Week 3 - Renal Assessment Flashcards
Learning Objective 1
Review the A & P of renal system
Kidneys - Location
Either side of vertebral columns
Kidneys - Function
- Maintain composition and volume of body fluid
- 1 million nephrons in each kidney remove Urea
- Creatinine and Uric acid from blood plasma to form urine
- Kidneys remove waste including urine
- body fluids remain stable if kidneys are functioning well
Bladder
- 3 layers of smooth muscle
- middle layer forms an involuntary sphincter that guards the opening between the bladder & urethra
- reservoir for urine
- innervated by ANS
- bladder wall stretches until the nerves are stimulated = need to urinate
Urethra
- convey urine from bladder to exterior of body
- Male urethra functions in the excretory & reproductive functions. 13.7 - 16.2 cm long
- the female urethra is 3.7 - 6.2 cm long.
- no portion of female urethra is external to body
Learning Objective 2
Discuss component of a renal assessment
- key concepts
- health history
- physical examination
- Key concepts include
- primary assessment (DRSABCDE)
- secondary assessment
- Health history
- physical examination & vital signs assessment
- focused assessment
- Health History
▪ Biographical data
▪ history of chief complaint /presenting problem
▪ Associated Symptoms
– Haematuria
– Urgency to void
– Confusion
– Dysuria
– Abdominal (especially flank) pain
– incontinence/retention
– change in appearance / smell of urine
– hesitancy of urine flow/ change in stream volume
- Health History
▪ Radial prostatectomy or trans-urethral resection of the prostate
- endometrial tissue removal within the pelvis
- pelvic floor surgery and bladder sling scaffolding
▪ Lifestyle factors
- smoking (carcinogenic chemicals resting in bladder)
▪ Fluid intake
- type and amount of fluid is assessed
- ask about alcohol intake (diuretic)
- Physical Examination - Skin, hair, and nails
- look for a swallow complexion also known as uraemia tinge
- look for mees’ lines which indicate chronic renal failure
- Health History
- Urinary continence history (bladder diary)
- Bowel elimination pattern (especially constipation)
- Menstrual history (onset, regularity, and last period)
- Pregnancy (gravida and para history)
▪ Past medical history
– Renal/urinary problems (cancer, infections & prostate)
– Hypertension
– Diabetes Type 1 or 2 (damages the glomeruli)
– Trauma to the abdomen, back or the kidney
Infection
- Health History also includes
▪ Medications
- Non - steroidal anti inflammatory drugs
(Voltaren)
- Diuretics (Frusemide)
- Angiotensin converting enzyme inhibitors (i.e perindopril)
- Antibiotics
- Physical Examination - Face and mouth
- look for oedema around the eyes
- smell for uraemic fetor from urea breakdown in saliva
- Physical Examination - The extremities
- scratch marks from uraemic pruritus
- look for arterio-venous fistula in the forearm
- look for oedema in the legs (or sacrum) from renal failure
- Physical Examination - Abdomen
- look for scars - nephrectomy and or transplant
- look for an enlarged abdomenascites or polycystic kidney disease.
- Physical Examination - Kidneys
- kidneys are usually not palpable unless enlarged.
- the right is lower that the left due to the liver
- Physical Examination - Bladder
- the bladder is usually a pelvic organ and is not palpable
- palpation is an upward motion from the pubic symphysis
- Physical Examination - Oedema
- pitting oedema occurs when excess fluid accumulates in the interstitial space
- pitting oedema is classified as
+1 = 2mm of pitting
+2 = 4mm of pitting
+3 = 6mm of pitting
+4 = 8mm of pitting
Physical Examination: Auscultation - renal arteries
- renal artery blood flow is best heard above the umbilicus
- position bell of stethoscope 2cm to the right and left
- presence of a bruit is abnormal in renal arteries
- a bruit indicates renal artery stenosis/narrowing
- commonly caused by atherosclerosis
Physical Examination: Auscultation - blood pressure
- up to 75% of patients with kidney disease will have hypertension
- hypertension decreases renal blood flow and exacerbates kidney disease.
Physical Examination: Percussion - Bladder
- Assessment of bladder distension (enlargement)
- start at symphysis pubis moving upwards to the umbilicus
- a urine filled bladder produces a dull sound
- tympany indicates the border of the bladder
- document as “bladder is _ cm below umbilicus.”
Learning Objective 3
Discuss common renal diagnostic tests and investigations
fluid balance chart
- essential for anyone receiving intravenous fluids
- commonly used for patients with renal/cardiac failure
- requires accurate measurement of input/output
Voiding chart
- aka bladder chart or diary
- records voiding patterns, volume, incontinence, pain and associated symptoms
- intake of fluids may also be included on the chart
0.5mL/kg/hr. or 30-
40mL/hr. normal output
Urine colour and discolourations
Blue
- medication side effect : amitriptyline
- foods : asparagus
- Dye after prostate surgery
Urine colour and discolourations
Dark Grey
- Urine contains melanin, melaninuria
Urine colour and discolourations
Tea
- Liver disease - with pale stools, jaundice
- Myoglobinuria
- Some medications or food dyes
- blood in urine
Urine colour and discolourations
Pink
- with menses
- foods: beets, berries, food dyes
- some laxatives
- kidney stones
- urinary tract infection
Urine colour and discolourations
Red
- blood in urine
- Nephritis, cystitis
- cancer
- following prostate surgery
Urine colour and discolourations
Orange
- medication side effect : Rifampicin for meningitis, pyridium, warfarin (coumadin)
- some foods, food dyes, laxatives
- dehydration
- jaundice (billirubinaemia)
Urine colour and discolourations - Amber
- Gold or concentrated with dehydration
- some laxatives
- food or supplements with b-complex vitamins
Urine colour and discolourations
Yellow
- Natural yellow is urochrome excretion, a pigment in blood
- bright neon yellow with supplements
Urine colour and discolourations
Yellow pale
- Clear, watery with excess liquids
- acute viral hepatitis, cirrhosis
Urine colour and discolourations
Cloudy
- Urinary tract infection
- kidney stones
Full Ward Test (FWT)
Also known as a ward urinalysis test (common on admission)
- Non sterile specimen collected (clean catch)
- uses reagent strips to detect abnormalities
Midstream Collection (MSU) - Sterile specimen container
- clean the perineal area with soap and water
- first part of void is discard
- CAPTURE MIDDLE PART OF VOID
- Finish voiding in the toilet
- stored in ward fridge for up to 1 hr
- used for culture or microbes and sensitivity to antibiotics
Catheter collection (CSU) - Sterile specimen container
- catheter clamped to prevent free flow of urine into drainage bag
- swab the access port on the catheter drainage tube
- withdraw urine using a sterile syringe
- inject urine into specimen container and unclamp catheter
- may be stored in ward fridge for up to 1 hr used for
24 hour urine collection
- place a sign in patients bathroom of the start and end times
- Provide a 24 hr sample of renal function
- measures levels of hormones and steroids
- creatinine clearance and protein can be measured
Bladder Scan - which measures volume of urine in the bladder
- should be used to determine if the bladder is emptying correctly
- male to female setting available (to compensate for uterus)
- can provide a print out of the scan and results which can go in the patients medical history
Post Void Residual volumes (PVR)
- Measured to determine how
completely the bladder empties
with voiding
- Less than 50ml PVR is considered normal
- when 100ml or more is retained further testing is indicated
- High PVR volumes can increase the risk of urinary tract infection
- the amount of urine left in the bladder is measured with the bladder scanner
Dialysis
- used to treat people who experience severely decreased
- a mechanical way of filtering waste from the blood
- two categories: haemodialysis and peritoneal dialysis
- HD requires vascular access - arteriovenous (AV) fistula or AV graft
- PD involves using blood vessels in the peritoneum to fill in for the kidneys. A fluid called dialysate is washed in & out of the peritoneal space.
- care of either catheter site is a nursing responsibility.
Nursing Assessment of dialysis fistula
- functioning fistula produces a bruit on auscultation & a thrill on palpation
- checked every shift
- a bruit is normal in a fistula but abnormal in other arteries
- the sound is produced by turbulent flow through the fistula
- No ID band, cannulation, venepuncture or BP
Learning Objective 4
Identify the most common renal conditions encountered in clinical practice
Common renal conditions - Acute disease
- temporary loss of kidney function : unable to filter waste products
- short term - <3 months
- rapid onset - few days
- in response to an injury or illness affecting the kidneys, drugs, blockages of the kidney or other factors
Common renal conditions - chronic disease
- occurs when kidneys have been damaged in a way that cannot be reversed.
- present for at least three months
- causes include: genetics, infection, immune disorders that attack the kidneys diabetes, and high BP
Common Renal Conditions: UTI
- Inflammation & infection of urinary tract - lower or upper
- Risk Factors
- Latrogenic, medications, behavioural, Antomic, Genetic
- Around 20, 500 hospitals acquired UTIs occur each year in Australian hospitals
- Bacterial infections are the most common cause of a UTI
- E Coli, klebsiella; candida albicans; pseudomonas
Common Renal Conditions: UTI
Signs & Symptoms
- Dysuria; Urgency & Frequency; pain during intercourse; offensive smelling urine.
Management
- antibiotics, fluids, hygiene, cotton and loose fitting underwear.
Learning Objective 5
Identify the developmental, social and
cultural considerations required when
performing a renal assessment.
Infants and children
- kidneys occupy large portion of abdomen at birth
- urine formation occurs at the third month of fetal development
- at about 2-3 years of age the child becomes aware of bladder filling and begins to inhibit voiding
Pregnancy
Full ward test - detect protein in the urine and elude to pre-eclampsia - further investigation can then be initiated
- cannot perform a bladder scan on a woman who is pregnant or postpartum
- fundus is palpable above pubic symphysis
Adults and late adulthood
- By 70 years of age 30-50% of glomeruli have stopped functioning
- Decreased oestrogen results in changes to the female urethra, bladder, vagina, and pelvic floor.
- men the prostate gland enlarges and can obstruct the flow of urine through the urethra.
Social and cultural considerations
130% increase in chronic kidney disease (CKD) in last 10 years from diabetes
Social and cultural considerations
higher (CKD) in pacific islander and Maori people
Social and cultural considerations
urinary incontinence affects 50% of woman over age of 50 and 30% of men over 70
Full Ward Test - Leukocytes
normal - non present
positive - infections
Full Ward Test - Nitrate
Full Ward Test - Urobilinogen
Full Ward Test - Protein
Full Ward Test - pH
Full Ward Test - blood
Full Ward Test- Specific Gravity
Full Ward Test - Ketones
Full Ward Test - Bilirubin
Full Ward Test - Glucose
- more glucose = increased thirst
