Unit III: Care of Clients with Complex Urinary/Renal Disorders Renal Assessment and Diagnostic Procedures A&P Review:

Kidneys (2): receive 20-25% cardiac output. Cortex: contains nephrons (1 million per kidney) (nephrons are the filtration and drain mechanisms) Medulla: contains loops of Henle and collecting ducts. (The nephrons hang down into the medulla.) Normal blood flow: 1200 mL/min Produce 180 L filtrate/day: 99% is of which is re-absorbed- depends on consistent pressure through glomeruli. (When there is problems with even a slight deviation with the pressure the kidneys act with hormones and other mechanism saving and or excreting electrolytes and other substances to force the blood flow to get better.) Tubules produce 1000 1500 mL urine/24 hrs. ADH (vasopressin): (one of the most important hormones in this whole process) (it raises the B/P) stimulates HO re-absorption in dry states Excess HO causes ADH and urinary excretion

Right kidney is slightly lower than the left because of the liver.

A&P Review: *Osmolarity: ratio of solutes to HO; variation of 1-2% causes thirst and ADH. (ratio of solid particles to water in the urine. If the osmilarity goes up it will cause you to start drinking and your urine will become more concentrated because your body is telling the kidneys to retain water.) *Osmolality: degree of concentration or dilution (measures in osmoles- unit of measuring osmotic pressure. 280 300 mOsm/L is normal limit for blood (urine osmolality is 200-800 mosm/kg is normal)(osmolality is the most accurate measure of the kidneys ability to loop or concentrate urine.)

A&P Review: Functions of Kidney: *Fluid balance: nL = urine when HO intake and vice versa. ---Daily weights are the reliable way to determine overall fluid status. 1 lb. = 500 mL. *Electrolytes balance: ---Sodium: most plentiful extracellular ion. 90% Na in filtrate is re-absorbed. What regulates this is Aldosterone (secreted by the renal cortex): aldosterone = Na in urine (meaning your retaining sodium). Aldosterone release controlled by angiotensin II. ---Potassium: most plentiful intracellular ion. ~90% K+ intake excreted. aldosterone = K+ excreted in urine (If the renal cortex is not producing enough aldosterone or it produces aldosterone that the kidneys dont respond to then sodium and potassium start building up in the blood because they dont get excreted.)

A lot of fluid a aa

Blood is coming through the arterial, and some of it goes into the glomerulus (which is a network of capillaries) and into bowmans capsule. There is an exchange that takes place here where a lot of fluid and electrolytes cross over into Bowmans capsule. (In bowmans capsule ultrafiltrate forms which consists of fluids and small molecules.)Usually small solutes cross over. Large molecules dont. If they do they will get reabsorbed back again very quick such as glucose molecules and protein molecules. ((Almost all glucose gets reabsorbed unless the patient has a problem with hyperglycemia in which case the blood concentration of glucose is so high that the kidneys cant cope with all of the reabsorbing. It reaches the renal threshold .This is why we say when diabetic patients have high glucose levels they will spill glucose into their urine.)

(all of the creatinine should be excreted which is a byproduct of protein metabolism.)

A&P Review Functions of Kidney, contd Acid-base balance (changes in the PH of the blood will cause these changes) ---Excretes organic acids and retains bicarbonate. Regulation of Blood pressure: Renin-Angiotensin-Aldosterone system ---Angiotensin II: most powerful vasoconstrictor known. Renal clearance of solutes: creatinine clearance (protein/muscle metabolism)good measure of GFR. (good indicator of overall kidney function. This is why they do 24 hour urine specimens in renal patients because they want to see over time how the glomeruli are concentrating or diluting urine. ) RBC Production: erythropoietin (the kidneys have a big role in RBC production. They produce a hormone walled erythropoietin that stimulates the bone marrow to produce more RBCs. This is a big problem for chronic renal failure patients. They

are always somewhat to severely anemic due to low erythropoietin production from damaged or nonfunctioning kidneys.) Vitamin D: The kidneys convert inactive to active form. This is very important in the regulation of bone resorption (process by which osteoclasts break down bone and release the minerals, resulting in a transfer of calcium from bone fluid to the blood) which is why many renal failure patients have a problem with osteoporosis because they dont convert vitamin D into the active form and vitamin D is what mediates the process of laying down bone and keeping calcium in your bones. A&P Review Functions of Kidney, contd Prostaglandins (produced by the kidneys in the presence of ischemia): closely associated with R-A-A system (basically what the prostaglandins do is mediate to increase the release of renin to help maintain kidney blood flow during ischemic states.) Excretion metabolic wastes and drug metabolites

History *Chief Complaint: state in patients own words *Renal Symptoms, e.g. hematuria, dysuria, edema, rapid weight gain (especially with decreased appetite), metallic taste (that cant be associated with any medication or anything thieve consumed), orthopnea, n/v. (also symptoms like nocturia, hiccups (that dont go away), mental status changes, unexplained anemia, and abdominal distention of unknown origin.) *Predisposing Risk Factors: use of OTCs, recent infections (doesnt have to be infections of the urinary tract because toxins from other infections can migrate.), severe trauma or strenuous physical activity (because of rhabdomyolysis. Rhabdomyolysis is the rapid break down of skeletal muscle tissue caused mainly by crush injuries, trauma to different parts of the body, or obstruction of the muscle blood supply where the muscle becomes ischemic, excessive muscle strain and strenuous physical activity, burns, and high voltage electrical shock. Basically what happens is rhabdomyolisis causes myoglobin to circulate in the blood and it quickly overwhelms the ability of the kidneys to clear it and it stops up those little capillaries because it is a big molecule. It will cause acute tubular necrosis and acute renal failure.) *Medical History: note diabetes and hypertension (because they have the biggest and most common effects on the kidneys.) *Previous Diagnostic Studies: note studies using contrast. (particularly recent ones.) *Current Medication Usage (not only prescription because there is a bunch of nephrotoxic drugs but also OTC and Herbal medications that have effects on the kidneys. One herbal that is popular called Echinacea that people take for colds has a direct effect on the kidneys in large doses. )( Glucosamineincreases blood sugar. Dandelion, Alfalfa, and Noni juice all contain increased amounts of potassium so if the patient already has a kidney problem it can make their fluid and electrolyte balance even worse.) *Social History and Family History (particularly their history of drug and alcohol abuse.) Geriatrics: (these are all normally aging except urinary incontinence.) *decreased ability to concentrate urine ---Higher risk for adverse reactions to meds and drug-drug interactions *decreased sensation of thirst

---Higher risk for dehydration and hypernatremia * decreased bladder capacity and bladder emptying (which can put them at risk for UTI) * Urinary incontinence ---Not a normal consequence of aging (but may be a problem with older folks who have co morbid conditions and thieve developed incontinence such as stroke patients.) Physical Examination Inspection: Bleeding: e.g. Grey-Turner sign (this is bruising of the flanks), bruising, abdominal distention and guarding . (these mainly has to do with kidney trauma) Fluid volume (usually fluid volume overload): neck veins (for JVD), hand veins, skin turgor, oral mucosa. (you will also be looking for bulging flanks and ascites which may form cause of fluid overload. It is best seen with the patient supine and the observer at the patients feet and looks to their abdomen that way. ) Edema: non-specific to renal problems. (which means it is caused by many different things, but it is something to be investigated.) Physical Examination Auscultation: Heart: gallops, pericardial friction rub (people who are having problems with fluid overload may have gallops (S3 gallop is a turbulence of blood in a stretched and overload ventricle. An S4 gallop is a vibration of four forceful atrial contractions from the atria being stretched from too much blood in it. A pericardial friction rub may be present in some chronic renal patients because of pericardial effusions because of the build up of metabolic waste products in their blood that sets up an irritation.) Blood Pressure: should always be assessed with orthostatic measurements Lungs: crackles, dyspnea, altered breathing patterns (for signs of respiratory distress) Physical Examination Palpation: (kidneys are not usually palpable however in some states it may be important to palpate to see if they are palpable in that patient.) Kidney: bimanual capturing approach (on hand on the anterior position of the flank and the other on the posterior); size and shape on each side are compared; to detect

size differences, masses, irregular surface (polycystic kidney disease is a chronic disease where the patients kidneys become very cystic and very irregular. It kind of looks like plastic bubble rap on the outside.) Bladder: palpate area between umbilicus and pubic bone for distention, pain, feeling of urgency. (Bladder ultrasound is a non-invasive, painless, bedside test to check amount of urine in bladder- more precise than palpation.) Bladder Ultrasound:

This ultrasound shows over-distended bladder w/ approx 450 mL urine. Physical Examination Percussion: Kidneys: dull, painless thud is normal. Pain indicates injury, infection. Abdomen: may have dull or hollow sounds (those are usually cause for suspecting fluid in the abdomen because the abdomen should have a tympanic sound. Shifting domis where there is areas of hallow vs. dull means that there may be fluid in the abdomen and when you move the patient around these sounds will shift around) Fluid wave: differentiates fluid in abdomen from solid bowel contents (basically you have the patient push down on the abdomen at the midline and you will start

taping one flank and you have your other hand on the other side to see if you can feel it on the opposite side. If you feel it then it is due to fluid transmission of the vibration. You can also see it by pushing against the patients abdomen with your hand on one side and the letting it go and watching the patients abdomen settle back. It should just snap back kind of like a rubber band, but with the fluid wave it will kind of wiggle like jello. In a normal patient you wont feel this.) Renal: ascites from fluid overload. Additional Assessment Parameters *Weight: one of most important measurements for renal and fluid status (This will be a test question) ---Body weight / fluid relationship: rapid gains and losses indicate fluid rather than nutrition. (normal weight loss if you are on a diet is 1 to 1 and a half pounds a week. If you are losing or gaining pounds a day it is fluid it is not nutrition)(one thing to remember is 1kg of weight is equal to 1 liter or 1000ml. That is important to remember.) *Intake and Output ---Urine ---Insensible losses: perspiration, stool, water vapor from lungs. (This is what makes even strict I/O difficult to measure as appose to the patients weight.) ---Other losses: emesis, gastric suction, wound drainage Additional Assessment Parameters *Hemodynamic Monitoring ---CVP: < 2mm Hg= fluid depletion; > 6 mm Hg= fluid overload ---PAWP (wedge): < 8 mm Hg= fluid depletion; > 12 mm Hg= fluid overload ---MAP: may be decreased or increased depending on fluid status ---CO / CI: Cardiac index (CI): < 2.2L/min/m = fluid depletion; > 4.4L/min/m = fluid overload (we usually pay more attention to the cardiac index because your taking the cardiac output and dividing it by the bodies surface area.) Additional Assessment Parameters Other Observations: Fluid and electrolyte imbalances: renal dysfunction often leads to these Mental status changes you may see:

---lethargy, confusion, coma: all result from Na, Ca, or Mg excess (because the kidneys are not getting rid of enough of these) ---anxiety, apprehension: Na deficit, fluid overload (Na deficit and fluid overload can happen together.) ---apathy, withdrawal: you will see this with hypovolemia. Laboratory Assessment Blood Serum Analysis Blood Urea Nitrogen (BUN): results from fall in excretion of urea- a by-product of protein met. (increased BUN can result from other things like drugs and other conditions so you cant rely on BUN to give you as clear a picture of as whats going on with the kidneys as creatinine.) because creatinine comes from the decreased glomerular filtration. It comes from the kidneys not being able to get rid of it period it doesnt come from anything else. It is more accurate than the BUN Creatinine: results from GFR. More accurate than BUN to indicate renal function. BUN:Creatinine ratio: nl = 10:1 (creatinine is more accurate than BUN because creatinine comes from the decreased glomerular filtration. It comes from the kidneys not being able to get rid of it period. It doesnt come from anything else. It is more accurate than the BUN.) Creatinine Clearance: amount creatinine in urine and blood over 24 hours. Creatinine clearance decreases as renal function decreases. (However we are very resilient. Most of these tests will come out normal until GFR is less than 50% of normal and so we can go a lot time without knowing that anything is wrong. People dont really get really sick with failing kidneys until the GFR is lower than like 20% of normal.) Osmolality: nl: 280-300 mOsm/L Anion Gap: difference between anions (Na, K) and cations (Cl and HCO3). Anion gap > 20 mEq/L indicates met. Acidosis (you wil see the anion gap on electrolyte panels. (What it does is add the NA and the K together. Then it adds the CL and HCO3 together. Then you subtract those two numbers. If there is a gap between those two numbers greater then 20 mEq/L then that indicates that the patient has metabolic acidosis. Metabolic acidosis is a hallmark of renal failure.) Hemoglobin and Hematocrit: hemodilution, hemoconcentration, production erythropoietin (H&H is checked because of the decreased production of erythropoietin. You will see a decrease in the H&H. You may also see it because of hemodilution cause of fluid overload. On the contrary you may see hemoconcentration from hypovolemia in which cause you will see an artificially high H&H. Then when you get them rehydrated the H&H comes back because the hemoconcentration has gone away. The concentrated H&H is all diluted out. The

patient is now euvolemic (normal blood volume) and you now have what the H&H really is. It can be upsetting to say the least.) Albumin: decrease causes generalized edema (you will see a decreased albumin in acute renal failure patients because their losing albumin all the time because of the permeability of the tubules in the kidneys to albumin. It causes a lot of albumin to escape into the urine and not be reabsorbed.)(In chronic renal failure you will se a decreased albumin but mainly because of nutritional reasons.) Laboratory Assessment Urine Analysis: Urine pH: indicates kidney regulation of acid-base (normal urine PH should be between 3 and 4.) Specific Gravity / Osmolality (we are trying to measure how much solute is in the urine. It will show us how well the kidneys are concentrating urine. Normal urine specific gravity is 1.010- 1.025. Urine osmolality is 200-800 osmoles per kg of patients weight.) Glucose: should not be present in urine Protein: amount correlates with severity of glomerular damage (up to 150 mg a day is normal because some escapes the reabsorption process. We are talking about grams of protein a day in patients with glomerular damage that is lost in the urine.) Electrolytes: 24 hour measurement of excretion (Remember that the first voided specimen is always thrown away. That time that the voiding is done and the specimen is thrown away is the time that the 24 hour urine starts. When the time comes for it to end you ask the patient to empty the bladder one more time and you collect that. These may also be correlated with blood draws that have to be done at certain times so that comparison is made between the serum and the urine.) Sediment: types of sediment in the urine indicate etiology of renal problems ( Hematuria: can be gross and/or microscopic (there should be no more than 3 RBC per field when theyre looking through a microscope because thats all that is normal.) (Ketones are also checked for. These may be present but they usually are not present at all, but in diabetic ketone acidosis (they may be strongly present), in starvation, and people on ketonic diets they may have ketones in their urine (and this is not an emergency.) (Bacteria. More than 100,000 per ml of any one organism is significant. One or two here or there is considered accident from the urine process. From the process of voiding itself.)

Renal Diagnostic Studies: *CT scan (with or without contrast) *Cystoscopy (which is an invasive test. Its used to visualize the urethra, the bladder, to biopsy, and to remove stones. There is a lot of stuff they do with cystoscopy.) *IVP (intravenous pyelogram ) (also invasive. The patient is injected with a lot of dilute contrast so there are allergy considerations and there are also hydration considerations. They have o be well hydrated. There are no restrictions. They may be asked not to eat anything before the test for 8-12 hours before the test but drinking is allowed. They may also be given laxatives to evacuate their bowels. In fact a lot of these tests where they are doing x-ray or fluoroscopy like an IVP and renal angiography they will have the patient do a bowel cleansing. ) *KUB *MRI (Patients are told in a renal MRI to avoid alcohol, caffeine, and smoking for 24 hours and not to take nay iron supplements they may be taking because of being around the magnets.) *Renal angiography (It is an invasive procedure. Contrast is used. It is like any other angiogram they will use a big blood vessel in the arm, leg, or groin. So all the issues of taking vitals signs, neurovascular checks on the on limb being used, and watching for bleeding are all applicable here.) *Renal biopsy (can be done several ways such as a brush biopsy to collect cells. IV fluids are giving to people after these procedures particularly to patients who underwent brush biopsy in order to prevent blood clots. You can expect that the urine will have blood in it 24-48 hours. The patient is going to need pain medication because they are going to have renal colic (a type of abdominal pain usually caused by kidney stones that is very severe)(With needle biopsies the patient is sedated but conscious enough for them to cooperate when they ask them to inhale and hold their breath when they insert the needle so that nothing is moving. They have them lay on their side with a sandbag underneath the opposite flank.)(With renal biopsy you need to make sure and check the patients coags because they are sticking a needle in there and you want to make sure that they wont bleed to death. Renal biopsy is also contraindicated if the patient only has one kidney, hypertension, morbid obesity, or bleeding disorder.) *Renal ultrasound (they look for obstructions, masses, and malformations) *Bladder ultrasound *Voiding cystourethrography (basically what they do is put a catheter into the bladder and fill the patients bladder up with dilute contrast agent and when the patient feels like they have to void they will take pictures while the patients voiding.

They will look at bladder size and any problems the patient may have with urinary retention. The only thing the teacher can think of with voiding cystourethrography was that it is very embarrassing for the patient to have to void in front of people especially older people. *Renal radionuclide scan (renogram) (A radio isotope is used. You should watch for iodine allergy because an iodine isotope is sometimes used. The test is time to allow the isotope to concentrate in the kidneys. It is used to evaluate kidney perfusions and identify masses. It can also estimate GFR. Post procedure your responsibility is to encourage fluids to flush the isotope out of the body.