Ignatavicius & Workman: Medical-Surgical Nursing: Critical Thinking for Collaborative Care, 5th Edition Answer Guidelines – Study Guide Case Studies Chapter 72: Assessment of the Renal/Urinary System Case Study: Assessment of the Renal/Urinary System A 74-year-old man is scheduled to have a series of urologic studies for diagnostic purposes. The physician orders the following: urinalysis, urine for culture and sensitivity, BUN, serum creatine, and 24-hour urine for creatinine clearance. The tests will be conducted on an outpatient basis. 1. Describe what the nurse should do to instruct the client in the collection of these laboratory specimens. See Table 72-5, “Collection of Urine Specimens.” Voided urine: Collect the first specimen voided in the morning. Send the specimen to the laboratory as soon as possible. Refrigerate the specimen if a delay is unavoidable. Clean-catch specimen for culture and sensitivity: Explain the purpose of the procedure to the client. Instruct the client to self-clean before voiding. Instruct the female client to separate the labia and use the sponges and solution provided to wipe with three strokes over the urethra. The first two wiping strokes are over each side of the urethra; the third wiping stroke is centered over the urethra from front to back. Instruct the male client to retract the foreskin of the penis and to similarly clean the urethra, using three wiping strokes with the sponge and solution provided (from the head of the penis downward). Instruct the client to initiate voiding after cleaning. The client then stops and resumes voiding into the container. Only 1 ounce (30 mL) is needed; the remainder of the urine may be discarded into the commode. Ensure that the client understands the procedure. Assist the client as needed. 24-Hour urine collection for creatinine clearance: Instruct the client thoroughly. Provide written materials to assist in instruction. Place signs appropriately. Inform all personnel or family caregivers of test in progress. Check laboratory or procedure manual on proper technique for maintaining the collection (e.g., on ice, in a refrigerator, or with a preservative). On initiation of the collection, ask the client to void, discard the urine, and note the time. If a Foley catheter is in use, empty the tubing and drainage bag at the start time and discard the urine. Collect all urine of the next 24 hours. Twenty-four hours after initiation, ask the client to empty the bladder and add that urine to the container. Do not remove urine from the collection container for other specimens. The BUN and serum creatinine will be collected through blood samples taken by a phlebotomist. 2. Which specimens should be collected first? The urinalysis should be collected first, so it is a concentrated specimen. The clean-catch specimen should be collected next, and the 24-hour collection started after the other two have Copyright © 2006, 2002 by Elsevier Inc. Answer Guidelines – Study Guide Case Studies 2 been collected and sent to the laboratory. 3. The client returns the collection container with a 24-hour urine specimen to the physician’s office. As he gives it to the nurse, he comments, "I had a hard time remembering to save it all. Actually, I think I missed some when I forgot and used a bathroom at the shopping mall yesterday." What should the nurse do? For a composite urine specimen, all urine within the designated time frame must be collected. The nurse should instruct the client to repeat the collection and save all of his urine to the sample. 4. Further tests are ordered for the client, including a renal ultrasound and intravenous pyelography (IVP). These are scheduled at an outpatient radiology clinic. Design a teachinglearning plan for the client to prepare him for these studies. See discussion beginning on textbook p. 1668. For the ultrasound: Explain the rationale for the procedure and share information about sensations commonly experienced during the procedure. For example, “This test will measure the amount of urine in your bladder. I will place a gel pad just above your pubic area, then place the probe that is a little bigger and heavier than a stethoscope on the gel.” For the IVP: Instruct the client about bowel preparation. Assess for allergy information and report to physician; instruct client that drugs such as steroids or antihistamines may be given before the procedure if there is a chance of allergic reaction. Explain the rationale for the procedure to the client. Instruct the client that he may be NPO after a light liquid supper before the procedure or he may be encouraged to take fluids freely, depending on the physician’s order. 5. Following the ultrasound and IVP, what assessments should be made for the client? Because there is no discomfort or risk involved with the ultrasound, no special follow-up care is indicated. Following the IVP, monitor the client for altered renal function and other effects of the dye. Ensure adequate hydration by urging the client to take oral fluid or by giving IV fluids. Hydration reduces the risk for renal damage. Monitor blood creatinine levels to assess ongoing renal function. Copyright © 2006, 2002 by Elsevier Inc.