1. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 29: Patient Assessment: Renal System

2. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins History Presenting problem –Organized system (NOPQRST) Past medical history Family history Personal/social history

3. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Review of Systems BASELINE VITAL SIGNS –Hyperthermia –Tachycardia –Tachypnea (above can indicate infection or fluid retention) –Hypertension Trousseau’s sign

4. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Question The nurse is gathering baseline data on a patient with a history of polycystic kidney disease. The nurse suspects that the patient has a fluid volume excess. Which of the following would confirm this suspicion? A. Hypothermia B. Hypertension C. Bradypnea D. Bradycardia

5. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer B. Hypertension Rationale: A patient with a fluid volume excess collects the excess fluid volume in the vascular system. This is evidenced by an increase in blood pressure. Hypothermia would not be associated with this. Tachypnea and tachycardia, not bradypnea and bradycardia, would be associated with neurohormonal compensation for the excess fluid.

6. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Review of Systems CARDIOVASCULAR –S1, S2, S3 and S4 –Friction rubs –Elevated jugular venous distention –Pitting/nonpitting edema –Quality of peripheral pulses –Bruit –Central venous access sites PULMONARY –Rhythm/rate of respirations –Auscultation for adventitious sounds (crackles, gurgles, wheezes)

7. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Review of Systems (cont.) INTEGUMENT –Oral mucous membranes –Skin turgor (tented, nontented) –Bruising/bleeding –Chvostek’s sign

8. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Review of Systems (cont.) URINARY SYSTEM –Inspection –Percussion –Auscultation for bruits ABDOMINAL SYSTEM –Inspection (ascites) –Auscultation (bowel sounds) –Percussion –Palpation

9. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Assessment of Renal Function Urinalysis –Normal color Hematuria –Odor Urine volume Urine pH Urine protein Urine glucose/ketones Urine sediment Red blood cells –Hematuria White blood cells –Pyuria

10. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Questions A patient presents to the ECU with burns over 45% of her total body surface area (TBSA). A Foley catheter has been inserted and the urine is a very dark brown. Which of the following is most likely responsible for the color of her urine? A. Rhabdomyolysis B. A previous urinary tract infection C. Acute renal failure D. Polycystic disease

11. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer A. Rhabdomyolysis Rationale: Due to the large percentage of TBSA and the resultant cellular damage, she is most likely experiencing rhabdomyolysis from large skeletal muscle breakdown, resulting in large molecules blocking the kidney tubules. This patient needs large amounts of fluid to decrease acute tubular necrosis. A previous urinary tract infection will result in cloudy, yellow urine. Acute renal failure is the overall result of the burn but isn’t the most specific answer in this cause. Polycystic disease doesn’t result in brown coloration of the urine.

12. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Urine Specific Gravity and Osmolality Specific gravity (SG) is a measurement of the kidney’s ability to concentrate or dilute urine. –The normal SG ranges from 1.001 to 1.022 –SG > 1.022 means the urine has a larger amount of particles than normal (e.g., glucose, protein, radiographic contrast material). Urine osmolality ranges from 300 to 900 mOsm/kg/24 h. –Becomes a static value of 150 mOsm in renal disease

13. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Serum Studies Creatinine –Normal: 0.6-1.2 mg/dL –Elevated in renal failure Creatinine Clearance –Normal: 80-120 mL/min –24-hour urine collection maintenance is important –Serum level drawn midpoint in specimen collection –Decreased in kidney failure BUN (Blood Urea Nitrogen) –Normal: 8-20 mg/dL –Influenced by protein and water changes Osmolality –Normal: 280-290 mOsm/kg –Elevated when sodium is retained Hematocrit/Hemoglobin –Normal: 35-50% –Elevated in dehydration

14. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Assessment of Renal Function: Diagnostic Studies Renal biopsy –Most invasive/definitive tool –Percutaneous –Open Renal angiography NURSING CARE FOR DIAGNOSTIC STUDIES –Preprocedure Informed consent Clotting labs; blood typing Sedation –Postprocedure Frequent vital signs Assess site and urine for bleeding

15. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Assessment of Electrolytes: Sodium NORMAL VALUESROLES/S SODIUM135-145 mEq/LMaintains osmolality, neuromuscular function, acid-base balance HIGH: Dehydration, mental confusion, stupor, seizure, coma LOW: Muscle twitching, weakness, hypotension, tachycardia

16. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Assessment of Electrolytes: Potassium NORMAL VALUES ROLES/S POTASSIUM 3.5-5.0 mEq/L Nerve impulse; muscular contractions; intracellular osmolality and acid-base balance HIGH: Muscle weakness and flaccid paralysis. ECG changes; cardiac arrest. Nausea, diarrhea, abdominal cramping. LOW: Muscle weakness, fatigue, and leg cramping. Dizziness, hypotension, ECG changes, cardiac arrest.

17. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Question In a patient with a history of chronic renal failure, which of the following lab values will you anticipate seeing? A. Serum calcium 12 mg/dL; serum phosphate 2 mg/dL B. Serum calcium 9 mg/dL; serum phosphate 4 mg/dL C. Serum calcium 5 mg/dL; serum phosphate 2 mg/dL D. Serum calcium 6 mg/dL; serum phosphate 7 mg/dL

18. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer D. Serum calcium 6 mg/dL; serum phosphate 7 mg/dL Rationale: In chronic renal failure, the kidneys cannot eliminate phosphate, so those levels are usually high. Also, calcium isn’t mobilized from the bone due to a decreased excretion of PTH, so calcium levels are often low. Answer B shows normal values.

19. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Assessment of Electrolytes Calcium (8.5-10.5 mg/dL) –Bone and tooth structure/strength –Renal failure causes this level to drop –Active form is the ionized form Phosphate (3–4.5 mg/dL) –Reciprocal relationship with calcium –Building block for ATP Magnesium (1.4-2.1 mEq/L) –Neuromuscular functioning –Can accumulate in serum, bone, and muscle in renal failure

20. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Assessment of Acid-Base Balance Normal pH is 7.35-7.45, pCO2 35-45, HCO3 22-26 Respiratory acidosis –pH below normal, pCO2 above normal Respiratory alkalosis –pH above normal, pCO2 below normal Metabolic acidosis –pH below normal, HCO3 below normal Metabolic alkalosis –pH above normal, HCO3 above normal

21. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Nursing Assessment of Fluid Balance Role of daily weights –Looking for trends is the single most important measurement –Same time of day, same scale and bed linen –Rapid changes are usually due to fluid loss/gain Intake and output –Usually every hour when critical –Trends are important Hemodynamic monitoring

22. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Hypervolemia and Hypovolemia HYPERVOLEMIA (fluid excess) –Extra heart sounds (S3/S4) –Weight gain –Crackles, gurgles on pulmonary auscultation –Elevated jugular venous distention, hepatosplenomegaly –Chest x-ray shows pulmonary congestion –Decreased urinary output –HIGH: CVP, PCWP –LOW: urinary output, serum osmolality HYPOVOLEMIA (volume loss) –Tachycardia –Orthostatic hypotension (be sure to take BP and HR) –Decreased urinary output –Tented skin turgor –Weight loss –HIGH: urine osmolality, hematocrit –LOW: urinary sodium, CVP, PCWP