Renal assessment

Mrs. Mutinda
 Subjective Data

• Past Health History. Question the patient

about the presence or history of diseases
that are related to renal or other urologic
problems.
• Some of these diseases are hypertension,
diabetes, SLE, skin or URTIs of
streptococcal origin, TB, viral hepatitis.
• Ask about fever or chills, dysuria,
urgency, incontinence, hematuria,
nocturia.
• Presence or history of genital lesions or
sexually transmitted diseases
• Habits: use of tobacco, alcohol, or
recreational drugs
• Others include: Congenital disorders,
neurologic conditions (e.g., stroke, back
injury), or trauma.
• Other risk factors: infections, benign
prostatic hyperplasia, and calculi,
multiparity, advanced age and family
history of UTIs
• Medications- This should include over-
the counter drugs, prescription
medications, and herbs.
• Drugs affect the urinary tract in several
ways:
• may be nephrotoxic, alter the quantity
and character of urine output, change
the color of urine, cause hematuria.
• Many drugs used for neurologic & MS
disorders affect the ability of the bladder or
sphincter to contract or relax normally.
• Surgery or Other Treatments. Ask the
patient about previous hospitalizations
related to renal or urologic diseases and all
urinary problems during past pregnancies.
• Inquire about the duration, severity, and
patient’s perception of any problem and
its treatment.
• Document past surgeries, particularly
pelvic surgeries, or urinary tract
instrumentation (e.g., catheterization).
• Ask the patient about any radiation or
chemotherapy treatment for cancer.
 Objective data: Physical examination
• Inspection. Assess for changes in the
following:
• Skin: Pallor, yellow-gray cast, excoriations,
changes in turgor, bruises, texture (e.g., rough,
dry skin).
• Face and extremities: Generalized edema,
peripheral edema,
• Abdomen- bladder distention, masses,
enlarged kidneys
• Mouth: Stomatitis, ammonia breath odor
• Abdomen: Skin changes described earlier,
striae, abdominal contour for midline
mass in lower abdomen or unilateral
mass
• Weight: Weight gain secondary to
edema; weight loss and muscle wasting
in kidney failure
• General state of health: Fatigue, lethargy,
and diminished alertness
• Palpation of the kidneys may help
determine their size and mobility.
• Kidney enlargement is suggestive of
neoplasm or other serious renal
pathologic conditions.
• If the bladder is full, it may be felt as a
smooth, round, firm organ and is
sensitive to palpation.
 Diagnostic studies
• Urinalysis- General examination of urine to
establish baseline information or provide data
to establish a tentative diagnosis and
determine need for further studies.
• Causes of persistent proteinuria include
glomerular diseases, malignancies, diabetes
mellitus, preeclampsia, hypothyroidism,
exposure to heavy metals, and use of NSAIDs.
• Nursing intervention-
• Try to obtain first urinated morning
specimen.
• Ensure specimen is examined within 1 hr
of urinating.
• Before collecting, wash perineal area.
 Urine culture
• Confirms suspected urinary tract
infection and identifies causative
organisms.
• Urine culture and sensitivity also identify
the antimicrobial therapy that is best
suited for the particular strains
identified.
• Nursing intervention- Use sterile container for
collection of urine.
• Touch only outside of container.
• For women clean meatus meticulously.
• For men, retract foreskin (if present) and
cleanse glans
• Use at least three cleansing sponges
• After cleaning, instruct patient to start
urinating and then continue voiding in sterile
container.
• Catheterization may be needed if patient is
unable to cooperate with procedure
 Renal function tests
• Renal function tests are used to evaluate
the severity of kidney disease and to
assess the patient’s clinical progress.
• These tests also provide information on
the effectiveness of the kidney in
carrying out its excretory function
 Blood Urea Nitrogen

• Used to detect renal problems.

Concentration of urea in blood is
regulated by rate at which kidney
excretes urea.
• Reference interval: 6-20 mg/dL (2.1-7.1
mmol/L).
• Nursing consideration- When
interpreting BUN, be aware that non
renal factors may cause increase (e.g.,
rapid cell destruction from infections,
fever, GI bleeding, trauma, athletic
activity and excessive muscle breakdown,
corticosteroid therapy).
 Creatinine levels
• Creatinine is the end product of muscle
and protein metabolism and is released
at a constant rate.
• Reference interval: 0.6-1.3 mg/dL (53-
115 μmol/L).
• Nursing care: Explain the test and watch
for postpuncture bleeding
 Creatinine clearance
• Detects and evaluates progression of
renal disease.
• Test measures volume of blood cleared
of endogenous creatinine in 1 minute,
which provides an approximation of the
glomerular filtration rate.
• The test gauges the rate at which
creatinine, is "cleared" from the blood by
the kidneys.
• Sensitive indicator of renal disease used
to follow progression of renal disease.
• Measured in mL/minute/1.73 m2
• Age Male Female
• Under 30 88–146 81–134
• 30–40 82–140 75–128
• 40–50 75–133 69–122
• 50–60 68–126 64–116
• 60–70 61–120 58–110
• 70–80 55–113 52–105
Endoscopic procedures
 Ultrasonography
• Ultrasonography is a non-invasive procedure
that uses sound waves passed into the body
through a transducer to detect abnormalities
of internal tissues and organs.
• The procedure involves passing sound waves
into body structures & recording images as
they are reflected back.
• A Computer interprets tissue density
based on sound waves and displays it in
picture form.
• Renal ultrasound is used to detect renal
or perirenal masses, differential
diagnosis of renal cysts, solid masses, &
identification of obstructions.
• It can be used safely in patients with
renal failure.
• Nursing care: Ultrasonography requires a
full bladder; therefore, fluid intake
should be encouraged before the
procedure.
• Explain the procedure to the patient
 Renal (CT) Scan
• Computed Tomography (CT) Scan:
Provides excellent visualization of kidneys.
• Shows location, size, and shape of kidney
and, in general, assesses blood flow,
glomerular filtration, tubular function, and
urinary excretion
• Also monitors function of a transplanted
kidney.
• Tumors, abscesses, suprarenal masses (e.g.
pheochromocytomas, adrenal tumors) &
obstructions can be detected.
• Abscesses, cysts, and tumors may appear as
cold spots because of non-functioning tissue.
• It is able to distinguish subtle differences in
density especially with use of IV-administered
contrast media.
 Nursing care
• Explain procedure to patient.
• Ask patient about iodine sensitivity.
• Inform patient that no pain or discomfort
should be felt during test.
• Instruct the patient to lie still during the
procedure while the machine takes
precise images.
• Sedation may be required if patient is
unable to cooperate.
 Magnetic resonance imaging (MRI)

• Useful for visualization of kidneys.

• Computer generated films rely on
radiofrequency waves and alteration in
magnetic field.
• Used in evaluating genitourinary masses,
nephrolithiasis, chronic renal infections, renal
or urinary tract trauma, metastatic disease,
and soft tissue abnormalities.
• Contraindications: presence of implanted
magnetic clips or prosthesis and pacemakers
• Nursing care: Explain procedure to pt.
• Reassure the patient that it is not painful.
• Have patient plus the nurse remove all metal
objects.
• Patients with a history of claustrophobia may
need to be sedated. A soothing music can help
 Intravenous
pyelogram (IVP)
• Visualizes urinary tract after IV injection of
contrast media.
• Presence, position, size, and shape of kidneys,
ureters, and bladder can be evaluated.
• Cysts, tumors, lesions, and obstructions cause
a distortion in normal appearance of these
structures.
• After the contrast agent is administered
intravenously, multiple x-rays are obtained to
visualize drainage structures.
• Contraindicated in Patients with significantly
decreased renal function because contrast
media can be nephrotoxic and worsen renal
function.
• Nursing care: Evening before procedure, give
cathartic or enema to empty colon of feces and
gas- to facilitate quality exam
• Before procedure, assess patient for iodine
sensitivity to avoid anaphylactic reaction.
• Inform patient that procedure involves lying on
table and having serial x-rays taken.
• After procedure, force fluids (if permitted) to
flush out contrast media. Monitor UECs .
 Renal angiography
• A renal angiogram, or renal arteriogram,
provides an image of the renal arteries.
• The femoral (or axillary) artery is pierced with
a needle, and a catheter is threaded up
through the femoral and iliac arteries into the
aorta or renal artery.
• A contrast agent is injected to opacify the
renal arterial supply.
• Angiography is used to evaluate renal
blood flow in suspected renal trauma, to
differentiate renal cysts from tumors, and
to evaluate hypertension.
• It is used preoperatively for renal
transplantation
• Nursing care- Before procedure: Prepare
patient the prior evening by giving cathartic or
enema.
• Before injection of contrast material, assess
for iodine sensitivity.
• The patient may experience a transient warm
feeling along the course of the blood vessel
when contrast media is injected.
• After procedure: Place a pressure
dressing over femoral artery injection
site.
• Observe site for bleeding.
• Have patient maintain bed rest with
affected leg straight.
• Take peripheral pulses in the involved leg
every 30-60 min to detect occlusion of blood
flow caused by a thrombus.
• Observe for complications, including
thrombus, embolus, local inflammation,
hematoma.
 Cystoscopy
• Inspects interior of bladder with a
tubular lighted scope (cystoscope).
• Lithotomy position is used.
• Indications: Can be used to insert
ureteral catheters, remove calculi, obtain
biopsy specimens of bladder lesions, and
treat bleeding lesions.
• Procedure may be done using local or
general anesthesia, depending on
patient’s needs and condition.
• Complications include urinary retention,
urinary tract hemorrhage, bladder
infection, and perforation of the bladder.
 Nursing care
• Before procedure
• Force fluids or give IV fluids if general
anesthesia is to be used.
• Ensure consent form is signed.
• Explain procedure to patient.
• Give preoperative medication.
• After procedure:
• Explain that burning on urination, pink-tinged urine,
and urinary frequency are expected effects.
• Observe for bright red bleeding, which is not normal.
• Do not let patient walk alone immediately after
procedure because orthostatic hypotension may
occur.
• Offer warm sitz baths, heat, mild analgesics to
relieve discomfort.
 Renal Biopsy
• Obtains renal tissue for examination to
determine type of kidney disease or to follow
progress of kidney disease.
• Technique is usually done as a skin
(percutaneous) biopsy through needle
insertion into lower lobe of kidney.
• Can be performed with CT or ultrasound
guidance.
 Contraindications
• Absolute contraindications are bleeding
disorders, single kidney, and uncontrolled
hypertension.
• Relative contraindications include
suspected renal infection and possible
vascular lesions.
 Nursing care
• Ensure blood has been done grouping
and cross matching
• Ensure consent form is signed.
• Before procedure: Ascertain coagulation
status through patient history,
medication history, CBC, hematocrit,
prothrombin time, and bleeding and
clotting time.
• Patient should not be taking aspirin or
warfarin
• After procedure:
• Apply pressure dressing and keep patient
on affected side for 30-60 min.
• Advise on bed rest for 24 hr.
• Take Vital signs every 5-10 min, first hour.
• Assess for flank pain, hypotension, Fever,
chills, urinary frequency, dysuria, and
hematuria.
• Inspect biopsy site for bleeding.
• Instruct patient to avoid lifting heavy objects
for 5-7 days and to not take anticoagulant
drugs until allowed by health care provider.