Nursing Care of Individualswith Genitourinary Disorders:

Renal TraumaRenal Vascular ProblemsAcute Kidney Injury

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The KidneyPrimary function

◦Regulate volume and composition of ECF (extracellular fluid)

◦Excrete waste productsOther functions

◦Regulate acid-base balance◦Control BP◦Produce Erthyropoietin◦Activate Vitamin D

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Kidney- macrostructure

kidney anatomy

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Kidney- microstructurenephron

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The NephronWhy is it called the functional unit of

the kidney?

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Glomerular Filtration RateGlomerular filtration rateUsed 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

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Glomerular Filtration RateFor 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

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GFRGFR too high

◦ increased urine output ◦threat of dehydration and electrolyte

depletionGFR too low

◦ insufficient excretion of wastes

GFR of 60 or higher is in the normal rangeGFR below 60 may mean kidney disease

GFR of 15 or lower may mean kidney failure

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The KidneyPrimary function

◦Regulate volume and composition of ECF (extracellular fluid)

◦Excrete waste productsOther functions

◦Regulate acid-base balance◦Control BP◦Produce Erthyropoietin◦Activate Vitamin D

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Functions of the KidneysRegulates acid-base balance

◦HCO3 and H+Controls Blood Pressure:

◦Renin Release

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RAASKidney senses low perfusionRenin 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 retained04/19/23 11

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Functions of the Kidneys 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

Erythropoietin promotes the formation of RBC’s in response to decreased O2 carrying capacity

Anemia from impaired erythropoietin

production and platelet abnormalities >

bleeding risk

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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?

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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?

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Review- Functions of the KidneyRegulate

◦Volume & composition of extracellular fluid

◦F&E balance

Acid/Base balanceBlood pressure regulationErythropoetin releaseVitamin D activation

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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

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Acute Kidney InjuryPre-renalHypovolemia

dehydration, shock, burnsDecreased cardiac output

CHF, MI, arrhythmiasDecreased vascular resistance

septic shockRenal vascular obstruction

renal artery stenosis, thrombusCauses related to decreased blood flow to the kidneys

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Acute Kidney InjuryIntra-renalConditions causing direct damage to renal tissue causing damage to nephrons

Result from ischemiaNephrotoxinsHemoglobin released from hemolysis

of red blood cellsMyoglobin released from necrotic

muscle cells

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Acute Kidney InjuryIntra-renalPrimary 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

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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

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Renal ischemia

Nephrotoxic agents

Acute Kidney InjuryIntra-renal

Acute Tubular Necrosis (ATN)

Nephrotoxic drugs/chemicals (ATN)◦Aminoglycosides*◦Radiographic contrast agents◦Arsenic, lead, carbon tetrachloride

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Acute Kidney InjuryIntra-renalHemolytic blood transfusion (ATN)

Trauma ◦crushing injuries which release

myoglobin◦damaged muscle tissue and blocks

tubules (rhabdomyolysis)(ATN)

What is Rhabdomyolysis?

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Compare & ContrastCompare & Contrast

Healthy ATN

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Lupus Nephritis‘Flea bite’ look

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Acute Kidney InjuryPost-renalMechanical

obstruction of urinary outflow

urine backs up into renal pelvis

BPH CalculiTraumaProstate cancer

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Stages of Acute Kidney InjuryInitiating 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

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Urine output in AKI varies widely & does NOT provide clinical correlation to the degree of injury!!!!!

Must look at GRF

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Oliguric PhaseOnset- 1-7 daysDuration- 10-14 daysUrine 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 & postFluid overloadUrine with RBCs, casts, WBCs, protein (if

glomerulus damaged)K+ likely elevated

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Oliguric PhaseMetabolic 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 excessdecreased GI absorption of Ca (Vit D) increase in Calcium secretion

Nitrogenous product accumulation◦ unable to eliminate urea and creatinine >

elevated BUN, serum creatinine

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Treatment – Oliguric phaseFluid 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?04/19/23 32

Treatment – Oliguric phaseIf fluid challenge fails- intake limitedFluid restriction

◦600ml + u.o. past 24 hours

Patient’s u.o. yesterday was 300ml. What will be the allowed fluid intake today?

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Diuretic PhaseOnset- days to weeksDuration- 1-3 weeksUrine Output- 1-3 liters/day

Signs & Symptoms to anticipateElevated BUN and Serum CreatinineWhat happens to intravascular volume?What happens to BP?Urine Na?K+ elevated or decreased?

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Recovery PhaseOnset- When BUN and Creatinine stabilizedDuration- 4-12 monthsUrine 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?

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Diagnostic tests in AKIBUN (blood urea nitrogen) Measurement of amount of urea in

bloodNormal -6-20 mg/dl

What is urea?BUN fluctuates

BUN elevated when?BUN decreased when?

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Diagnostic tests in AKISerum 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 20:104/19/23 37

Diagnostic tests in AKICreatinine 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

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24 hour urineWhat is the nurses role in the

collection of a 24 hour urine?What if they have a foley cath?

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Diagnostic tests in AKIUrine Specific GravityNormal= 1.003-1.030Will be fixed a 1.010 usually in AKI due to

kidneys losing ability to concentrate urine

Serum ElectrolytesSodiumPotassiumCalciumPhosphorus

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Diagnostic tests in AKISerum ElectrolytesSerum Sodium Normal= 135-145

May be high, low, or normalWhen would it be high/low?

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Diagnostic tests in AKISerum ElectrolytesSerum Potassium Normal= 3.5-5 meq/L

Almost always increased in renal failure

Why? Two major reasons

If > 6.0 treatment to prevent….04/19/23 42

Diagnostic tests in AKISerum ElectrolytesSerum Phosphorus Normal=2.8-4.5mg/dl

Almost always increased. Why?

What other process is occurring to increase serum phosphorus?

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Diagnostic tests in AKISerum ElectrolytesSerum Calcium Normal=9.0-11.0 mg/dl

Almost always decreased, why?

What other process is occurring to decrease serum calcium?

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Diagnostic tests in AKIABGsMetabolic 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

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Management of AKITreat the primary disease/condition

Prevention ◦Frequent monitoring for early signs

of AKI in at risk patients

◦What are these signs?

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Management of AKIAssess for FVD vs FVE

◦VS◦Strict I&O◦Daily weights◦Monitor labs- which ones?

Metabolic acidosis◦Administer NaHCO3 IV as ordered

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Management of AKIHyperkalemia

◦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

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Management of AKICalcium imbalance

◦Calcium Gluconate

Phosphorus imbalance◦Calcium supplements, Phosphate

binders

Hypertension◦Lasix, Amlodipine, Metoprolol

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Management of AKIAnemia

◦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

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Renal Trauma

Etiology:Men under age 30

Blunt force from fallsMVA Sports injuries Knife/gunshot woundsImpalement injury, rib fractures

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Renal TraumaCommon Manifestations:

◦Hematuria-microscopic to gross ◦Pain- Flank or abdominal ◦Decreased Urine Output- oliguria or

anuria◦Localized swelling, tenderness◦Turner’s sign

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renal trauma

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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)

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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

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Renal Trauma-InterventionsNursing ManagementBedrestPrevent complicationsClose Observation for s/sx shock

◦H&H◦I&O◦Daily weights◦VS

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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 output be if patient had

bilateral nephrectomy? ______.◦Observe ACC of urine◦TCDB & incentive spirometery Incision in flank area, 12th rib

removed◦Medicate for pain as ordered

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Renal Vascular ProblemsNephrosclerosis

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?

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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

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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? 04/19/23 61

Treatment/Collaborative CareAnti-hypertensive MedicationsDilation of renal artery by Percutaneous

Transluminal AngioplasyBypass Graft of Renal ArteryNephrectomy

Renal Artery Stenosis

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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

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Renal Vein Thrombosis/OcclusionPathophysiology/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

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Renal Vein Thrombosis/OcclusionTreatment/Collaborative CareDiagnosis

◦Renal venography

Management◦Thrombolytic drugs◦Anticoagulant therapy◦Surgical thrombectomy◦Corticosteroids

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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

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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 ionsC. increases calcium absorption in the

colonD. exchanges sodium for potassium in

the colon

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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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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

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ActivityThe 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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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

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Which urinary symptom is the most common initial manifestation of AKI?

a-dysuriab-anuriac-hematuriad-oliguria

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