Differentiating Low Urine Output

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Differentiating Low Urine Output
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Test Yourself on Renal Nursing

• Which of the following conditions is a common
  cause of prerenal ARF?
• Atherosclerosis
• Decreased cardiac output
• Benign prostatic hyperplasia
• Rhabdomyolysis

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• 2. A patient is admitted with a diagnosis of
  hydronephrosis secondary to calculi. The calculi
  have been removed and postobstructive diuresis is
  occurring. Which of the following should you do?
• Take vital signs every 8 hours
• Weigh the patient every other day
• Assess urine output every shift
• Monitor the patients electrolyte levels.

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• 3. Serum creatinine levels provide the most
  accurate picture of renal function because
• Serum creatinine is rapidly absorbed by the renal
  tubules
• A slow urine flow through the kidneys increases
  creatinine levels
• Elevated serum creatinine levels indicate a
  decrease in glomerular function
• Serum creatinine levels are related to the rate
  of urine flow through the kidneys

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• 4. Which of the following causes the nausea
  associated with renal failure?
• Oliguria
• Gastric ulcers
• Electrolyte imbalance
• Accumulation of metabolic wastes

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• 5. Which of the following patients is at greatest
  risk for developing acute renal failure?
• A dialysis patient who gets influenza
• A teenager who has an appendectomy
• A pregnant woman who has a fractured femur
• A patient with diabetes who has a heart
  catheterization

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So whats the big deal about low urine output?
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Glomerular Filtration Rate (GFR)
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This is the typical appearance of the blood
vessels (vasculature) and urine flow pattern in
the kidney. The blood vessels are shown in red
and the urine flow pattern in yellow.
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So Whats the Problem?Top Three Questions

• Are they dry? 60-70
• 2. Are they obstructed? 5-10
• 3. Is it the kidneys? 30

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What is it about BUN and Creatinine?

• BUN
• state of renal perfusion
• Creatinine
• actual tubular function
• Creatinine Clearance
• direct indicator of GFR

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BUN Creat Symptoms Causes Diagnosis
Normal Normal Urine output none, fluctuating Distended bladder Hematuria Increased BP/HR Abdominal pain
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BUN Creat Symptoms Causes Diagnosis
Normal Normal Urine output none, fluctuating Distended bladder Hematuria Increased BP/HR Urinary tract obstruction Catheter blocked, kinked, in wrong place Prostate issues Ovarian cancer Kidney stones Pregnancy Antihistmanines
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BUN Creat Symptoms Causes Diagnosis
Normal Normal Urine output none, fluctuating Distended bladder Hematuria Increased BP/HR Urinary tract obstruction Catheter blocked, kinked, in wrong place Prostate issues Ovarian cancer Kidney stones Pregnancy Antihistmanines Prerenal
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BUN Creat Symptoms Causes Diagnosis
Normal Slightly up Urine output low Vomiting Bloody diarrhea Hypotension Elevated HR Weight loss/gain JVD
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BUN Creat Symptoms Causes Diagnosis
Normal Slightly up Urine output low Vomiting Bloody diarrhea Hypotension Elevated HR Weight loss/gain JVD Hypotension Hypoperfusion Dehydration, blood loss, vomiting/diarrhea diuretics, third spacing Drugs NSAIDS, contrast media Decreased PVR Sepsis, BP meds, cirrhosis Cardiac pump failure MI, CHF, arrythmias, cardiac myopathy, cardiac arrest
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BUN Creat Symptoms Causes Diagnosis
Normal Slightly up Urine output low Vomiting Bloody diarrhea Hypotension Elevated HR Weight loss/gain JVD Hypotension Hypoperfusion Dehydration, blood loss, vomiting/diarrhea diuretics, third spacing Drugs NSAIDS, contrast media Decreased PVR Sepsis, BP meds, cirrhosis Cardiac pump failure MI, CHF, arrythmias, cardiac myopathy, cardiac arrest Prerenal
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BUN Creat Symptoms Causes Diagnosis
Urine output low to none Increased temperature Hypertension Increased RR Arrythmias Change in LOC Volume overload
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BUN Creat Symptoms Causes Diagnosis
Urine output low to none Increased temperature Hypertension Increased RR Arrythmias Change in LOC Volume overload Prolonged or untreated pre and postrenal failure Ischemia ATN, prolonged CV surgeries Nephrotoxic meds Drugs, contrast dye, toxins, pesticides Trauma Glomerulonephritis Carcinomas Rhabdomylolysis
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BUN Creat Symptoms Causes Diagnosis
Urine output low to none Increased temperature Hypertension Increased RR Arrythmias Change in LOC Volume overload Prolonged or untreated pre and postrenal failure Ischemia ATN, prolonged CV surgeries Nephrotoxic meds Drugs, contrast dye, toxins, pesticides Trauma Glomerulonephritis Carcinomas Rhabdomylolysis Intrarenal
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Jugular Vein Distention
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Nursing Management

• Goal Get the blood flowing to the kidneys again!
• Patient safety
• IVF
• Diuretics (furosemide, mannitol)
• Put in a foley
• IO
• Daily weight
• Keep MAP gt60
• Monitor the labs
• Anticipate CRRT or dialysis

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Hemodialysis AV Shunt Dos Donts

• Never take a blood pressure in the arm with the
  AV shunt. Use the opposite arm.
• Do not draw blood or insert needles of any kind
  in the arm with the AV Shunt. Use the opposite
  arm.
• If you touch one of the veins near the wrist, you
  will feel a rhythmic pulsation called a thrill.
  This normal.
• Protect the arm from injury. Any banging,
  crushing or minor cuts can become very serious
  especially if bleeding occurs.
• Any bleeding from the arm with the AV shunt is an
  arterial bleed! If bleeding occurs or if one of
  the veins is ruptured under the skin from trauma,
  apply direct pressure to the site immediately.

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• Sowhats the big deal about low urine output?

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Case Study - E.B.
3 days ago Today
Na 142, K 4.9, Cl 100 CO2 26, glucose 158 BUN 28, creatinine 2.2 Na 140, K 6.0, Cl 104, CO2 24, glucose 104 BUN 68, creatinine 4.0 UO past 8 hours 160 mls

• 160 ml.

• Abnormalities and causes
• ARF category
• Next action
• Oliguria and anuria
• Explanation for increase in BUN and creatinine
• Nursing interventions and priorities in ARF
• Am I going to die?

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Case Study - F.F.
Today
Na 144, K 4.0, CL 101 CO2 26, Phos 2.6 total protein 7.8, albumin 4.0 BUN 18, creatinine 0.8

• Priorities
• Hydronephrosis
• ARF category
• Relationship between creatinine and GFR

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Case Study - F.F.

• Staghorn stone in the renal pelvis

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Case Study - C.W.
Admit Day 2
K 6.2 BUN 90, creatinine 2.1 Hgb 8.4, Hct 25 WBC 16,000 Intake 8498 - Output 3660 4838

• Signs and symptoms
• Elevated K
• Elevated BUN and creatinine
• ARF category
• Monitor fluid status
• 6 assessments of fluid balance

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