Nursing Care of

Individuals
with Genitourinary
Disorders:
10/15/16

The Kidney
Primary

function
Regulate volume and composition of
ECF (extracellular fluid)
Excrete waste products
Other functions
Regulate acid-base balance
Control BP
Produce Erthyropoietin
Activate Vitamin D
10/15/16

Kidney- macrostructure
kidney

anatomy

10/15/16

Kidney- microstructure
nephron

10/15/16

The Nephron
Why

is it called the functional unit of

the kidney?

10/15/16

Glomerular Filtration Rate

Glomerular

filtration rate
Used 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

10/15/16

Glomerular Filtration Rate

For

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
10/15/16

GFR
GFR

too high
increased urine output
threat of dehydration and electrolyte
depletion
GFR too low
insufficient excretion of wastes
GFR

of60 or higheris in the normal range

GFRbelow 60may mean kidney disease
GFR of15 or lowermay mean kidney
failure
10/15/16

The Kidney
Primary

function
Regulate volume and composition of
ECF (extracellular fluid)
Excrete waste products
Other functions
Regulate acid-base balance
Control BP
Produce Erthyropoietin
Activate Vitamin D
10/15/16

Functions of the Kidneys

Regulates

acid-base balance
HCO3 and H+
Controls Blood Pressure:
Renin Release

10/15/16

10

RAAS
Kidney

senses low perfusion

Renin 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 retained
10/15/16

11

10/15/16

12

Functions of the Kidneys

Erythropoietin

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

10/15/16

13

Functions of the Kidneys

Erythropoietin

promotes the formation

of RBCs in response to decreased
O2 carrying capacity

Anemia

from impaired erythropoietin

production and platelet abnormalities

>
bleeding risk
10/15/16

14

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 patients serum calcium
level?

10/15/16

15

Functions of the Kidneys

Inability

of kidneys to activate vitamin Dhypocalcemia > 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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16

ReviewFunctions of the Kidney

Regulate

Volume & composition of

extracellular fluid
F&E balance
Acid/Base

balance
Blood pressure regulation
Erythropoetin release
Vitamin D activation
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17

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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18

Acute Kidney Injury

Pre-renal

Hypovolemia
dehydration, shock, burns
Decreased cardiac output
CHF, MI, arrhythmias
Decreased vascular resistance
septic shock
Renal vascular obstruction
renal artery stenosis, thrombus
Causes related to decreased blood
flow to the kidneys
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19

Acute Kidney Injury

Intra-renal

Conditions causing direct damage

to renal tissue causing damage to
nephrons
Result

from ischemia
Nephrotoxins
Hemoglobin released from hemolysis
of red blood cells
Myoglobin released from necrotic
muscle cells
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20

Acute Kidney Injury

Intra-renal

Primary 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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21

Acute Tubular Necrosis(ATN)

Renal ischemia
Disruption basement
membrane;destructio
n tubular epithelium
Nephrotoxic agents
Necrosis tubular
epithelium plug
tubules; basement
membrane intact.

Renal
ischemia

Potentially reversible IF
Basement not
destroyed and tubular
epithelium
regenerates

Nephrotoxi
c agents

10/15/16

22

Acute Kidney Injury

Intra-renal
Acute

Tubular Necrosis (ATN)

Nephrotoxic

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

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23

Acute Kidney Injury

Intra-renal
Hemolytic

blood transfusion (ATN)

Trauma

crushing injuries which release

myoglobin
damaged muscle tissue and blocks
tubules (rhabdomyolysis)(ATN)
What

is Rhabdomyolysis?
10/15/16

24

Healthy

ATN

Compare & Contrast

10/15/16

25

Lupus

Nephritis
Flea bite look

10/15/16

26

Acute Kidney Injury

Post-renal
Mechanical

obstruction of
urinary outflow
urine backs up
into renal pelvis
BPH
Calculi
Trauma
Prostate cancer
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27

Stages of Acute Kidney Injury

Initiating

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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28

Urine

output in AKI varies widely

& does NOT provide clinical
correlation to the degree of
injury!!!!!

Must

look at GRF

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29

Oliguric Phase
Onset-

1-7 days
Duration- 10-14 days
Urine 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 & post
Fluid overload
Urine with RBCs, casts, WBCs, protein (if
glomerulus damaged)
K+ likely elevated
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30

Oliguric Phase
Metabolic

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 excess

decreased 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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31

Treatment 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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32

Treatment Oliguric phase

If

fluid challenge fails- intake limited

Fluid restriction
600ml + u.o. past 24 hours
Patients

u.o. yesterday was 300ml.

What will be the allowed fluid intake
today?

10/15/16

33

Diuretic Phase
Onset- days to weeks
Duration-

1-3 weeks
Urine Output- 1-3 liters/day
Signs

& Symptoms to anticipate

Elevated BUN and Serum Creatinine
What happens to intravascular volume?
What happens to BP?
Urine Na?
K+ elevated or decreased?
10/15/16

34

Recovery Phase
Onset-

When BUN and Creatinine stabilized

Duration- 4-12 months
Urine 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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35

Diagnostic tests in AKI

BUN

(blood urea nitrogen)

Measurement of amount of urea in
blood
Normal -6-20 mg/dl
What

is urea?
BUN fluctuates
BUN elevated when?
BUN decreased when?
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36

Diagnostic tests in AKI

Serum

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 20:1

10/15/16

37

Diagnostic tests in AKI

Creatinine

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
10/15/16

38

24 hour urine
What

is the nurses role in the

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

10/15/16

39

Diagnostic tests in AKI

Urine

Specific Gravity
Normal= 1.003-1.030
Will be fixed a 1.010 usually in AKI due to
kidneys losing ability to concentrate urine
Serum

Electrolytes
Sodium
Potassium
Calcium
Phosphorus
10/15/16

40

Diagnostic tests in AKI

Serum

Electrolytes
Serum Sodium
Normal= 135-145
May

be high, low, or normal

When would it be high/low?

10/15/16

41

Diagnostic tests in AKI

Serum

Electrolytes
Serum Potassium
Normal= 3.5-5 meq/L
Almost

always increased in renal failure

Why? Two major reasons

If

> 6.0 treatment to prevent.

10/15/16

42

Diagnostic tests in AKI

Serum

Electrolytes
Serum Phosphorus
Normal=2.8-4.5mg/dl
Almost

always increased. Why?

What

other process is occurring to

increase serum phosphorus?
10/15/16

43

Diagnostic tests in AKI

Serum

Electrolytes
Serum Calcium
Normal=9.0-11.0 mg/dl
Almost

always decreased, why?

What

other process is occurring to

decrease serum calcium?
10/15/16

44

Diagnostic tests in AKI

ABGs
Metabolic

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

10/15/16

45

Management of AKI
Treat

the primary disease/condition

Prevention

Frequent monitoring for early signs

of AKI in at risk patients
What are these signs?

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46

Management of AKI
Assess

for FVD vs FVE

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

Metabolic

acidosis
Administer NaHCO3 IV as ordered

10/15/16

47

Management of AKI
Hyperkalemia

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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48

Management of AKI
Calcium

imbalance
Calcium Gluconate

Phosphorus

imbalance
Calcium supplements, Phosphate
binders

Hypertension

Lasix, Amlodipine, Metoprolol

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49

Management of AKI
Anemia

Administer epogen/procrit as ordered

PRBCs
Diet
Fluid restriction
Low K+, low Na
Low protein- why?
Emergency dialysis
K+>6.0, FVE, uremia, metabolic
acidosis
10/15/16

50

Renal Trauma
Etiology:
Men under age 30
Blunt force from falls
MVA
Sports injuries
Knife/gunshot wounds
Impalement injury, rib fractures

10/15/16

51

Renal Trauma
Common

Manifestations:
Hematuria-microscopic to gross
Pain- Flank or abdominal
Decreased Urine Output- oliguria or
anuria
Localized swelling, tenderness
Turners sign

10/15/16

52

renal trauma

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10/15/16

53

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)

10/15/16

54

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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55

Renal Trauma-Interventions
Nursing

Management

Bedrest
Prevent

complications
Close Observation for s/sx shock
H&H
I&O
Daily weights
VS

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56

Renal Surgery-Nephrectomy
Indications

for
Nephrectomy:
Renal tumor
Massive Trauma
Polycystic
Kidney Disease
Donating a
Healthy kidney
10/15/16

57

Renal SurgeryNephrectomy
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
10/15/16

58

Renal Vascular Problems

Nephrosclerosis

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?
10/15/16

59

Patho of Nephrosclerosis
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

Development

10/15/16

60

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?
10/15/16

61

Renal Artery Stenosis

Treatment/Collaborative

Care
Anti-hypertensive Medications
Dilation of renal artery by Percutaneous
Transluminal Angioplasy
Bypass Graft of Renal Artery
Nephrectomy

10/15/16

62

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

10/15/16

63

Renal Vein
Thrombosis/Occlusion
Pathophysiology/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
10/15/16

64

Renal Vein
Thrombosis/Occlusion
Treatment/Collaborative

Care

Diagnosis

Renal venography
Management

Thrombolytic drugs
Anticoagulant therapy
Surgical thrombectomy
Corticosteroids
10/15/16

65

Your patient develops AKI

after being on Amphotericin
for 1 week:
The

patients 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

10/15/16

66

Your patients 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
10/15/16

67

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?
10/15/16

68

The clients BUN is elevated in

AKI. What is the likely cause of
this
finding?
a-fluid
retention
b-hemolysis
c-below

of red blood cells

normal protein intake

d-reduced

renal blood flow

10/15/16

69

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?
10/15/16

70

A 24 hours urine for creatinine

clearance is ordered. Which task is
appropriate
to
delegate
to
the
the
a) instruct patient to collect all urine with
clinical
assistant?
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

10/15/16

71

Which urinary symptom is

the most common initial
manifestation of AKI?
a-dysuria
b-anuria
c-hematuria
d-oliguria

10/15/16

72