Nursing Care of Individual Experiencing a Kidney Disorder: Vascular Disorders Kidney Trauma Acute Kidney Injury modified by Kelle Howard RN, MSN, CNE

Nursing Care of Individual Experiencing a Kidney Disorder:

Vascular DisordersKidney Trauma

Acute Kidney Injurymodified by Kelle Howard RN, MSN, CNE

revised Fall 2012

04/19/23 1

Kidney A & P -excellent site for kidney pathophysiology

I. A&P of the Kidney- (locate structures)

• Fibrous capsule• Renal cortex• Renal medulla• Pyramids• Papillae• Minor calyx• Major calyx • Renal pelvis• Ureter

04/19/23 2

II. Functions of the Kidneys

• Regulates ______ & _________ of extracellular fluid

• Regulates fluid & electrolyte balance thru processes of: glomerular__________, tubular

_________, and tubular _____________.

Name some of the F & Es regulated by kidneys __________________

04/19/23 3

Functions of the Kidneys (cont) • Regulates acid-base balance through _________• *Hormonal functions: (BP control), multisytem effect.

– Renin Release

04/19/23 4

RAAS=

How the RAAS Pathway Works

04/19/23 5

Valerie KolmerValerie Kolmer

20062006

Quick Quiz

Pick the correct pathway of the RAAS

1. Renin – Angiotensin II – ACE – ADH – Aldosterone

2. Renin – Angiotensin I – Aldosterone – ADH –ACE

3. Renin-Angiotensin I-ACE-Angiotensin II-Aldosterone

04/19/23 6

Functions of the Kidneys (cont)

• Erythropoietin Release– If a patient has acute kidney injury, what

condition will occur?– WHY???

04/19/23 7

Functions of the Kidneys (cont)

• Activated Vitamin D– Necessary to absorb Calcium in the GI tract.

If a patient has acute kidney injury, what will happen to the patient’s serum calcium level? __________________

04/19/23 8

Review: Functions of the Kidneys

• Regulate– 1.___________– 2.___________– 3.___________– 4.___________

• Release of ________________• Activation of _______________

04/19/23 9

Nephron- functional unit of the Kidney!

• How the Nephron Works! Click-watch YouTube video!

04/19/23 10

Identify the Nephron’s Parts

• Glomerulus• Bowman’s capsule• Proximal tubule• Loop of Henle• Distal tubule• Collecting duct

04/19/23 11

Kidney Trauma Etiology:

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

Common Manifestations:Microscopic to gross hematuriaFlank or abdominal painOliguria or anuriaLocalized swelling, tenderness, ecchymosis over the

flank area - aka: ____________Signs/Symptoms depend upon severity injury*Severe blood loss/signs shock

04/19/23 12

Kidney Trauma

04/19/23 13

Kidney Trauma

• What are common diagnostic tests used in kidney trauma?

04/19/23 14

CT-determine if peritoneal violation and predict need for laparotomy-here initially see extravasation and fluid in paracolic gutters (peritoneal violation) and also a hematoma in perirenal space

Kidney Trauma:Interventions

• Minor Trauma– Conservative – Bedrest and close observation– Monitor for S & S of what?

04/19/23 15

Kidney Trauma:Interventions

Moderate to Major Trauma Surgical

Surgical repair, maybe nephrectomy Percutaneous arterial embolization during

angiography Nursing management

Accurate assessment Monitor H & H levels Bedrest, close observation,

evaluate S & S of ____________ Fluid mgt Prevent complications/monitor I & O Manage drainage tubes Daily weights****

04/19/23 16

Kidney Surgery:Nephrectomy

• Indications for Nephrectomy:

– kidney tumor– massive trauma– polycystic kidney disease– donating a healthy kidney

– What are the different types and approaches?

04/19/23 17

Kidney Surgery:Nephrectomy

• Post Op Nursing Management– Strict I & O

• Urine output should be at least _____.• What should the UO be if patient had bilateral

nephrectomy? ______.

– Observe urine– Daily weights– TCDB & IS

• Incision in flank area

– Medicate for pain as ordered

04/19/23 18

Vascular Disorders of the Kidney: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 _____

04/19/23 19

Vascular Disorders of the Kidney:Renal Artery Stenosis

Definition: narrowing of one or both renal arteries

due to atherosclerosis or structural abnormalities.

Common Manifestation:uncontrollable HTNmedications do not work

04/19/23 20


• Treatment/Collaborative Care– Diagnostic Tests

• Renal arteriogram-most definitive– Management

• Conservative-antihypertensive meds• Percutaneous Transluminal Angioplasty• Surgical re-vacularization (Graft)• Nephrectomy

04/19/23 21


– Treatment/Collaborative Care

04/19/23 22

What type of procedure is this?

What are some post procedure nursing care interventions?

Vascular Disorders of the Kidney: Renal Vein Thrombosis/Occlusion

• Definition: – 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

04/19/23 23

Vascular Disorders of the Kidney:Renal Vein Thrombosis/Occlusion

– Pathophysiology/etiology• Cause unclear: thrombus forms in renal vein• Associated with trauma, nephrotic syndrome gradual deterioration of kidney function

– Common Manifestations/Complications• Decreased GFR• Signs of kidney failure• **Complication ---*_______________

04/19/23 24

Vascular Disorders of the KidneyRenal Vein Thrombosis/Occlusion

• Treatment/Collaborative Care– Diagnosis- renal venography– Management

• Thrombolytic drugs• Anticoagulant therapy• Surgical thrombectomy• Cortiocosteroids

04/19/23 25

Acute Kidney Injury(AKI)

(previously known as Acute Renal Failure)Definition: Rapid decline in renal function- leads to

accumulation of nitrogenous wastes (azotemia)Kidneys unable to remove urea from blood-

become uremic -- aka uremia

(multiple body symptoms affected)

04/19/23 26

Acute Kidney Injury

Etiology of AKI:– Pre-renal– Intra-renal– Post renal

04/19/23 27

Etiology of Acute Kidney InjuryPre-renal

Most common cause of pre-renal AKI

• Causes of “pre-renal” AKI• Hypovolemia: dehydration, shock, burns, N&V, diarrhea

• Decreased cardiac output: CHF, MI, arrythmias

• Dec. vascular resistance (septic shock, etc)

• Renal vascular obstruction: renal artery stenosis, thrombus

04/19/23 28

Etiology of Acute Kidney Injury:Intra-renal

• Direct injury to the kidneys/nephrons– causing damage to renal tissue (parenchyma)

– ATN (acute tubular necrosis)• *Destruction of tubular epithelial cells, slough, plug tubules- abrupt

decline in renal function-recovery possible if basement membrane remains intact & tubular epithelium regenerates

• Most common cause of Intra-renal AKI

04/19/23 29

Etiology of Acute Kidney Injury:Intra-renal

• Hemolytic blood transfusion (ATN)• Trauma (crush injuries > release myoglobin>damage muscle tissue > blocks tubules) (rhabdomylosis) (ATN)• Nephrotoxic drugs/chemicals (ATN)

– Aminoglycosides*– Radiographic contrast agents– Arsenic, lead, carbons– Drug overdose

• Acute glomerulonephritis/pyelonephritis• Systemic Lupus

04/19/23 30

Etiology of Acute Kidney Injury:Intra-renal (ATN)

– Renal ischemia • Destruction tubular

epithelium

– Nephrotoxic agents• Necrosis tubular epithelium…

plug tubules.

– Potentially reversible IF• Basement not destroyed and

tubular epithelium regenerates

04/19/23 31

Renal ischemia

Nephrotoxic agents

Etiology of Acute Kidney Injury: Post-renal

• Causes of “post-renal failure” – mechanical obstruction of urinary outflow– urine backs up into renal pelvis

• BPH (Benign Prostatic Hypertrophy)• Calculi• Trauma• Prostate cancer

04/19/23 32

Diagnostic Tests:Acute Kidney Injury

• BUN (blood urea nitrogen)– Normal = 6-20 mg/dl; measurement of amt of

nitrogen, in the form of urea, in blood

• Serum Creatinine: – Normal = 0.6 – 1.3 mg/dl– Directly related to GFR

• 2 X pts. normal = 50% nephron fx loss• 10 X pts. normal = 90% nephron fx loss• MORE ACCURATE INDICATOR of kidney function

than BUN

04/19/23 33


• Creatinine clearance– Most accurate indicator of kidney function– Reflects GFR (glomerular filtration rate)

– Involves a 24 hr urine/serum creatinine– Formula:

• urine creatinine X urine volume

serum creatinine• Normal= 70-135ml/minute

– (+/- 120-125ml/minute)

04/19/23 34


– Urine Specific Gravity• Normal= 1.003-1.030• Fixed - 1.010 usually in AKI

– Can indicate ATN– Kidneys lose ability to concentrate urine

– Serum Electrolyte• 1. Serum Sodium Normal= 135-145meq/L

– May be high, low, or normal

04/19/23 35


– Serum Electrolytes

2. Serum K+

Normal= 3.5-5.0 meq/dL

• Almost always increased in kidney failure• Why?

04/19/23 36



3. Serum Calcium

Normal= 8.6-10.2mg/dL

Almost always decreased

Why?

04/19/23 37



4. Serum Phosphorus

Normal= 2.4 - 4.4mg/dL

Almost always increased Why?

04/19/23 38


– 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 & ____________

04/19/23 39

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

04/19/23 40

Acute Kidney Injury: 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 and 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

04/19/23 41


04/19/23 42

Metabolic acidosis:

kidneys unable to synthesize HCO3, cannot excrete H+ and acid metabolites; serum bicarbonate dec. because used to buffer H+

Result: Kussmaul breathing

Ca deficit & phosphate excess:

dec. GI absorption Ca (lack of active vitamin D)

Nitrogenous product accumulation:

unable to eliminate urea and creatinine > elevated BUN, serum creatinine


04/19/23 43


04/19/23 44

Treatment

If fluid challenge fails, fluid intake is usually limited and client is placed on fluid restrictionRestriction is limited to 600ml (includes insensible loss) + UO over the past 24 hours

Physician will specify in the orders how much

Acute Kidney Injury: Diuretic Phase

Onset: days to weeks

Duration: about 10 days (1-3 weeks)

Urine output: 1-3 liters/day

Signs and Symptoms to anticipate?

What happens to fluid volume?

Elevated BUN and serum creatinine

K likely to be elevated or decreased???

What happens to urine Na?

What happens to blood pressure?

04/19/23 45

Acute Kidney Injury: Recovery Phase

– Onset: • When BUN and Creatinine

are stabilized

– Duration: • 4-12 months

– Urine output: • Normal

• Signs and Symptoms to anticipate?

– Monitor for signs and symptoms of F & E imbalances

– All body systems for effects of fluid volume changes

04/19/23 46

Acute Kidney InjuryManagement/Interventions

04/19/23 47

1- Treat primary disease/condition whether it is pre-intra-post renal problem.

2- Prevention: Frequent monitoring for early signs of AKI in at risk patients


3- Assess for Fluid V deficit vs Fluid V overload

Vital signs – HR, BP, RR Strict I & O Daily weights 500ml =1lb. (1kg = approx 1000ml) Monitor lab value

4- Metabolic Acidosis Administer NaHCO3 I.V. as ordered

04/19/23 48

Acute Kidney Injury Management/Interventions

04/19/23 49

5- Hyperkalemia Give insulin & glucose I.V. or

Sodium bicarbonate I.V. or

Calcium gluconate or

Dialysis or

Kayexalate po/enema or

Dietary restrictions

(not necessarily in this order)


04/19/23 50

6- Calcium Imbalance

Administer calcium supplements as ordered

7- Treat Hypertension (HTN)

8- Phosphorus Imbalance

Administer phosphate binders

*Amphogel *Basaljel, Renagel

Oscal Phoslo

*Cautious use of aluminum-based phosphate binders

can cause encephalopathy


04/19/23 51

9- Assess for anemia

Administer Epogen/Procrit as orderedPRBCs as ordered what do you have to watch for?

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 with s/s, Fluid V overload, uremia

Metabolic acidosis <15 HCO3


• 11a Emergency Dialysis– Intermittent hemodialysis (HD)

• Used when rapid changes are required– Continuous Renal Replacement Therapy (CRRT)

• Much slower blood flow rates than HD• CVVHD

– Continuous venovenous hemodialysis» Solute loss via convection/diffusion

• CVVH– Continuous venovenous hemofiltration

» Solute loss via convection (more like mammalian filtration)» Replacement fluid via hemodilution

• Both use double lumen catheter

CVVH/CVVHD

• When is it indicated?– acute kidney injury– pt usually has low blood pressure or other

contraindications to hemodialysis • Not a treatment for acute hypokalemia

– slow continuous process– sessions usually last between 12 to 24hrs– usually performed daily in the ICU

Documents

Nursing Care of Individual Experiencing a Kidney Disorder: Vascular Disorders Kidney Trauma Acute Kidney Injury modified by Kelle Howard RN, MSN, CNE