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.
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
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 kidney’s
ability to concentrate urine. Measured by
multiple-test dipstick (most common
method), refractometer-instrument 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.
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.
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.
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.
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) radiographAn 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.
Renal Systems (Diagnostic test)
Computed tomography (CT) & MRIprovide 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.
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.
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.
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.
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.
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
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
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.
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.
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.
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
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
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.
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.
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.
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.
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
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.
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.
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.
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.
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.
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.
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.
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.
Kidney Transplant
Avoid prolonged period of setting
Recognize the signs & symptoms of
infection & rejection.
Avoid contact sports
Use medications & maintained
immunosuppressive therapy for life.