1/11/2016 1 a. Fibrous capsule b. Renal cortex c. Renal medulla d. Pyramids e. Papillae f....

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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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Renal A & P

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Elimination of _______ & _________ Can you name some of these substances?

__________________________ Regulates fluid & electrolyte balance thru

processes of: __________, _________, and _____________.

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Name a few of these Fluid and Electrolyes regulated by kidneys

__________________ __________________ __________________

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Regulates acid-base balance HCO3 and H+

Hormonal (endocrine) functions: Renin Release

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Erythropoietin Release If a patient has chronic kidney disease

or chronic renal failure, what condition will occur and WHY???

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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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Why is it called the functional unit of the Kidney???

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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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Etiology:

Blunt force from falls, MVA, sports injuries, knife/gunshot wounds, impalement injury, rib fractures

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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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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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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?

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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Indications for Nephrectomy: Renal tumor Massive Trauma Polycystic Kidney Disease Donating a Healthy kidney

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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

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I. Hypertension & Nephrosclerosis

Sustained elevation of the systemic blood pressure can result from or cause kidney disease---How?

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

Common Manifestations: Uncontrollable HTN

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How could a renal artery stenosis result in HTN?

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Treatment/Collaborative Care

Anti-hypertensive Medications Dilation of renal artery by Percutaneous Transluminal Angioplasy

Bypass Graft of Renal Artery Stent placement

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Treatment/Collaborative Care

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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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What is missing from the ARF definition?

What is the difference between uremia and azotemia???

____________________________

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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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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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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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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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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

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

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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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Which of the following urinary symptoms is the most common initial manifestations of ARF?a-dysuriab-anuria

c-hematuria d-oliguria

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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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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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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?

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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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 1.6 12 1.2

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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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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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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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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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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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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 decreaseserum calcium??? __________________

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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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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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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? ________

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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? _______

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4- Metabolic Acidosis

Administer NaHCO3 I.V. as ordered

5-HyperkalemiaWhat 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

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Sodium Bicarbonate I.V. Correct acidosis; get potassium into cells

Kayexalate po or enemaSodium exchanged for potassium in the GI tract; produced osmotic diarrhea

Dietary Restrictions Potassium

Avoid foods high in K+;

Name some of those foods: ________________

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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

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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

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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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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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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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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