Transcript Document 7120844
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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
a. Fibrous capsule b. Renal cortex c. Renal medulla d. Pyramids e. Papillae f. Minor calyx g. Major calyx h. Renal pelvis i. 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 _____________.
Name a few of these F&Es regulated by kidneys __________________
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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)
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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
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a. Glomerulus b. Bowman ’ s capsule c. Proximal tubule d. Loop of Henle e. Distal tubule f. Collecting duct
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HOW THE KIDNEY WORKS
http://www.youtube.com/watch?v=glu0dzK4db U
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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 in flank area, 12 th rib removed Medicate 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
the
arterioles and glomerular capillaries
in ↓
Decreased blood flow which leads to ischemia and patchy necrosis ↓ Destruction of glomeruli ↓ Decrease in GFR 21
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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…
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How could a renal artery stenosis result in HTN?
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RENAL ARTERY STENOSIS
Treatment/Collaborative Care
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Anti-hypertensive Medications Dilation of renal artery by Percutaneous Transluminal Angioplasy Bypass Graft of Renal Artery
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RENAL ARTERY STENOSIS
Treatment/Collaborative Care
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RENAL VASCULAR PROBLEMS: III. RENAL VEIN THROMBOSIS
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Renal Vein Occlusion Definition: Blockage or obstruction of Renal Vein by a thrombus.
Risk Factors: Nephrotic syndrome Use of Birth control pills Certain Malignancies
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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
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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
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
Nephrotoxic agents 35
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ETIOLOGY OF ACUTE RENAL FAILURE POST-RENAL Identify three causes of pelvis) “ post-renal failure ” (mechanical obstruction of urinary outflow; urine backs up into renal 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 12 1.6
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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INITIATING PHASE OF ARF: What Signs and Symptoms to Anticipate?
What stage?
Initiating Phase Onset: begins at time of insult Urine less that 400 ml in 24 hours Urine possibly with RBC ’ s; WBC ’ s depending on the causative agent Duration: hours to days Urine output: <20ml/h or 100-400 ml/24 hours or CAN HAVE NORMAL URINE OUTPUT !
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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
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DIURETIC PHASE OF ARF: What Signs and Symptoms to Anticipate?
What stage?
Diuretic Phase Onset: days to weeks Duration: 10 days (1-3 weeks) Fluid Volume Overload or Fluid Volume Deficit???
Elevated BUN and serum creatinine K likely to be elevated or decreased??? Urine output:1-3 liters/day Hyponatremia and hypotension
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RECOVERY PHASE OF ARF: What Signs and Symptoms to Anticipate?
What stage?
Recovery Phase Onset: When BUN and Creatinine are stablized Continue to monitor for signs and symptoms of F & E imbalances Duration: 4-12 months All body systems for effects of fluid volume changes Urine output: Normal
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TREATMENT DURING: OLIGURIC/NON 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????
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TREATMENT DURING: OLIGURIC/NON OLIGURIC 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? ________ 56
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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? _______ 57
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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 58
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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: ________________ 59
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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 60
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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 61
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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. 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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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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