Chapter 1 : Diagnostic tests renal system

diagnostic test and nursing considerations

1. Chapter II Diagnostic Studies for Patients with Renal and Urinary System Dysfunction: Nursing Management 1 Renal and Urinary System Nursing Care/ H.AKOUM

2. Objectives On completion of this chapter, the learner will be able to: Describe the diagnostic studies used to determine upper and lower urinary tract function 2

3. LABORATORY STUDIES Tests of Renal Function Description Renal function tests are used to determine effectiveness of the kidneys' excretory functioning, to evaluate the severity of kidney disease, and to follow the patient's progress. There is no single test of renal function; best results are obtained by combining a number of clinical tests. Renal function is variable from time to time. 3 Renal and Urinary System Nursing Care/ H.AKOUM

4. LABORATORY STUDIES Tests of Renal Function Nursing and Patient Care Considerations Test Purpose/ Rationale Test protocol Normal values Renal concentration test Specific gravity Osmolality of urine Tests the ability to concentrate solutes in the urine. Concentration ability is lost early in kidney disease; hence, this test detects early defects in renal function. Fluids may be withheld 12-24 hours to evaluate the concentrating ability of the tubules under controlled conditions. Specific gravity measurements of urine are taken at specific times to determine urine concentration. 1.010–1.025 300–900 mOsm/kg/24 h, 50–1,200 mOsm/kg random sample 4 Renal and Urinary System Nursing Care/ H.AKOUM

5. LABORATORY STUDIES Tests of Renal Function Nursing and Patient Care Considerations Test Purpose/Rationale Test protocol Normal values Creatinine clearance 24 hour urine test Provides a reasonable approximation of rate of glomerular filtration. Measures volume of blood cleared of creatinine in 1 minute. Most sensitive indication of early renal disease. Useful to follow progress of the patient's renal status. Collect all urine over 24-hour period. Draw one sample of blood within the period. 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 5

6. LABORATORY STUDIES Tests of Renal Function Nursing and Patient Care Considerations Test Purpose/Rationale Test protocol Normal values Serum creatinine A test of renal function reflecting the balance between production and filtration by renal glomerulus . Most sensitive test of renal function. Obtain sample of blood serum. 0.6–1.2 mg/ dL (50–110 μ mol/L) Serum urea nitrogen (Blood urea nitrogen [BUN]) Serves as index of renal excretory capacity. Serum urea nitrogen depends on the body's urea production and on urine flow. (Urea is the nitrogenous end-product of protein metabolism.) Affected by protein intake, tissue breakdown. Obtain sample of blood serum. 7–18 mg/ dL Patients over age 60 years: 8–20 mg/ dL 6

7. LABORATORY STUDIES Tests of Renal Function Nursing and Patient Care Considerations Test Purpose/Rationale Test protocol Protein Random specimen may be affected by dietary protein intake. Proteinuria >150 mg/24 hours may indicate renal disease. Collect all urine over 24-hour period. Microalbumin / Creatinine ratio Sensitive test for the subsequent development of proteinuria ; >30 mcg/mg creatinine predicts early nephropathy. Collect random urine specimen 7

8. LABORATORY STUDIES Tests of Renal Function Nursing and Patient Care Considerations Test Purpose/Rationale Test protocol Urine casts Mucoproteins and other substances present in renal inflammation; help to identify type of renal disease ( eg , red cell casts present in glomerulonephritis , fatty casts in nephrotic syndrome, white cell casts in pyelonephritis ). Collect random urine specimen. 8 Renal and Urinary System Nursing Care/ H.AKOUM

9. LABORATORY STUDIES Prostate-Specific Antigen Description PSA is an amino acid glycoprotein that is measured in the serum by a simple blood test. An elevated PSA indicates the presence of prostate disease, but is not exclusive to prostate cancer. Level rises continuously with the growth of prostate cancer. Normal serum PSA level is less than 4 ng / mL. Levels less than 10 ng / mL may be indicative of benign prostatic hyperplasia (BPH) and not necessarily prostate cancer. Patients who have undergone treatment for prostate cancer are monitored periodically with PSA levels for recurrence. 9 Renal and Urinary System Nursing Care/ H.AKOUM

10. LABORATORY STUDIES Prostate-Specific Antigen Nursing and Patient Care Considerations No patient preparation is necessary. Some clinicians prefer not to perform digital rectal examinations of the prostate at the same time that a PSA is drawn, to prevent artificial elevation of PSA level, although this association has not been proved. Clinical laboratories may differ slightly in methods used for determining PSA; patients having serial PSA should be sent to the same laboratory. 10 Renal and Urinary System Nursing Care/ H.AKOUM

11. LABORATORY STUDIES Urinalysis Description Involves examination of the urine for overall characteristics, including appearance, pH, specific gravity, and osmolality as well as microscopic evaluation for the presence of normal and abnormal cells. Appearance: normal urine is clear. Cloudy urine ( phosphaturia ) is not always pathologic, related only to the precipitation of phosphates in alkaline urine. Normal urine may also develop cloudiness on refrigeration or from standing at room temperature. Abnormally cloudy urine due to pus ( pyuria ), blood, epithelial cells, bacteria, fat, colloidal particles, phosphate, or lymph fluid ( chyluria ). 11 Renal and Urinary System Nursing Care/ H.AKOUM

12. LABORATORY STUDIES Urinalysis 2. Odor: normal urine has a faint aromatic odor. Characteristic odors produced by ingestion of asparagus, thymol . Cloudy urine with ammonia odor urea-splitting bacteria such as Proteus, causing UTIs. Offensive odor may be due to bacterial action in presence of pus. 12 Renal and Urinary System Nursing Care/ H.AKOUM

13. LABORATORY STUDIES Urinalysis 3. Color: shows degree of concentration and depends on amount voided. Normal urine is clear yellow or amber because of the pigment urochrome . Dilute urine is straw-colored. Concentrated urine is highly colored; a sign of insufficient fluid intake. Cloudy or smoky colored: may be from hematuria , spermatozoa, prostatic fluid, fat droplets, chyle . Red or red-brown: due to blood pigments, porphyria , transfusion reaction, bleeding lesions in urogenital tract, some drugs and food (beets). Yellow-brown or green-brown: may reveal obstructive lesion of bile duct system or obstructive jaundice. Dark brown or black: due to malignant melanoma, leukemia. 13 Renal and Urinary System Nursing Care/ H.AKOUM

14. LABORATORY STUDIES Urinalysis 4. pH of urine: reflects the ability of kidney to maintain normal hydrogen ion concentration in plasma and extracellular fluid; indicates acidity or alkalinity of urine. pH should be measured in fresh urine because the breakdown of urine to ammonia causes urine to become alkaline. Normal pH is around 6 (acid); may normally vary from 4.6 to 7.5. Urine acidity or alkalinity has relatively little clinical significance unless the patient is on a special diet or therapeutic program or is being treated for renal calculous disease. 5. Specific gravity: reflects the kidney's ability to concentrate or dilute urine; may reflect degree of hydration or dehydration. Normal specific gravity ranges from 1.005 to 1.025. Specific gravity is fixed at 1.010 in chronic renal failure. In a person eating a normal diet, inability to concentrate or dilute urine indicates disease. 14 Renal and Urinary System Nursing Care/ H.AKOUM

15. LABORATORY STUDIES Urinalysis 6. Osmolality is an indication of the amount of osmotically active particles in urine ( number of particles per unit volume of water) . It is similar to specific gravity, but is considered a more precise test; it is also easy only 1 to 2 mL of urine are required. Average value is 300 to 1,090 mOsm / kg for females; 390 to 1,090 mOsm /kg for males. 15 Renal and Urinary System Nursing Care/ H.AKOUM

16. LABORATORY STUDIES Urinalysis Nursing and Patient Care Considerations Freshly voided urine provides the best results for routine urinalysis; some tests may require first morning specimen. Obtain sample of about 30 mL. Urine culture and sensitivity tests are typically performed using the same specimen obtained for urinalysis; therefore, use clean-catch or catheterization techniques. Patients with urinary diversions, especially ileal conduit diversions, require special techniques to obtain urine that is not contaminated with bacteria from the intestinal diversion. 16 Renal and Urinary System Nursing Care/ H.AKOUM

17. LABORATORY STUDIES Urinalysis TECHNIQUE FOR OBTAINING CLEAN-CATCH MIDSTREAM VOIDED SPECIMEN EQUIPMENT Antiseptic solution or liquid soap solution Sterile water 4 أ—4- inch gauze pads Disposable gloves for nurse assisting female patient Sterile specimen container 17 Renal and Urinary System Nursing Care/ H.AKOUM

18. LABORATORY STUDIES Urinalysis Nursing Action Rationale Male patient 1 . Instruct the patient to expose glans and cleanse area around meatus . Wash area with mild antiseptic solution or liquid soap. Rinse thoroughly . 1. The urethral orifice is colonized by bacteria. Urine readily becomes contaminated during voiding. Rinse antiseptic solution or soap solution thoroughly because these agents can inhibit bacterial growth in a urine 2. Allow the initial urinary flow to escape. 2. The first portion of urine washes out the urethra and contains debris. 3. Collect the midstream urine specimen in a sterile container. 3. The midstream sample reflects the status of the bladder. 4. Avoid collecting the last few drops of urine. Prostatic secretions may be introduced into urine at the end of the urinary stream in men. 18

19. LABORATORY STUDIES Urinalysis Nursing Action Rationale Female patient 1 . Ask the patient to separate her labia to expose the urethral orifice. If no one is available to assist the patient, she may sit backward on the toilet seat facing the water tank or sit on (straddle) the wide part of the bedpan. 1. Keeping the labia separated prevents labial or vaginal contamination of the urine specimen. By straddling the toilet seat or bedpan, the patient's labia are spread apart for cleansing. 2. Clean the area around the urinary meatus with pads soaked with antiseptic/soap solution. Rinse thoroughly. Wipe the perineum from the front to the back. Do not use pads more than once. 2. The first portion of urine washes out the urethra and contains debris. To avoid contamination from the anus. 19

20. LABORATORY STUDIES Urinalysis Nursing Action Rationale Female patient 3. While the patient keeps the labia separated, instruct her to void forcibly. 3. This helps wash away urethral contaminants. 4. Allow initial urinary flow to drain into bedpan (toilet) and then catch the midstream specimen in a sterile container, making sure that the container does not come in contact with the genitalia. 4. The first portion of urine washes out the urethra. Have the patient remove the container from the stream while she is still voiding. Follow-up phase 1. Send specimen to laboratory immediately. A culture should be performed as soon as possible to avoid multiplication of urinary bacteria and lysis of cells. 20 Renal and Urinary System Nursing Care/ H.AKOUM

21. Diagnostic imaging X-ray of Kidneys, Ureters , and Bladder ( kub ) Description Consists of plain film of the abdomen Delineates size, shape, and position of kidneys Reveals deviations, such as calcifications (stones), hydronephrosis , cysts, tumors, or kidney displacement 21 Renal and Urinary System Nursing Care/ H.AKOUM

22. Diagnostic imaging X-ray of Kidneys, Ureters , and Bladder ( kub ) Nursing and Patient Care Considerations No preparation is needed. Usually done before other testing. Patient will be asked to wear a gown and remove all metal from the X-ray field. 22 Renal and Urinary System Nursing Care/ H.AKOUM

23. Diagnostic imaging Intravenous Pyelogram (Intravenous Urogram ) Description I.V. introduction of a radiopaque contrast medium that concentrates in the urine and thus facilitates visualization of the kidneys, ureter , and bladder. The contrast medium is cleared from the bloodstream by renal excretion. 23 Renal and Urinary System Nursing Care/ H.AKOUM

24. Diagnostic imaging Intravenous Pyelogram (Intravenous Urogram ) Nursing and Patient Care Considerations Contraindicated in patients with renal failure, uncontrolled diabetes, or multiple myeloma. Contraindicated in patients receiving drug therapy for chronic bronchitis, emphysema, or asthma and in patients taking metformin ( Glucophage ). Patients with known iodine/contrast material allergy must have steroid/antihistamine preparation; in some cases, an anesthesiologist must be available. Bowel preparation is necessary: Clear liquids only the day before the examination. Cathartics/laxatives are given the evening before the examination. Nothing by mouth (NPO) after midnight the day of the examination (if scheduled for afternoon, clear liquids only in the morning). 24 Renal and Urinary System Nursing Care/ H.AKOUM

25. Diagnostic imaging Retrograde Pyelography Description Injection of opaque material through ureteral catheters, which have been passed up ureters into renal pelvis by means of cystoscopic manipulation. The opaque solution is introduced by gravity or syringe injection. May be done when intravenous pyelography (IVP) is contraindicated or if IVP provides inadequate visualization of the collecting system. 25 Renal and Urinary System Nursing Care/ H.AKOUM

26. Diagnostic imaging Retrograde Pyelography Nursing and Patient Care Considerations Contraindicated in patients with UTI, or with suspected perforation of the ureter or bladder; allergic reactions to contrast material are rare in this examination. 26 Renal and Urinary System Nursing Care/ H.AKOUM

27. Diagnostic imaging Cystourethrogram Description Visualization of urethra and bladder by X-ray after retrograde instillation of contrast material through a catheter. An examination of only the bladder is a cystogram ; of only the urethra is a urethrogram . Used to identify injuries, tumors, or structural abnormalities of the urethra or bladder; or to evaluate emptying problems or incontinence (voiding cystourethrogram ). 27 Renal and Urinary System Nursing Care/ H.AKOUM

28. Diagnostic imaging Cystourethrogram Nursing and Patient Care Considerations Carries risk of infection due to instrumentation. Allergy to contrast material is not a contraindication. Additional X-rays may be taken after catheter is removed and patient voids (voiding cystourethrogram ). Provide reassurance to allay patient's embarrassment. 28 Renal and Urinary System Nursing Care/ H.AKOUM

29. Diagnostic imaging Renal Angiography Description I.V. catheter is threaded through the femoral and iliac arteries into the aorta or renal artery. Contrast material is injected to visualize the renal arterial supply. Evaluates blood flow dynamics, demonstrates abnormal vasculature, and differentiates renal cysts from renal tumors. May be done to embolize a kidney before nephrectomy for renal tumor. 29 Renal and Urinary System Nursing Care/ H.AKOUM

30. Diagnostic imaging Renal Angiography Nursing and Patient Care Considerations Clear liquids only after midnight before the examination; adequate hydration is essential. Continue oral medications (special orders needed for diabetic patients). I.V. required. May not be done on the same day as other studies requiring barium or contrast material . Maintain bed rest for 8 hours after the examination , with the leg kept straight on the side used for groin access. Observe frequently for hematoma or bleeding at access site. Keep sandbag at bedside for use if bleeding occurs. 30 Renal and Urinary System Nursing Care/ H.AKOUM

31. Diagnostic imaging Ultrasound Description Uses high-frequency sound waves passed into the body and reflected back in varying frequencies based on the composition of soft tissues. Organs in the urinary system create characteristic ultrasonic images that are electronically processed and displayed as an image. Abnormalities, such as masses, malformations, or obstructions, can be identified; useful in differentiating between solid and fluid-filled masses. A noninvasive technique. 31 Renal and Urinary System Nursing Care/ H.AKOUM

32. Diagnostic imaging Ultrasound Nursing and Patient Care Considerations Ultrasound examination of the prostate is performed using a rectal probe . A Fleet enema may be ordered just within hours of the examination. Ultrasound examination of the bladder requires that the bladder be full. Patient should not have had any studies using barium for 2 days before ultrasound of the kidney or bladder. 32 Renal and Urinary System Nursing Care/ H.AKOUM

33. Diagnostic imaging Computed Tomography Scan Description An imaging method in which the kidneys are scanned in successive layers by a narrow X-ray beam. A computer printout is obtained of the absorption values of the tissues in the plane that is being scanned. It may be used to define kidneys nodules, kidneys abnormalities. 33 Renal and Urinary System Nursing Care/ H.AKOUM

34. Diagnostic imaging Computed Tomography Scan Nursing and Patient Care Considerations Describe test to patient and family. Test takes about 30 minutes. Be alert to allergies to iodine or other radiographic contrast media that might be used during testing. Consider the contraindication of X-rays for the pregnant patient, especially for computed tomography (CT) scans with contrast media. 34 Renal and Urinary System Nursing Care/ H.AKOUM

35. Diagnostic imaging Magnetic Resonance Imaging Description A type of emission tomography based on magnetizing patient tissue, generating a weak electromagnetic signal, and mapping that signal for visualization. Provides contrast between various soft tissues. Traditional radiographic contrast media are not used but gadolinium injection may be necessary, depending on the patient's medical history and anatomy to be imaged The hazards of MRI during pregnancy are unknown. X-ray radiation is not used during MRI. 35 Renal and Urinary System Nursing Care/ H.AKOUM

36. Diagnostic imaging Magnetic Resonance Imaging Nursing and Patient Care Considerations Explain procedure to patient and assess ability to remain still in a closed space; sedation may be necessary if the patient is claustrophobic. Evaluate patient for contraindications to MRI: implanted devices such as pacemakers and neurostimulators that may malfunction; metallic implants such as prosthetic valves or joints, or metallic surgical clips that may move out of place. Check with MRI technician about the use of equipment, such as ventilator or mechanical I.V. pump, in MRI room. Evaluate the patient for claustrophobia, and teach relaxation techniques to use during test. Sedation may be necessary. 36 Renal and Urinary System Nursing Care/ H.AKOUM

37. Patient Care During Urologic Testing With Contrast Agents For some patients, contrast agents are nephrotoxic and allergenic. The following guidelines can help the nurse and other caregivers respond quickly in the event of a problem. Nursing Actions for Room Preparation Have emergency equipment and medications available in case the patient has an anaphylactic reaction to the contrast agent. Emergency supplies include epinephrine, corticosteroids, and vasopressors ; oxygen; and airway and suction equipment. 37 Renal and Urinary System Nursing Care/ H.AKOUM

38. Patient Care During Urologic Testing With Contrast Agents Nursing Actions for Patient Preparation Obtain the patient’s allergy history with emphasis on allergy to iodine, shellfish, and other seafood, because many contrast agents contain iodine. Notify physician and radiologist if the patient is allergic or suspected to be allergic to iodine. Obtain health history. Contrast agents should be used with caution in older patients and patients who have diabetes mellitus, multiple myeloma, renal insufficiency, or volume depletion. Inform the patient that he or she may experience a temporary feeling of warmth, flushing of the face, and an unusual flavor (seafood) in the mouth when the contrast agent is infused. Monitor patient closely for allergic reaction and monitor urine output. 38 Renal and Urinary System Nursing Care/ H.AKOUM

39. Urology endoscopic procedures cystoscopie Description Cystoscopy is a method of direct visualization of the urethra and bladder by means of a cystoscope that is inserted through the urethra into the bladder. It has a self-contained optical lens system that provides a magnified, illuminated view of the bladder. Uses include: To inspect bladder wall directly for tumor, stone, or ulcer and to inspect urethra for abnormalities or to assess degree of prostatic obstruction. To allow insertion of ureteral catheters for radiographic studies, or before abdominal or GU surgery. To see configuration and position of ureteral orifices. To remove calculi from urethra, bladder, and ureter . To diagnose and treat lesions of bladder, urethra, and prostate. 39 Renal and Urinary System Nursing Care/ H.AKOUM

40. Urology endoscopic procedures cystoscopie Nursing and Patient Care Considerations Simple cystoscopy is usually performed in an office setting. More complicated cystoscopy involving resections or ureteral catheter insertions are done in the operating room cystoscopy suite, where I.V. sedation or general anesthesia may be used. The patient's genitalia are cleaned with an antiseptic solution just before the examination. A local topical anesthetic ( Xylocaine gel) is instilled into the urethra before insertion of cystoscope . Because fluid flows continuously through the cystoscope , the patient may feel an urge to urinate during the examination. Contraindicated in patients with known UTI. 40 Renal and Urinary System Nursing Care/ H.AKOUM

41. Urology endoscopic procedures cystoscopie Nursing interventions after cystoscopic examination: Monitor for complications: urinary retention, urinary tract hemorrhage, infection within prostate or bladder. Expect the patient to have some burning on voiding, blood-tinged urine, and urinary frequency from trauma to mucous membrane of the urethra. Administer or teach self-administration of antibiotics prophylactically as ordered to prevent UTI. Advise warm sitz baths or analgesics, such as ibuprofen or acetaminophen, to relieve discomfort after cystoscopy . Increase hydration. Provide routine catheter care if urine retention persists and an indwelling catheter is ordered. 41 Renal and Urinary System Nursing Care/ H.AKOUM

42. Urology endoscopic procedures cystoscopie 42 Renal and Urinary System Nursing Care/ H.AKOUM

43. Needle Biopsy of Kidney Description Performed by percutaneous needle biopsy through renal tissue with ultrasound guidance or by open biopsy through a small flank incision; useful in securing specimens for electron and immunofluorescent microscopy to determine diagnosis, treatment, and prognosis of renal disease 43 Renal and Urinary System Nursing Care/ H.AKOUM

44. Needle Biopsy of Kidney Nursing and Patient Care Considerations Prebiopsy nursing management Ensure that coagulation studies are carried out to identify the patient at risk for postbiopsy bleeding and that serum creatinine , urinalysis, and urine culture are done. Ensure that patient fasts for several hours before the procedure, as ordered. Establish an I.V. line, as ordered. Describe the procedure to the patient, including holding breath (to prevent movement of the thorax) during insertion of the biopsy needle. 44 Renal and Urinary System Nursing Care/ H.AKOUM

45. Needle Biopsy of Kidney Post biopsy nursing management Place the patient in a prone position immediately after biopsy and on bed rest for 8 to 24 hours to minimize bleeding. Take vital signs every 5 to 15 minutes for the first hour and then with decreasing frequency if stable to assess for hemorrhage, which is a major complication. Watch for rise or fall in blood pressure, anorexia, vomiting, or development of a dull, aching discomfort in abdomen. Assess for flank pain (usually represents bleeding into the muscle) or colicky pain (clot in the ureter ). Assess for backache, shoulder pain, or dysuria . Persistent bleeding may be suspected when an enlarging hematoma is palpable through the abdomen. 45 Renal and Urinary System Nursing Care/ H.AKOUM

46. Needle Biopsy of Kidney If perirenal bleeding develops, avoid palpating or manipulating the abdomen after the first examination has determined that a hematoma exists. Collect serial urine specimens to evaluate for hematuria . Assess for any patient complaints, especially frequency and urgency on urination. Keep fluid intake at 3,000 mL daily if tolerated, unless the patient has renal insufficiency. Check results of hematocrit and hemoglobin (done the following morning) to assess for anemia, unless the vital signs change before then. Prepare for transfusion and surgical intervention for control of hemorrhage, which may necessitate surgical drainage or nephrectomy . 46 Renal and Urinary System Nursing Care/ H.AKOUM

47. Needle Biopsy of Kidney Instruct the patient on the following after biopsy: Avoid strenuous activity, strenuous sports, and heavy lifting for at least 2 weeks. Notify health care provider if any of the following occur: flank pain, hematuria , lightheadedness and fainting, rapid pulse, or any other signs and symptoms of bleeding. Report for follow-up 1 to 2 months after biopsy; will be checked for hypertension, and the biopsy area is auscultated for a bruit. 47 Renal and Urinary System Nursing Care/ H.AKOUM

48. 48 Renal and Urinary System Nursing Care/ H.AKOUM