Renal system physical assessment

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Renal system (physical assessment)

• Inspection Skin- pallor, yellow-gray,
  excoriations, changes in turgor, bruises,
  texture(e.g. rough, dry skin)
• Mouth stomatitis, ammonia breath.
• Face extremities- generalized edema, peripheral
  edema, bladder distention, masses, enlarged
  kidney.
• Abdomen-abdominal contour for midline mass in
  lower abdomen (may indicate urinary retention) or
  unilateral mass.
• Weight weight gain 2nd to edema, weight loss
  muscle wasting in renal failure.

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Renal system (physical assessment)

• General state of health- fatigue, lethargy,
  diminished alertness.
• Palpation- No costovertebral angle tenderness,
  nonpalpable kidney bladder, no palpable masses.
• Percussion Tenderness in the flank may be
  detected by fist percussion. If CVA tenderness
  pain are present, indicate a kidney infection or
  polycystic kidney disease.
• Auscultation The abdominal aorta renal
  arteries are auscultated for a bruit, which
  indicates impaired blood flow to the
  kidneys

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Renal Systems (Diagnostic test)

• Urinalysis- evaluation of the renal system for
  determining renal disease.
• Wash perineal area use a clean container.
• Obtain 10 to 15 mL of the 1st AM sample
• If the client is menstruating, indicate this on
  the lab. requisition form.
• Specific Gravity-measures the kidneys ability to
  concentrate urine. Measured by multiple-test
  dipstick (most common method), refractometer-instr
  ument used in the lab, urinometer (least accurate
  method). Cold specimens produce a false high
  reading. Factors that interfere with an accurate
  reading include radiopaque contrast agents,
  glucose proteins.

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Renal Systems (Diagnostic test)

• A decrease in SG (less conc. urine) occurs with
  increased fluid intake, diuretic administration,
  diabetes insipidus.
• An increase SG (more conc. Urine) occurs with
  insufficient fluid intake, decreased renal
  perfusion, or the presence of ADH.
• Urine Culture Sensitivity- identifies the
  presence of microorganisms determines the
  specific abx. that will treat the existing
  microorganisms. Note that urine from a client who
  forced fluids may be too dilute to provide a
  positive culture.

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Renal Systems (Diagnostic test)

• Creatinine clearance test- A blood timed urine
  specimen that evaluates kidney function.
• Blood is drawn at the start of the test the AM
  of the day that the 24-hour urine specimen
  collection is complete. Maintain the urine
  specimen on ice or refrigerate. If the client is
  taking steroids, check with MD regarding the
  administration of these medications during test.
  Encourage adequate fluids before during the
  test.

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Renal Systems (Diagnostic test)

• Vanillymandelic acid (VMA)- to diagnose
  pheochromocytoma, a tumor of the adrenal gland.
  The test identifies an assay of urinary
  catecholamines in the urine. Instruct to avoid
  foods such as caffeine, cocoa, cheese, gelatin at
  least 2 days prior to beginning of the collection
  during collection. Save all urine on ice or
  refrigerate. Instruct to avoid stress to
  maintain adequate food fluids during the test.

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Renal Systems (Diagnostic test)

• Uric acid- A 24-hour collection to diagnose gout
  kidney disease.
• Encourage fluids a regular diet during testing.
  Place the specimen on ice or refrigerate.
• KUB (Kidney, ureters, bladder) radiograph-An
  x-ray film that views the urinary system
  adjacent structures used to detect urinary
  calculi.
• Bladder ultrasonography-A noninvasive method of
  measuring the volume of urine in the bladder.

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Renal Systems (Diagnostic test)

• Computed tomography (CT) MRI- provide
  cross-sectional views of the kidney urinary
  tract.
• Intravenous pyelogram (IVP)- the injection of a
  radiopaque dye that outlines the renal system.
  Performed to identify abnormalities in the
  system. Withhold food fluids after midnight
  before the test. Inform the client abt. Possible
  throat irritation, flushing of the face, warmth
  or salty taste that may experienced during the
  test.

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Renal Systems (Diagnostic test)

• Renal angiography- the injection of a radiopaque
  dye through a catheter for examination of the
  renal arterial supply. Assess the client for
  allergies to iodine, seafood radiopaque dyes.
  Inform about possible burning feeling of heat
  along the vessel when the dye is injected.
• NPO after MN on the night of the test. Instruct
  to void immediately before the procedure.
  Inspect the color temperature of the involved
  extremities. Inspect site for bleeding.

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Renal Systems (Diagnostic test)

• Renal Scan- An IV injection of a radiopaque for
  visual imaging of renal blood flow. Instruct that
  imaging may be repeated at various interval
  before the test is complete. Assess for signs of
  delayed allergic reactions, such as itching
  hives.
• Cystometrogram (CMG)- A graphic recording of the
  pressures exerted at varying phases of the
  bladder. Inform of the voiding requirements
  during after the procedure.

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Renal Systems (Diagnostic test)

• Cystoscopy Biopsy- the bladder mucosa is
  examined for inflammation, calculi or tumors by
  means of a cystoscope, a biopsy may be obtained.
  NPO after MN before the test. Monitor for
  postural hypotension. Note that pink-tinged or
  tea-colored urine is common. Monitor for bright,
  red or clots notify MD.
• Renal biopsy- insertion of a needle into the
  kidney to obtain a sample of tissue for exam. NPO
  after MN. Provide pressure to the biopsy site for
  30 minutes. Check site for bleeding. Force fluids
  to 1500-2000 mL. Instruct to avoid heavy lifting
  strenuous activity for 2 weeks.

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Urinary Tract Infection (UTI)

• Inflammation of the bladder from infection or
  obstruction of the urethra.
• The most common causative organism are E. coli,
  Enterobacter, pseudomonas, serratia.
• More common in women because they have shorter
  urethra than men, the location of the urethra
  in women is close to the rectum.
• Sexually active pregnant women are most
  vulnerable to UTI.

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Urinary Tract Infection (UTI)

• Causes Allergens or irritants, such as soaps,
  sprays, bubbles bath
• Bladder distention, calculus, hormonal changes
  influencing alterations in vaginal flora.
• Indwelling urethral catheter, loss of bacterial
  properties of prostatic secretions in the male
• Sexual intercourse, urinary stasis, use of
  spermicides, wet bathing suits

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Urinary Tract Infection (UTI)

• Assessment Frequency urgency, burning on
  urination, voiding in small amount, inability to
  void, incomplete emptying of the bladder, lower
  abdominal discomfort or back discomfort, cloudy,
  dark, foul smelling urine, hematuria, bladder
  spasms, malaise, chills, fever, nausea
  vomiting.
• Implementation Obtain urine C/S to identify
  bacterial growth. Instruct to force fluids up to
  3000 mL a day. Provide meticulous perineal care
  with an indwelling catheter. Instruct to avoid
  alcohol. Provide heat to abdomen or sitz bath for
  complaints of discomfort

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Urinary Tract Infection (UTI)

• Nursing Diagnosis Acute pain r/t inflammation of
  mucosal tissue of UT as manifested by pain on
  urination, flank pain, bladder spasms.
• Provide relief by administering analgesics such
  as Pyridium or combination agents (Urised). Alert
  that urine color will be orange blue or green
  with combination agents.
• Teach the use of nonpharmacologic technique-
  heating pad, warm showers.

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Urinary Tract Infection (UTI)

• Impaired urinary elimination r/t UTI as
  manifested by bothersome urgency, hematuria or
  concern over altered elimination pattern
• Obtain midstream voided specimen for C/S.
• Administer antimicrobial drugs.
• Teach signs symptoms of UTI.
• Encourage adequate fluid to help prevent
  infection and dehydration.

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Urolithiasis

• Formation of urinary stones urinary calculi
  formed in the ureters.
• When a calculus occludes the ureter blocks the
  flow of urine, the ureter dilates, producing a
  condition known as hydroureter.
• If the obstruction is not removed, urinary stasis
  results in infection, impairment of renal
  function on the side of the blockage, resultant
  hydronephrosis irreversible kidney damage.

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Urolithiasis

• Causes Family history of stone formation
• Diet high in CA, vitamin D, milk, protein,
  purines
• Obstruction urinary stasis
• Dehydration
• Use of diuretics, which can cause volume
  depletion
• Immobilization
• Hypercalcemia, hyperparathyroidism
• Elevated uric acid, such as gout

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Urolithiasis

• Nursing Assessment Nausea, vomiting, dietary
  intake of purines, phosphates, low fluid intake
  chills.
• Elimination Decreased u/o, urinary urgency,
  feeling of bladder fullness.
• General Acute, severe colicky pain in flank,
  back, abdomen groin or genitalia burning
  sensation on urination, dysuria,anxiety.
• Skin warm, flushed skin or pallor with cool.
• Urinary tenderness on palpation on renal areas,
  passage of stone(s).
• Increased BUN creatinine WBC, calcium,
  phosphorus, uric acid.
• KUB- calculi or anatomic changes on IVP

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Urolithiasis

• Implementation Force fluids up to 3000 mL/day,
  unless contraindicated-to facilitate the passage
  of the stone prevent infection.
• Strain all urine for the presence of stones.
• Turn and reposition immobilized clients.
• Administer analgesics response to pain.
• Instruct in the diet specific to the stone
  composition.

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Urolithiasis

• Surgical therapy
• Nephrolithomy- incision into the kidney to remove
  the stone.
• Pyelolithotomy- incision into the renal pelvis to
  remove the stone.
• Ureterolithotomy-removal of stone in the ureter.
• Cystotomy- indicated for bladder calculi.
• Lithotripsy- procedure used to eliminate calculi
  in the kidney. Hematuria is common after the
  procedure. A stent is often placed after the
  procedure to promote passage and to prevent
  obstruction, then removed 1 to 2 weeks after
  lithotripsy.

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Urinary Tract Infection (UTI)

• Teaching teach good perineal care to wipe from
  front to back.
• Instruct to void every 2 to 3 hours.
• Instruct to void drink a glass of water after
  intercourse.
• Encourage menopausal women to use estrogen
  vaginal creams to restore pH.
• Instruct the female to use water- soluble
  lubricants for coitus, especially after menopause.

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Polycystic Kidney Disease

• A cystic formation and hypertrophy of the kidney,
  which lead to cystic rupture, infection,
  formation of scar tissue and damaged nephrons.
• The ultimate results of this disease is renal
  failure.
• Types Infantile inherited autosomal recessive
  trait that results in the death of the infants
  within few month after birth.
• Adult dominant trait results in end-stage renal
  disease.

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Polycystic Kidney Disease

• Assessment Flank lumbar pain or abdominal pain,
  fever, chills, UTIs, hematuria, proteinuria,
  pyuria HTN, palpable abdominal masses enlarged
  kidney.
• Implementation
• Monitor for gross hematuria which indicates cyst
  rupture.
• Increase sodium water loss intake because
  sodium loss rather than retentions.
• Provide bed rest if cyst ruptured bleeding
  occurs

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Polycystic Kidney Disease

• Implementation Prepare for percutaneous cyst
  puncture for relief of obstruction or draining an
  abscess.
• Prepare client for dialysis and encourage genetic
  counseling.

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Renal Tumors

• May be benign or malignant Common sites of
  metastasis include bone, lungs, liver, spleen or
  other kidney.
• Assessment Dull flank pain, palpable renal mass,
  painless hematuria. Unknown cause.
• Treatment Radical nephrectomy Removal of the
  entire kidney, adjacent adrenal gland renal
  artery vein.
• Radiation therapy chemotherapy.

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Renal Tumors

• Implementation Monitor abdomen for distention
  caused by bleeding
• Observe bed linens under the client for bleeding
• Monitor for hypotension, decreases in urinary
  output alterations in LOC, indicating
  hemorrhage.
• Monitor urinary ouput
• Do not irrigate or manipulate the nephrostomy
  tube if in place.

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Nephrotic Syndrome

• Arising from protein wasting 2nd to diffuse
  glomerular damage.
• Assessment Proteinuria, edema, anemia,, malaise,
  irritability, HTN, waxy pallor of the skin,
  amenorrhea or abnormal menses.
• Implementation Monitor I/O. Bedrest if edema
  present, monitor daily weights.
• Administer plasma expanders, to raise the osmotic
  pressure.

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Nephrosclerosis

• Sclerosis of the small arteries arterioles of
  the kidney. There is decreased blood flow, which
  results in patchy necrosis of the renal
  parenchyma.
• Benign occurs in adults 30 to 50 yrs. of age. It
  is caused by vascular changes resulting from
  hypertension and from atherosclerosis process.
• Malignant-complication of HTN,characterized by
  sharp increase in BP with a diastolic pressure
  greater than 130 mm Hg.
• Treatment- aggressive antihypertensive therapy.
  The prognosis is poor.

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Phases of ARF

• Oliguric phase GFR decrease,hyperkalemia, fluid
  overload, elevated BUN creatinine.
• Diuretic phase GFR Begins to increase,
  hypokalemia, hypovolemia, gradual decline in BUN,
  creatinine.
• Recovery phase BUN is stable normal, complete
  recovery may take 1 to 2 years.

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Stages of Chronic RF

• Stage 1 Diminished renal reserve-renal function
  is reduced, no accumulation of metabolic wastes,
  nocturia polyuria occurs as a result of
  decreased ability to concentrate urine.
• Stage 11 Renal Insufficiency metabolic waste
  begin to accumulate, oliguria edema occur as a
  result of decreased responsiveness to diuretics.
• Stage 111 excessive accumulation of metabolic
  waste. Kidney are unable to maintain homeostasis.
  Dialysis is required.

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Kidney Transplant

• Implantation of a human kidney from a compatible
  donor into a recipient.
• Performed for irreversible kidney failure.
• Immunosuppressive medications must be taken for
  life.
• Complications Graft rejection- fever, malaise,
  elevated WBC, graft tenderness, signs of
  deteriorating renal function, acute HTN, anemia.
  Occurs immediately after surgery to 48
  hours-removal of rejected kidney.

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Kidney Transplant

• Avoid prolonged period of setting
• Recognize the signs symptoms of infection
  rejection.
• Avoid contact sports
• Use medications maintained immunosuppressive
  therapy for life.

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