Nursing Care of Individual With Genitourinary Disorders

• 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

• __________________

http://www.ccmtutorials.com/renal/pathphys/index.htm

• __________________

• __________________

• Functions of the Kidneys (cont)

• Regulates acid-base balance

• HCO3 and H+

• Hormonal (endocrine) functions:

• Renin Release


• Erythropoietin Release

• If a patient has chronic kidney disease or chronic renal failure, what condition will occur and WHY???


• 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.

http://www.youtube.com/watch?v=glu0dzK4dbU

• 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


• 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


• 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


• 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


• 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


• 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



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

______________________



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??? __________________



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??? __________________


• 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


• 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


• 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


• 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 Potassium Levels



• 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

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Nursing Care of Individual With Genitourinary Disorders