Week 13: Chp 61: Imaging Studies for Renal and Urinary System

Question 1

Nursing Responsibilities regarding the studies

Answer 1

patient educations, patient preparation, and monitoring for complications during and after the study

Question 2

Patient education should include?

Answer 2

indications for the study, preparation for the study, what to expect during the study, possible complication, and any required follow-up care

Question 3

Agents commonly used for bowel preparation

Answer 3

enemas, magnesium citrate, bisacodyl (Dulcolax), and castor oil

Question 4

Bowel preparation agents that are used cautiously with patients with renal impairment

Answer 4

fleet enemas and magnesium citrate

Question 5

Bedside Sonography

Answer 5

• portable ultrasound scanner (non-invasive)
• estimate volume of urine contained in the bladder; used to assess for presence of urine remaining in the bladder after voiding (postvoid residual) or to determine if there is a need for intermittent catheterization in a patient who is not independently voiding
• done by the nurse
• no preparation
• results in no discomfort or risk to patient

Question 6

What Happens in a Bedside Sonography

Answer 6

conductive gel is placed over the symphysis pubis, and the probe is positioned above the pubic bone, pointing downward toward the coccyx

• the scanner displays the estimated volume of urine contained in the bladder
• for accuracy, scan should be completed twice, and results should be averaged
• large volumes in bladder following voiding or in a patient unable to spontaneously void indicate need for catheterization

Question 7

X-ray of the kidneys, ureters, and bladder (KUB)

Answer 7

is a simple abdominal x-ray take with the patient lying in the supine position

• reveals the size and anatomy of the renal and urinary system structures
• can reveal masses, obstructions, and calculi within the kidneys and urinary tract
• no preparation
• no discomfort or risk to patient
• should be avoided during pregnancy

Question 8

Intravenous Urography (IV pyelography)

Answer 8

• requires radiographical dye (contrast) via an IV line with the patient in supine position
• the contrast is circulated within the venous blood and upon reaching the kidneys is filtered by the glomeruli and is then excreted in the urine
• following the injection of dye, x-rays are preformed at specific time intervals; a final x-ray is taken after the patient voids to measure the volume of any residual urine in the bladder
• This test reveals the size and anatomy of the KUB as well as any tumors, cysts, calculi, and obstructions within the urinary tract

Question 9

Pre-procedure for Intravenous Urography (IV pyelography)

Answer 9

• complete bowel prep the evening prior to procedure and remain NPO 8 hours prior; nurse should confirm this request was completed
• instruct patient this study lasts 30 to 45 minutes and results in no discomfort; he or she may feel a brief flushing sensation of the body and a salty taste in the mouth during the injection of the contrast
• ensure signed informed consent has been obtained after education regarding the indication and potential risks of the procedure
• assess baseline serum creatinine prior to the study because of the nephrotoxic potential of the contrast
• question for allergies to contrast dye

Question 10

Nursing Considerations for patients receiving IV contrast for radiographical studies

Answer 10

> confirm the presence of signed informed consent
assess for a history of allergies to contrast, iodine, and shellfish (patients with these allergies may be pre-medicated with steroids)
confirm the presence of emergency medications and equipment at bedside
review baseline serum creatinine as evidence of renal function
review patient history for presence of renal dysfunction
educate patient regarding the flushing sensation and salty taste during contrast administration
ensure patency if IV
assess for signs of delayed reaction to contrast (e.g. rash, dyspnea, tachycardia)
increase fluid intake following the study
if warranted, monitor serum creatinine values

Question 11

Renal Ultrasound

Answer 11

utilized to identify masses, cysts, and obstruction within the kidneys

• patient is exposed to no radiation
• non-invasive
• used to determine kidney size
• used to differentiate between renal cysts and tumors
• may be ordered to drink up to 24 oz of fluid 1 hour prior to the study without voiding until completion of the ultrasound

Question 12

What happens during a renal ultrasound?

Answer 12

conductive gel is applied to the patients skin, and an external probe is moved across the abdomen
-ultrasound images are produced as sound waves enter the body and are reflected back

Question 13

Kidneys that are smaller than normal may be indicative of what?

Answer 13

chronic kidney disease

Question 14

Kidneys that are larger than normal may indicate what?

Answer 14

polycystic process or an obstruction

Question 15

Post-procedure of Intravenous Urography (IV pyelography)

Answer 15

-increase fluid intake to ensure adequate excretion of the contrast
-monitor for changes in urine output, irritation at IV site, and delayed signs of reaction to the contrast (e.g. rash, dyspnea, tachycardia)
>if there is a concern for changes in renal function related to the contrast, subsequent serum creatinine lab test may be ordered

Question 16

Computed Tomography (CT scan)

Answer 16

produced three-dimensional images of the renal and urinary system structures as well as the surrounding tissues

• may be used for further examine findings from studies such as x-rays or ultrasounds
• capable of detecting slight variances in densities, providing more specific diagnostic results related to kidney size, tumors or other masses, renal vessels, and obstruction
• patient required to lay completely still during procedure
• scan lasts 10 to 15 minutes

Question 17

Pre-procedure for CT scan

Answer 17

• remain NPO for several hours prior to procedure if required
• ensure signed informed consent after education regarding the indication and potential risks of the procedure; patient education includes requirement to lay completely still while the scanner rotates around the body; if patient is anxious or unable to follow instruction, sedation or anxiolytic may be required; scan lasts 10 to 15 minutes
• assess allergies and baseline renal function because CT scans are performed with or without IV contrast; contrast may be withheld with known renal dysfunction

Question 18

Magnetic Resonance Imaging (MRI)

Answer 18

varies from x-rays and CT scans in its use of magnetic forces rather than ionizing radiation to produce images for diagnostic testing

• known for its ability to reveal contrasts between soft tissues of the body
• useful in examining the tissue of the kidneys to assess for abnormalities

Question 19

Pre-procedure for MRI

Answer 19

-Educate the patient
>procedure is painless and can last up to 90 minutes
>remove any metal objects; jewelry, removable metal dental devices, hearing aids, glasses, and body piercing’s
>the machinery used for MRI is a cylinder surrounded by a large magnet; the patient lies on a moveable examination table and is slowly guided through the cylinder
>patient with a known claustrophobia or unable to lie still for other reasons may require sedation or anxiolytic medications prior to the MRI; open MRI equipment is available for use in patients who are claustrophobic, obese, or unable to lie still for other reasons
-ensure signed informed consent has been obtained after education regarding the indication and potential risks of the procedure
-assess for the presence of pacemakers and some other types of implanted medical devices because MRI is contraindicated in patients with these devices present
-assess allergies and baseline renal function because MRI is infrequently performed with IV contrast

Question 20

Cystography “cystograms”

Answer 20

contrast dye is injected into the bladder via a urinary catheter or a cystoscope, and a thin, lighted instrument is inserted into the urethra and slowly advanced into the bladder

• can be used to assess the bladder for abnormalities, including calculi and masses
• also be used to examine the bladder if trauma is suspected

Question 21

Urethrography “urethrogram”

Answer 21

assess for trauma to the urethra
-specific type of this diagnostic test: a voiding cystourethrogram (VCUG) can be used to determine if vesicoureteral reflex is present

Question 22

Urethrography: VCUG

Answer 22

“voiding cystourethrogram”
-used to determine if vesicoureteral reflex is present
-requires the patient to void after the bladder is filled with contrast while x-rays are taken
>if reflux is present, urine is backflowing from the bladder into the ureters and/or kidneys, increasing the patient’s risk of developing kidney infections

Question 23

Pre-procedure for Cystography and Urethrography

Answer 23

• educate the patient regarding the indication and risks for the procedure; the insertion and use of the urinary catheter or cystoscope should be thoroughly explained
• ensure that informed consent has been obtained
• -assess for allergies to contrast, iodine, and shellfish; because the contrast dye does not enter the bloodstream, there is no danger of nephrotoxicity

Question 24

Post-procedure for Cystography and Urethrography

Answer 24

• monitor the patient for signs and symptoms of infection because the instrumentation used increases the risk for infection
• educate the patient on signs and symptoms of infection and adequacy of urine output once discharged

Question 25

Arteriography “angiography”

Answer 25

involves visualizing the renal vasculature to assess for strictures, bleeding, renovascular hypertension, and other vascular abnormalities

• requires placement of a catheter into the femoral artery
• catheter is then advanced to the level of the renal arteries, and IV contrast is injected to highlight any vascular abnormalities

Question 26

Pre-procedure for Arteriography “angiography”

Answer 26

• educate the patient regarding the indication of the study and its potential risks; also, educate the patient about the bowel preparation that should occur the evening prior to the angiogram and the need to remain NPO after midnight
• ensure signed informed consent has been obtained
• assess for allergies to contrast, iodine, and shellfish

Question 27

Post-procedure for Arteriography “angiography”

Answer 27

• apply manual pressure to femoral site following removal of the femoral catheter until the bleeding has stopped; a pressure dressing should then be placed over the site, and the nurse should assess the site frequently per policy for bleeding
• monitor vital signs
• monitor color, temperature, and pulses distal to the femoral site every 30 to 60 minutes to assess for signs of the development of thrombus or hematoma, which can occlude distal blood flow
• have patient lie with the affected leg straight for the prescribed time, usually 8 to 12 hours

Question 28

Renography (kidney scan)

Answer 28

utilized to assess renal blood flow
-a radionuclide is injected intravenously and is absorbed by the kidney tissue; an external probe is then placed over the kidney to detect radiation emissions; images are produced by these emissions
-useful in determining kidney size, general blood flow through the kidneys, glomerular and tubular filtration, and urinary excretion
>signed informed consent following education about the indications and risks of the study
>no specific preparation or monitoring during or after procedure

Question 29

The nurse understands that an abnormal VCUG indicates which of the following?
A. The presence of mass in the bladder
B. An increased risk of kidney infection
C. Incomplete emptying of the bladder
D. Decreased creatinine clearance

Answer 29

B. an increased risk of kidney infection

Question 30

Renal Biopsy

Answer 30

involves removing a tissue sample via a small percutaneous (through the skin and other tissue) site using CT or ultrasound guidance while the patient is sedated and lying in the prone position
-useful in ruling out malignant processes and diagnosing renal abnormalities that have not been successfully diagnosed with other diagnostic tests

Question 31

Pre-procedure for Renal Biopsy

Answer 31

• educate patient regarding the procedure and associated risks
• ensure that a signed informed consent has been obtained
• NPO for 4 to 6 hours prior to the procedure and has stopped taking aspirin, warfarin (Coumadin), and other agents that may affect the ability to the blood to clot normally prior to the procedure
• send a type and screen and coagulation laboratory values, including a platelet count, prothrombin time, and activated partial thromboplastin time, to the lab prior to the study because of the risk of bleeding
• obtain baseline vital signs and monitor vital signs frequently during biopsy

Question 32

Post-procedure for Renal Biopsy

Answer 32

-apply manual pressure to the sit until bleeding has stopped; a pressure dressing should then be applied, and the nurse should monitor the site frequently per policy for bleeding
-assess hematocrit and hemoglobin levels post-procedure because bleeding can sometimes occur internally with no external indications; signs of internal bleeding include flank pain, decreased urine output, decreased BP, and other signs of hypovolemia and shock
-patient remains bedrest for up to 24 hours following renal biopsy
-educate the patient regarding:
>some local discomfort may occur at the site of the biopsy, but pain radiating to the abdomen and flank should be reported
>increase fluid intake following the biopsy to prevent clot formation in the urinary tract, which could obstruct the flow of urine
>most common complication following a biopsy is hematuria; typically resolves in 48 to 72 hours following the procedure; inform the patient that within this time hematuria is an expected finding, but notify healthcare provider of hematuria occurring beyond 72 hours after procedure; also be told to notify the provider of presence of clots in the urine or any difficulty with voiding
>avoid heavy lifting for 1 week following procedure
>do not resume taking anticoagulant medication until instructed to do so

Question 33

Cystoscopy

Answer 33

a surgical procedure utilized to diagnose and/or treat bladder problems

• a cystoscope is a tubular, lighted device that is inserted through the urethra while the patient is sedated and in the lithotomy position
• diagnostic tool; can be used to assess for bladder trauma, urethral trauma, or urinary tract obstruction
• can be used to remove an enlarged prostate gland, bladder tumors, or renal calculi
• can be performed using local or general anesthesia

Question 34

Pre-procedure for Cystoscopy

Answer 34

• educate the patient regarding the indication of the study and its potential risks; also, educate the patient about the bowel preparation that should occur the evening prior to the cystoscopy and the need to remain NPO after midnight
• ensure signed informed consent has been obtained
• assess baseline vital signs before administration of anesthesia and at frequent intervals throughout ad immediately following the procedure

Question 35

Post-procedure for Cystoscopy

Answer 35

-assess urine volume to ensure adequate output
-educate the patient regarding the following:
>expected findings following cystoscopy include urinary frequency and pink-tinged urine, gross bleeding and/or clots in the urine are not normal and should be reported
>mild analgesics and topical measures such as warm, moist heat and sitz baths may be used to manage the discomfort following the procedure
>monitor for signs and symptoms of infection (e.g. fever, chills, dysuria) and report immediately

Question 36

The nurse is caring for a patient receiving IV contrast for a renal CT scan. Nursing responsibilities related to the administration of IV contrast include which of the following? (select all that apply)
A. to assess for allergies to contrast, iodine, and seafood prior to the study
B. to educate the patient to increase fluid intake following the study
C. to obtain an order for NPO status following the study
D. to ensure that IV contrast is administered only through a central line
E. to assess that patient’s baseline creatinine value prior to the study

Answer 36

A. to assess for allergies to contrast, iodine, and seafood prior to the study
B. to educate the patient to increase fluid intake following the study
E. to assess the patient’s baseline creatinine value prior to the study