renal urinary assessment2

7/29/2019 Renal Urinary Assessment2

1/13

Unit III: Care of Clients with Complex Urinary/Renal Disorders

Renal Assessment and Diagnostic Procedures

A&P Review:

Kidneys (2): receive 20-25% cardiac output.

Cortex: contains nephrons (1 million per kidney) (nephrons are the filtration anddrain mechanisms)

Medulla: contains loops of Henle and collecting ducts. (The nephrons hang downinto the medulla.)

Normal blood flow: 1200 mL/min

Produce 180 L filtrate/day: 99% is of which is re-absorbed- depends on consistentpressure through glomeruli. (When there is problems with even a slight deviation

with the pressure the kidneys act with hormones and other mechanism saving andor excreting electrolytes and other substances to force the blood flow to get better.)

Tubules produce 1000 1500 mL urine/24 hrs.

ADH (vasopressin): (one of the most important hormones in this whole process) (itraises the B/P)

stimulatesHO re-absorption in dry states

Excess HO causes ADH and urinary excretion

Right kidney is slightly lower than the left because of the liver.


2/13

A&P Review:

*Osmolarity: ratio of solutes to HO; variation of 1-2% causes thirst and ADH.(ratio of solid particles to water in the urine. If the osmilarity goes up it will causeyou to start drinking and your urine will become more concentrated because yourbody is telling the kidneys to retain water.)

*Osmolality: degree of concentration or dilution (measures in osmoles- unit ofmeasuring osmotic pressure. 280 300 mOsm/L is normal limit for blood (urineosmolality is 200-800 mosm/kg is normal)(osmolality is the most accurate measureof the kidneys ability to loop or concentrate urine.)

A&P Review:

Functions of Kidney:

*Fluid balance: nL = urine when HO intake and vice versa.

---Daily weights are the reliable way to determine overall fluid status. 1 lb. = 500mL.

*Electrolytes balance:

---Sodium: most plentiful extracellular ion. 90% Na in filtrate is re-absorbed. Whatregulates this is Aldosterone (secreted by the renal cortex): aldosterone = Na inurine (meaning your retaining sodium). Aldosterone release controlled byangiotensin II.

---Potassium: most plentiful intracellular ion. ~90% K+ intake excreted. aldosterone = K+ excreted in urine

(If the renal cortex is not producing enough aldosterone or it produces aldosteronethat the kidneys dont respond to then sodium and potassium start building up in

the blood because they dont get excreted.)


3/13

A lot of fluid a aa

Blood is coming through the arterial, and some of it goes into the glomerulus (whichis a network of capillaries) and into bowmans capsule. There is an exchange thattakes place here where a lot of fluid and electrolytes cross over into Bowmanscapsule. (In bowmans capsule ultrafiltrate forms which consists of fluids and smallmolecules.)Usually small solutes cross over. Large molecules dont. If they do they

will get reabsorbed back again very quick such as glucose molecules and proteinmolecules.

((Almost all glucose gets reabsorbed unless the patient has a problem withhyperglycemia in which case the blood concentration of glucose is so high that thekidneys cant cope with all of the reabsorbing. It reaches the renal threshold .Thisis why we say when diabetic patients have high glucose levels they will spillglucose into their urine.)


4/13

(all of the creatinine should be excreted which is a byproduct of proteinmetabolism.)

A&P Review

Functions of Kidney, contd

Acid-base balance (changes in the PH of the blood will cause these changes)

---Excretes organic acids and retains bicarbonate.

Regulation of Blood pressure: Renin-Angiotensin-Aldosterone system

---Angiotensin II: most powerful vasoconstrictor known.

Renal clearance of solutes: creatinine clearance (protein/muscle metabolism)-

good measure of GFR. (good indicator of overall kidney function. This is why they do24 hour urine specimens in renal patients because they want to see over time howthe glomeruli are concentrating or diluting urine. )

RBC Production: erythropoietin (the kidneys have a big role in RBC production.They produce a hormone walled erythropoietin that stimulates the bone marrow toproduce more RBCs. This is a big problem for chronic renal failure patients. They


5/13

are always somewhat to severely anemic due to low erythropoietin production fromdamaged or nonfunctioning kidneys.)

Vitamin D: The kidneys convert inactive to active form. This is very important inthe regulation of bone resorption (process by which osteoclasts break down boneand release the minerals, resulting in a transfer of calcium from bone fluid to theblood) which is why many renal failure patients have a problem with osteoporosisbecause they dont convert vitamin D into the active form and vitamin D is what

mediates the process of laying down bone and keeping calcium in your bones.

A&P Review

Functions of Kidney, contd

Prostaglandins (produced by the kidneys in the presence of ischemia): closelyassociated with R-A-A system (basically what the prostaglandins do is mediate toincrease the release of renin to help maintain kidney blood flow during ischemic

states.)

Excretion metabolic wastes and drug metabolites


6/13

History

*Chief Complaint: state in patients own words

*Renal Symptoms, e.g. hematuria, dysuria, edema, rapid weight gain (especially withdecreased appetite), metallic taste (that cant be associated with any medication oranything thieve consumed), orthopnea, n/v. (also symptoms like nocturia, hiccups(that dont go away), mental status changes, unexplained anemia, and abdominaldistention of unknown origin.)

*Predisposing Risk Factors: use of OTCs, recent infections(doesnt have to beinfections of the urinary tract because toxins from other infections can migrate.),severe trauma or strenuous physical activity (because of rhabdomyolysis.Rhabdomyolysis is the rapid break down of skeletal muscle tissue caused mainly bycrush injuries, trauma to different parts of the body, or obstruction of the muscleblood supply where the muscle becomes ischemic, excessive muscle strain andstrenuous physical activity, burns, and high voltage electrical shock. Basically whathappens is rhabdomyolisis causes myoglobin to circulate in the blood and it quicklyoverwhelms the ability of the kidneys to clear it and it stops up those littlecapillaries because it is a big molecule. It will cause acute tubular necrosis and acuterenal failure.)

*Medical History: note diabetes and hypertension (because they have the biggestand most common effects on the kidneys.)

*Previous Diagnostic Studies: note studies using contrast. (particularly recent ones.)

*Current Medication Usage (not only prescription because there is a bunch ofnephrotoxic drugs but also OTC and Herbal medications that have effects on thekidneys. One herbal that is popular called Echinacea that people take for colds has adirect effect on the kidneys in large doses. )( Glucosamineincreases blood sugar.Dandelion, Alfalfa, and Noni juice all contain increased amounts of potassium so ifthe patient already has a kidney problem it can make their fluid and electrolytebalance even worse.)

*Social History and Family History (particularly their history of drug and alcohol

abuse.)Geriatrics: (these are all normally aging except urinary incontinence.)

*decreased ability to concentrate urine

---Higher risk for adverse reactions to meds and drug-drug interactions

*decreased sensation of thirst


7/13

---Higher risk for dehydration and hypernatremia

* decreased bladder capacity and bladder emptying (which can put them at risk forUTI)

* Urinary incontinence

---Not a normal consequence of aging (but may be a problem with older folks whohave co morbid conditions and thieve developed incontinence such as strokepatients.)

Physical Examination

Inspection:

Bleeding: e.g. Grey-Turner sign (this is bruising of the flanks), bruising, abdominaldistention and guarding . (these mainly has to do with kidney trauma)

Fluid volume (usually fluid volume overload): neck veins (for JVD), hand veins, skinturgor, oral mucosa. (you will also be looking for bulging flanks and ascites whichmay form cause of fluid overload. It is best seen with the patient supine and theobserver at the patients feet and looks to their abdomen that way. )

Edema: non-specific to renal problems. (which means it is caused by manydifferent things, but it is something to be investigated.)


Auscultation:

Heart: gallops, pericardial friction rub (people who are having problems with fluidoverload may have gallops (S3 gallop is a turbulence of blood in a stretched andoverload ventricle. An S4 gallop is a vibration of four forceful atrial contractionsfrom the atria being stretched from too much blood in it. A pericardial friction rubmay be present in some chronic renal patients because of pericardial effusionsbecause of the build up of metabolic waste products in their blood that sets up anirritation.)

Blood Pressure: should always be assessed with orthostatic measurements

Lungs: crackles, dyspnea, altered breathing patterns (for signs of respiratory

distress)


Palpation: (kidneys are not usually palpable however in some states it may beimportant to palpate to see if they are palpable in that patient.)

Kidney: bimanual capturing approach (on hand on the anterior position of the flankand the other on the posterior); size and shape on each side are compared; to detect


8/13

size differences, masses, irregular surface (polycystic kidney disease is a chronicdisease where the patients kidneys become very cystic and very irregular. It kind oflooks like plastic bubble rap on the outside.)

Bladder: palpate area between umbilicus and pubic bone for distention, pain,

feeling of urgency.

(Bladder ultrasound is a non-invasive, painless, bedside test to check amount ofurine in bladder- more precise than palpation.)

Bladder Ultrasound:

This ultrasound shows over-distended bladder w/ approx 450 mL urine.


Percussion:

Kidneys: dull, painless thud is normal. Pain indicates injury, infection.Abdomen: may have dull or hollow sounds (those are usually cause for suspectingfluid in the abdomen because the abdomen should have a tympanic sound. Shiftingdomis where there is areas of hallow vs. dull means that there may be fluid in theabdomen and when you move the patient around these sounds will shift around)

Fluid wave: differentiates fluid in abdomen from solid bowel contents (basicallyyou have the patient push down on the abdomen at the midline and you will start


9/13

taping one flank and you have your other hand on the other side to see if you canfeel it on the opposite side. If you feel it then it is due to fluid transmission of thevibration. You can also see it by pushing against the patients abdomen with your

hand on one side and the letting it go and watching the patients abdomen settleback. It should just snap back kind of like a rubber band, but with the fluid wave it

will kind of wiggle like jello. In a normal patient you wont feel this.) Renal: ascitesfrom fluid overload.

Additional Assessment Parameters

*Weight: one of most important measurements for renal and fluid status (This willbe a test question)

---Body weight / fluid relationship: rapid gains and losses indicate fluid rather thannutrition. (normal weight loss if you are on a diet is 1 to 1 and a half pounds a week.If you are losing or gaining pounds a day it is fluid it is not nutrition)(one thing toremember is 1kg of weight is equal to 1 liter or 1000ml. That is important to

remember.)

*Intake and Output

---Urine

---Insensible losses: perspiration, stool, water vapor from lungs. (This is what makeseven strict I/O difficult to measure as appose to the patients weight.)

---Other losses: emesis, gastric suction, wound drainage


*Hemodynamic Monitoring

---CVP: < 2mm Hg= fluid depletion; > 6 mm Hg= fluid overload

---PAWP (wedge): < 8 mm Hg= fluid depletion; > 12 mm Hg= fluid overload

---MAP: may be decreased or increased depending on fluid status

---CO / CI: Cardiac index (CI): < 2.2L/min/m = fluid depletion; > 4.4L/min/m =fluid overload (we usually pay more attention to the cardiac index because yourtaking the cardiac output and dividing it by the bodies surface area.)


Other Observations:

Fluid and electrolyte imbalances: renal dysfunction often leads to these

Mental status changes you may see:


10/13

---lethargy, confusion, coma: all result from Na, Ca, or Mg excess (because thekidneys are not getting rid of enough of these)

---anxiety, apprehension: Na deficit, fluid overload (Na deficit and fluid overload canhappen together.)

---apathy, withdrawal: you will see this with hypovolemia.

Laboratory Assessment

Blood Serum Analysis

Blood Urea Nitrogen (BUN): results from fall in excretion of urea- a by-product ofprotein met. (increased BUN can result from other things like drugs and otherconditions so you cant rely on BUN to give you as clear a picture of as whats going

on with the kidneys as creatinine.) because creatinine comes from the decreasedglomerular filtration. It comes from the kidneys not being able to get rid of it period

it doesnt come from anything else. It is more accurate than the BUNCreatinine: results from GFR. More accurate than BUN to indicate renal function.BUN:Creatinine ratio: nl = 10:1 (creatinine is more accurate than BUN becausecreatinine comes from the decreased glomerular filtration. It comes from thekidneys not being able to get rid of it period. It doesnt come from anything else. It is

more accurate than the BUN.)

Creatinine Clearance: amount creatinine in urine and blood over 24 hours.Creatinine clearance decreases as renal function decreases. (However we are veryresilient. Most of these tests will come out normal until GFR is less than 50% ofnormal and so we can go a lot time without knowing that anything is wrong. People

dont really get really sick with failing kidneys until the GFR is lower than like 20%of normal.)

Osmolality: nl: 280-300 mOsm/L

Anion Gap: difference between anions (Na, K) and cations (Cl and HCO3). Aniongap > 20 mEq/L indicates met. Acidosis (you wil see the anion gap on electrolytepanels. (What it does is add the NA and the K together. Then it adds the CL andHCO3 together. Then you subtract those two numbers. If there is a gap betweenthose two numbers greater then 20 mEq/L then that indicates that the patient hasmetabolic acidosis. Metabolic acidosis is a hallmark of renal failure.)

Hemoglobin and Hematocrit: hemodilution, hemoconcentration, productionerythropoietin (H&H is checked because of the decreased production oferythropoietin. You will see a decrease in the H&H. You may also see it because ofhemodilution cause of fluid overload. On the contrary you may seehemoconcentration from hypovolemia in which cause you will see an artificiallyhigh H&H. Then when you get them rehydrated the H&H comes back because thehemoconcentration has gone away. The concentrated H&H is all diluted out. The


11/13

patient is now euvolemic (normal blood volume) and you now have what the H&Hreally is. It can be upsetting to say the least.)

Albumin: decrease causes generalized edema (you will see a decreased albumin inacute renal failure patients because their losing albumin all the time because of thepermeability of the tubules in the kidneys to albumin. It causes a lot of albumin toescape into the urine and not be reabsorbed.)(In chronic renal failure you will se adecreased albumin but mainly because of nutritional reasons.)

Laboratory Assessment

Urine Analysis:

Urine pH: indicates kidney regulation of acid-base (normal urine PH should bebetween 3 and 4.)

Specific Gravity / Osmolality (we are trying to measure how much solute is in the

urine. It will show us how well the kidneys are concentrating urine. Normal urinespecific gravity is 1.010- 1.025. Urine osmolality is 200-800 osmoles per kg ofpatients weight.)

Glucose: should not be present in urine

Protein: amount correlates with severity of glomerular damage (up to 150 mg aday is normal because some escapes the reabsorption process. We are talking aboutgrams of protein a day in patients with glomerular damage that is lost in the urine.)

Electrolytes: 24 hour measurement of excretion (Remember that the first voidedspecimen is always thrown away. That time that the voiding is done and the

specimen is thrown away is the time that the 24 hour urine starts. When the timecomes for it to end you ask the patient to empty the bladder one more time and youcollect that. These may also be correlated with blood draws that have to be done atcertain times so that comparison is made between the serum and the urine.)

Sediment: types of sediment in the urine indicate etiology of renal problems (

Hematuria: can be gross and/or microscopic (there should be no more than 3 RBCper field when theyre looking through a microscope because thats all that isnormal.)

(Ketones are also checked for. These may be present but they usually are not

present at all, but in diabetic ketone acidosis (they may be strongly present), instarvation, and people on ketonic diets they may have ketones in their urine (andthis is not an emergency.)

(Bacteria. More than 100,000 per ml of any one organism is significant. One or twohere or there is considered accident from the urine process. From the process ofvoiding itself.)


12/13

Renal Diagnostic Studies:

*CT scan (with or without contrast)

*Cystoscopy (which is an invasive test. Its used to visualize the urethra, the bladder,to biopsy, and to remove stones. There is a lot of stuff they do with cystoscopy.)

*IVP (intravenous pyelogram ) (also invasive. The patient is injected with a lot ofdilute contrast so there are allergy considerations and there are also hydrationconsiderations. They have o be well hydrated. There are no restrictions. They maybe asked not to eat anything before the test for 8-12 hours before the test butdrinking is allowed. They may also be given laxatives to evacuate their bowels. Infact a lot of these tests where they are doing x-ray or fluoroscopy like an IVP andrenal angiography they will have the patient do a bowel cleansing. )

*KUB

*MRI (Patients are told in a renal MRI to avoid alcohol, caffeine, and smoking for 24hours and not to take nay iron supplements they may be taking because of beingaround the magnets.)

*Renal angiography (It is an invasive procedure. Contrast is used. It is like any otherangiogram they will use a big blood vessel in the arm, leg, or groin. So all the issuesof taking vitals signs, neurovascular checks on the on limb being used, and watchingfor bleeding are all applicable here.)

*Renal biopsy (can be done several ways such as a brush biopsy to collect cells. IV

fluids are giving to people after these procedures particularly to patients whounderwent brush biopsy in order to prevent blood clots. You can expect that theurine will have blood in it 24-48 hours. The patient is going to need pain medicationbecause they are going to have renal colic (a type of abdominal pain usually causedby kidney stones that is very severe)(With needle biopsies the patient is sedated butconscious enough for them to cooperate when they ask them to inhale and holdtheir breath when they insert the needle so that nothing is moving. They have themlay on their side with a sandbag underneath the opposite flank.)(With renal biopsyyou need to make sure and check the patients coags because they are sticking aneedle in there and you want to make sure that they wont bleed to death. Renalbiopsy is also contraindicated if the patient only has one kidney, hypertension,

morbid obesity, or bleeding disorder.)

*Renal ultrasound (they look for obstructions, masses, and malformations)

*Bladder ultrasound

*Voiding cystourethrography (basically what they do is put a catheter into thebladder and fill the patients bladder up with dilute contrast agent and when thepatient feels like they have to void they will take pictures while the patients voiding.


13/13

They will look at bladder size and any problems the patient may have with urinaryretention. The only thing the teacher can think of with voiding cystourethrographywas that it is very embarrassing for the patient to have to void in front of peopleespecially older people.

*Renal radionuclide scan (renogram) (A radio isotope is used. You should watch foriodine allergy because an iodine isotope is sometimes used. The test is time to allowthe isotope to concentrate in the kidneys. It is used to evaluate kidney perfusionsand identify masses. It can also estimate GFR. Post procedure your responsibility isto encourage fluids to flush the isotope out of the body.

renal urinary assessment2

Documents