ARF in at risk patients

3- Assess for Fluid V deficit vs Fluid V overload

Strict I & O

Daily weights 500ml-=1 lb. (1kg = approx 1000ml fluid)

Monitor lab values…which ones?

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4- Metabolic Acidosis

Administer NaHCO3 I.V. as ordered

5- Hyperkalemia Give insulin & glucose I.V.

Sodium Bicarbonate I.V.

Kayexalate po or enema

Dietary Restrictions Potassium

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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

*Cautious use of aluminun-based phosphate binders

can cause encephalopathy

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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, Fluid V overload, uremia

Metabolic acidosis <15 HCO3

12/5/20151 nursing care of individual experiencing a renal disorder: vascular disorders renal trauma...

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