RENAL SYSTEM ASSESSMENT PYRAMID POINTS Renal and urinary

RENAL SYSTEM ASSESSMENT

PYRAMID POINTS • • • Renal and urinary tract assessment techniques Risk factors associated with renal disorders Normal renal function test results Procedure for collecting a 24 -hour urine test Preprocedure and postprocedure care for an intravenous pyelogram (IVP) and renal angiogram • Preprocedure care for a client scheduled for a cystoscopy and biopsy • Expected and unexpected findings in the postprocedure period following cystoscopy and biopsy

RENAL SYSTEM From Herlihy, B. & Maebius, N. (2000). The human body in health and illness. Philadelphia: W. B. Saunders.

LOCATION OF COSTOVERTEBRAL ANGLE From Beare PG, Myers JL (1998): Adult Health Nursing, ed. 3 St. Louis: Mosby.

RISK FACTORS OF RENAL DISORDERS • • Associated medical conditions Contact sports Family history of renal disease Frequent urinary tract infections High-sodium diet History of hypertension Medication use Trauma and injury

NORMAL RENAL FUNCTION TESTS • • • Blood urea nitrogen (BUN), 8 to 25 mg/dl Serum creatinine, 0. 6 to 1. 3 mg/dl Creatinine clearance, 100 to 120 ml/minute Uric acid serum, 2. 5 to 8. 0 ng/dl Uric acid urine, 250 to 750 mg/24 hours

URINALYSIS • DESCRIPTION – A urine test for evaluation of the renal system and for determining renal disease • IMPLEMENTATION – Wash perineal area and use a clean container – Obtain 10 to 15 ml of the first morning sample – Note that refrigerated samples may alter the specific gravity – If the client is menstruating, indicate this on the laboratory requisition form

SPECIFIC GRAVITY DETERMINATION • DESCRIPTION – A urine test that measures the kidney’s ability to concentrate urine – Normal value is 1. 016 to 1. 022 – An increase in specific gravity (more concentrated urine) occurs with insufficient fluid intake, decreased renal perfusion, or the presence of ADH – A decrease in specific gravity (less concentrated urine) occurs with increased fluid intake, diuretic administration, and diabetes insipidus

SPECIFIC GRAVITY DETERMINATION • IMPLEMENTATION – Can be measured by multiple-test dipstick (most common method), refractometer (an instrument used in the laboratory setting), or by a urinometer (least accurate method) – Factors that interfere with an accurate reading include radiopaque contrast agents, glucose, and proteins – Cold specimens may produce a false high reading

URINE CULTURE AND SENSITIVITY • DESCRIPTION – A urine test that identifies the presence of microorganisms and determines the specific antibiotics that will appropriately treat the existing microorganism

URINE CULTURE AND SENSITIVITY • IMPLEMENTATION – Clean perineal area and urinary meatus with bacteriostatic solution – Collect midstream sample in a sterile container – Send the collected specimen to the laboratory immediately – Note that urine from the client who forced fluids may be too dilute to provide a positive culture – Identify any sources of potential contaminants during the collection of the specimen, such as the hands, skin, clothing, hair, or vaginal or rectal secretions

CREATININE CLEARANCE TEST • DESCRIPTION – A blood and timed urine specimen that evaluates kidney function – Blood is drawn at the start of the test and the morning of the day that the 24 -hour urine specimen collection is complete

CREATININE CLEARANCE TEST • IMPLEMENTATION – Encourage adequate fluids before and during the test – Instruct the client to avoid tea, coffee, and medications during testing – If the client is taking corticosteroids or thyroid medication, check with the physician regarding the administration of these medications during testing – Maintain the specimen on ice or refrigerate, and check with the laboratory regarding the addition of a preservative to the specimen during collection

VANILLYLMANDELIC ACID (VMA) TEST • DESCRIPTION – A 24 -hour urine collection to diagnose pheochromocytoma, a tumor of the adrenal gland – The test identifies an assay of urinary catecholamines in the urine

VANILLYLMANDELIC ACID (VMA) TEST • IMPLEMENTATION – Instruct the client to avoid foods such as caffeine, cocoa, vanilla, cheese, gelatin, licorice, and fruits for at least 2 days prior to beginning the urine collection and during the collection, and to avoid taking medications for 2 to 3 days prior to beginning the test as prescribed – Instruct the client to avoid stress and to maintain adequate food and fluids during the test

VANILLYLMANDELIC ACID (VMA) TEST • IMPLEMENTATION – Save all urine, label the container, add preservative, and place the specimen on ice or refrigerate – Check with the laboratory regarding medication restrictions

URIC ACID TEST • DESCRIPTION – A 24 -hour urine collection to diagnose gout and kidney disease • IMPLEMENTATION – Encourage fluids and a regular diet during testing – Place the specimen on ice or refrigerate, and check with the laboratory regarding the addition of a preservative

KIDNEYS, URETERS, AND BLADDER RADIOGRAPH • DESCRIPTION – Known as a KUB – An x-ray film that views the urinary system and adjacent structures – Used to detect urinary calculi • IMPLEMENTATION – There is no specific preparation

BLADDER ULTRASONOGRAPHY • DESCRIPTION – A noninvasive method of measuring the volume of urine in the bladder – May be performed for evaluating urinary frequency or inability to urinate • IMPLEMENTATION – There is no specific preparation

INTRAVENOUS PYELOGRAM (IVP) • DESCRIPTION – The injection of a radiopaque dye that outlines the renal system – Performed to identify abnormalities in the system

INTRAVENOUS PYELOGRAM (IVP) • PREPROCEDURE – Obtain a consent form – Assess the client for allergies to iodine, seafood, and radiopaque dyes – Withhold food and fluids after midnight on the night before the test – Inform the client about possible throat irritation, flushing of the face, warmth, or a salty taste that may be experienced during the test

INTRAVENOUS PYELOGRAM (IVP) • POSTPROCEDURE – Monitor vital signs – Instruct the client to drink at least 1 liter of fluid unless contraindicated – Assess the venipuncture site for bleeding – Monitor urinary output

RENAL ANGIOGRAPHY • DESCRIPTION – The injection of a radiopaque dye through a catheter for examination of the renal arterial supply

RENAL ARTERY AND OTHER INTERNAL STRUCTURES OF THE KIDNEY From Herlihy, B. & Maebius, N. (2000). The human body in health and illness. Philadelphia: W. B. Saunders.

RENAL ANGIOGRAPHY • PREPROCEDURE – Obtain a consent form – Assess the client for allergies to iodine, seafood, and radiopaque dyes – Inform the client about a possible burning feeling or a feeling of heat along the vessel when the dye is injected – Withhold food and fluids after midnight on the night before the test

RENAL ANGIOGRAPHY • PREPROCEDURE – Instruct the client to void immediately before the procedure – Administer enemas as prescribed – Shave injection sites as prescribed – Assess and mark the peripheral pulses

RENAL ANGIOGRAPHY • POSTPROCEDURE – Assess vital signs and peripheral pulses – Provide bed rest and use of a sandbag at the insertion site for 4 to 8 hours – Assess the color and temperature of the involved extremity – Inspect the catheter insertion site for bleeding or swelling – Force fluids unless contraindicated – Monitor urinary output

RENAL SCAN • DESCRIPTION – An IV injection of a radioisotope for visual imaging of renal blood flow

RENAL SCAN • PREPROCEDURE – Obtain a consent form – Assess for allergies – Assist with administering radioisotope as necessary – Instruct the client that he or she will be required to remain motionless – Instruct the client that imaging may be repeated at various intervals before the test is complete

RENAL SCAN • POSTPROCEDURE – Encourage fluids unless contraindicated – Assess the client for signs of delayed allergic reaction, such as itching and hives – Note that the radioactivity is eliminated in 24 hours – Follow standard precautions when caring for incontinent clients and double-bag client linens per agency policy

CYSTOMETROGRAM (CMG) • DESCRIPTION – A graphic recording of the pressures exerted at varying phases of the bladder • PREPROCEDURE – Inform the client of the voiding requirements during the procedure • POSTPROCEDURE – Monitor the client’s voiding after the procedure

CYSTOSCOPY AND BLADDER BIOPSY • DESCRIPTION – The bladder mucosa is examined for inflammation, calculi, or tumors by means of a cystoscope – Tissue may be obtained for biopsy

CYSTOSCOPE IN THE MALE BLADDER From Phipps WJ, Sands, J, Marek JF: Medical-surgical nursing: concepts and clinical practice, ed. 6, St. Louis, 1999, Mosby.

CYSTOSCOPY AND BLADDER BIOPSY • PREPROCEDURE – Obtain a consent form – Withhold food and fluids after midnight on the night before the test – Administer enemas and medications as prescribed

CYSTOSCOPY AND BLADDER BIOPSY • POSTPROCEDURE – Monitor vital signs – Monitor for postural hypotension – Force fluids as prescribed – Monitor intake and output – Encourage deep-breathing exercises to relieve bladder spasms – Administer analgesics as prescribed – Administer sitz baths for back and abdominal pain

CYSTOSCOPY AND BLADDER BIOPSY • POSTPROCEDURE – Note that leg cramps are common due to the lithotomy position maintained during the procedure – Assess the urine for color and consistency – Note that pink-tinged or tea-colored urine is common – Monitor for bright red urine or clots and notify the physician if this occurs

RENAL BIOPSY • DESCRIPTION – Insertion of a needle into the kidney to obtain a sample of tissue for examination

RENAL BIOPSY From Black, J. , Hawks, J, and Keene, A. (2001). Medical-surgical nursing, ed 6, Philadelphia: W. B. Saunders

RENAL BIOPSY • PREPROCEDURE – Assess vital signs – Assess baseline clotting studies – Obtain a consent form – Withhold food and fluids after midnight on the night before the test • DURING THE PROCEDURE – Position the client prone with a pillow under the abdomen and shoulders

RENAL BIOPSY • POSTPROCEDURE – Monitor vital signs – Monitor hemoglobin and hematocrit – Place the client in the supine position and on bed rest for 8 hours as prescribed – Provide pressure to the biopsy site for 30 minutes – Check the biopsy site for bleeding – Force fluids to 1500 to 2000 ml as prescribed – Instruct the client to avoid heavy lifting and strenuous activity for 2 weeks