QSEN & Renal Diagnostic Procedures

QSEN Competencies

• Gerontological considerations specific to older adult clients
• Safety considerations and steps for nurses to ensure client safety
• Importance of a holistic approach in providing care
• Integration of research into clinical practice
• Highlights the use of information technology to support nursing practice
• Focuses on integrating planning processes to meet clients’ needs
• Highlights delivery of care using an interprofessional approach
• Relates content to social determinants of health

Renal Diagnostic Procedures

• Evaluate kidney function using renal diagnostic procedures and lab tests
• Testing kidney function helps providers diagnose disease and evaluate treatment effectiveness
• The nurse must verify the client signed an informed consent for most diagnostic procedures and tests

Laboratory Tests and Findings

Blood Creatinine

• Protein and muscle breakdown results in blood creatinine
• Kidney disease is the only condition elevating creatinine levels
• Kidney function loss of 50% or more elevates creatinine values
• Blood creatinine values remain constant in older adults who don't have kidney disease despite decreased muscle mass and creatinine amount

Blood Urea Nitrogen (BUN)

• Breakdown of protein in the liver leads to BUN which is urea nitrogen excreted by kidneys
• Dehydration, infection, chemotherapy, steroid therapy, and blood reabsorption in damaged liver tissue affects BUN
• Elevated BUN suggests kidney disease
• Liver failure limits urea production, reducing BUN when liver and kidney failure occurs

Urinalysis

• Urinalysis evaluates kidney waste products and detects urologic disorders
• Early-morning specimens provide a more concentrated sample
• Urinalysis identifies color, clarity, concentration/dilution, specific gravity, acidity/alkalinity
• It detects drug metabolites, glucose, ketone bodies, and protein
• Glucose, ketone bodies, and protein, including leukocyte esterase and nitrites, typically indicate conditions like diabetes mellitus, fat metabolism issues, infection, or cancer
• Urine culture and sensitivity identifies bacteria and determines antibiotic type
• A 24-hr urine collection measures creatinine, urea nitrogen, sodium, chloride, calcium, catecholamines, and proteins
• A 24-hr collection for creatinine clearance measures the glomerular filtration rate for impaired kidney function

Guidelines for 24-hr Specimen Collection

• Reinforce client teaching:
• Void before defecating
• Avoid placing toilet paper in the urine collection container
• Have the client void to begin the test, discard the initial void
• Collect all subsequent urine for the next 24 hr
• Post notices on the client's medical record and in the toilet to alert personnel
• Collect all urine voided over the next 24 hr in an approved container
• Keep the container on ice or refrigerated
• Collect the final urine sample as close as possible to the end of the 24 hr
• Restart the test if any urine collection sample is missed

Renal Diagnostic Procedures

Radiography (X-Ray)

• Renal X-ray of kidneys, ureters, and bladder (KUB or flat plate) without contrast dye
• Aids in visualizing structures & detecting renal calculi, strictures, calcium deposits, or obstructions
• Detects gas in the GI tract and ascites
• Ask if clients are pregnant
• Instruct clients to remove clothing, jewelry, and metal objects
• No known complications

CT Scan

• 3D imaging to monitor the renal/urinary system for kidney size and obstruction, cysts, or masses
• Enhances images with IV iodine-based contrast media
• Ask if clients are pregnant and check for iodine allergy
• Tell clients to remove clothing, jewelry, and metal objects
• Check for metformin use since it can adversely affect the kidneys Monitor for delayed allergic reaction to dye/contrast media
• Dyspnea, tachycardia, rash, hives
• Encourage clients to increase fluid intake following procedure
• Contrast media can cause acute kidney injury
• Risk of complications is greater for older adults, dehydrated clients, clients with previous renal insufficiency, or those taking nephrotoxic drugs

MRI

• MRI is useful for staging cancer, similar to a CT scan
• Clients lie down and need to remain still
• Avoid with metal implants due to magnet
• Can result in poor imaging if a client cannot lie still

Ultrasound

• Ultrasound evaluates kidney size, images ureters, bladder, masses, cysts, calculi, and obstructions in the lower urinary tract
• A good alternative is excretory urography
• Provide skin care by removing gel after the procedure
• Minimal risk

Cystography, Cystourethrography, Voiding Cystourethrogram (VCUG)

• VCUG detects urethral or bladder injury after contrast media instillation through a urinary catheter
• Provides an image of the bladder (cystography) and ureters (cystourethrography)
• VCUG uses X-rays to detect urine reflux during urination in the ureters
• Contrast media does not reach the bloodstream/kidneys and is non-nephrotoxic
• Determine the presence of allergy to contrast media or iodine
• Monitor for infection for the first 72 hr post-procedure
• Encourage fluid intake to dilute urine and minimize burning during urination
• Report urine output less than 30 mL/hr if suspected pelvic or urethral trauma
• Reinforce reports of bright red bleeding, abdominal/flank pain, chills, or fever after procedure
• Results in UTIs due to catheter placement
• Can indicate a cloudy, foul-smelling urine, urgency, urine positive for leukocyte esterase and nitrites, sediment, and RBCs

Kidney Biopsy

• Removal of tissue sample for cytological examination through excision/needle aspiration
• Clients receive sedation and continual monitoring
• Review coagulation studies, ensure NPO status for at least 4 hr, and position clients prone with a pillow under abdomen before the procedure
• Monitor vitals, check dressings and urinary output (hematuria), and review hgb and hct values after procedure
• Administer analgesia, ensure a pressure dressing is on puncture site, monitor dressings for infection/hemorrhage, and monitor urine for output and gross hematuria
• Initial urine will contain some blood but clears within 24 hr
• Reinforce bed rest for up to 24 hr afterward
• Hemorrhage can cause hypotension, tachycardia, dizziness, or back/flank pain
• Watch for an infection which can cause cloudy/foul-smelling urine, urgency, and positive urine for leukocyte esterase/nitrites/sediment/RBCs
• Urinary retention can also occur
• Liver/bowel puncture can also occur during a kidney biopsy so monitor for pain, tenderness, rigidity, and decreased bowel sounds

Cystoscopy, Cystourethroscopy

• Discover abnormalities of bladder wall (cystoscopy) and/or occlusions of the ureter/urethra (cystourethroscopy)
• Clients receive anesthesia and be sure to check for bleeding and infection
• Clients require NPO status after midnight, and laxatives the night before the procedure
• Monitor vitals and urine output after the procedure
• Note urine color (pink-tinged)
• Irrigate urinary catheter with 0.9% sodium chloride if blood clots are present
• Encourage oral fluids to increase output and reduce any burning sensation
• Client teaching includes monitoring for urinary retention, hematuria, increased abdominal pain, fever, chills, and dysuria for at least 72 hr post procedure
• Can lead to bladder or ureter perforation, sepsis, hematuria, urinary retention, and UTI

Retrograde Pyelogram, Cystogram, Urethrogram

• Identifies ureter/renal pelvis obstruction/structural disorders (pyelogram) by instilling contrast media during cystoscopy
• Identifies bladder fistulas/diverticula/tumors (cystogram) and urethra (urethrogram) by instilling contrast media during cystoscopy Nursing Actions: Same as cystoscopy Complications: Same as cystoscopy, plus ureter obstruction-related ureteral edema (pyelogram)

Renal Scan

• Monitors renal blood flow and estimates glomerular filtration rate (GFR)
• IV injection of radioactive material produces a scanned kidney image
• Encourage clients to void before the scan and drink fluid as directed
• Reinforce remaining still during the scan
• If clients received captopril during, monitor blood pressure and alert them about possible orthostatic hypotension
• Increase fluid intake for hypotension and to promote excretion of the radioisotope
• Does not cause nephrotoxicity Clients do not excrete dangerous radioactive material in the urine, meaning they are not at risk

Excretory Urography

• Detects obstruction/parenchymal masses and observes kidney size by using IV contrast media (iodine-based)
• Nursing Actions: Same as KUB
• Encourage increased fluids a day before the procedure
• Bowel cleansing with laxative/enema to remove fecal matter for clearer visualization
• NPO after midnight
• Determine allergies to iodine, seafood, eggs, milk, or chocolate; or if clients have asthma
• Check creatinine and BUN levels
• Withhold metformin 24 hours before (risk for lactic acidosis if iodine-based contrast dye is used)
• Assist with administering parenteral or oral fluids to flush media (to prevent complications) after the procedure
• Diuretics increase media excretion
• Monitor creatinine and BUN blood levels before resuming metformin and urine output; pink tinge is expected Note hematuria or clots
• Contrast media can cause acute kidney injury, allergy to iodine dye, hypoglycemia/acidosis, and hemorrhage

Gerontological Considerations

• Kidney size and function decrease with age
• Blood flow adaptability decreases with age, especially during hypotensive or hypertensive crises
• GFR decreases by half the rate of a young adult
• Diabetes mellitus, hypertension, and heart failure can affect older adults
• Older adults are more susceptible to kidney injuries from contrast media and medications due to decreased kidney size, blood flow, and GFR
• Tubular changes can cause urgency and nocturnal polyuria

Hemodialysis and Peritoneal Dialysis

• Dialysis sustains patients with acute or chronic kidney injuries
• However, it doesn’t replace hormonal kidney function
• Hemodialysis is one type and peritoneal dialysis is the other type

Functions of Dialysis

• Rids excess fluid/electrolytes from the body
• Achieves acid-base balance
• Eliminates waste products
• Restores internal homeostasis via osmosis, diffusion, and ultrafiltration

Hemodialysis

• Blood shunted from the body to a dialyzer
• Requires vascular access and then returns back into circulation
• Hemodialysis is initiated when uremia manifestations are severe

Indications for Hemodialysis

• Can treat renal insufficiency, acute kidney injury, chronic kidney disease, medication/illicit drug toxicity, persistent hyperkalemia, pulmonary edema, severe hypertension, and hypervolemia that isn’t responding to diuretics

Client Presentation

• Fluid volume changes, electrolyte and pH imbalances, and nitrogenous wastes can be treated using hemodialysis
• Clients may experience fluid overload, neurologic changes, and bleeding
• They also have uremia, which is defined as cognitive impairment, pruritus, nausea, and vomiting

Nursing Actions - Preprocedure

• Check for informed consent
• Use temporary hemodialysis dual-lumen catheter or subcutaneous device
• Use until the provider inserts the access for a long-term device
• Monitor patency of long-term device
• Includes AV fistula or AV graft, presence of bruit, palpable thrill, distal pulses, and circulation
• Avoid taking blood pressure, administering injections, performing venipunctures, or inserting IV catheters on the arm that has an access site
• Elevate the extremity after surgical creation of AV fistula to reduce swelling
• Obtain vitals, LAB values (BUN, blood creatinine, electrolytes, hematocrit), and weight
• Discuss medications to withhold with the provider
• Withhold any dialyzable medications and those that lower blood pressure until after dialysis

Client Education - Hemodialysis

• Needed three times per week, for 3-5 hour insertion into an artery and insertion into a vein

Nursing Actions - Postprocedure

• Monitor vitals and LAB values (BUN, blood creatinine, electrolytes, hematocrit)
• Decreases in blood pressure and changes in laboratory values are common following dialysis
• Compare pre and post procedure weights
• Estimates amount of fluid the procedure removed (1 L fluid equals 1 kg, which is 2.2 lb)
• Watch for complications, such as: -Hypotension, clotting of vascular access, headache, muscle cramps, and bleeding
• Also note bleeding or infection at access site, disequilibrium syndrome manifestations (nausea, vomiting, headache), and hypovolemia manifestations, which are hypotension, dizziness, and tachycardia

Further Considerations - Hemodialysis

• Avoid invasive procedures for 4 to 6 hours after dialysis due to bleeding risk from anticoagulation
• Monitor the access site for bleeding, patency, and infection
• Ensure the client knows AV fistula and AV graft precautions, and knows to alert the nurse of early findings of disequilibrium syndrome
• Clients should check the access site at intervals (apply pressure when there's bleeding) and contact the provider if bleeding lasts longer than 30 minutes

Client Education - Hemodialysis Continued

• Clients can avoid carrying objects or constricting the extremity or sleeping on the side of the vascular access

Hemodialysis: Complications

• Anticoagulants prevent blood clots from forming
• Bleeding Cannulation can introduce infection Immunosuppressive disorders increase the infection risk
• Advanced age is a risk factor for dialysis induced hypotension as well as access site complications and disease

Nursing Actions for Hemodialysis

• Avoid compression and venipuncture on the access site
• Graft site- listen for palpable or audible thrill, and assess site for redness, drainage or fever
• Disequilibrium syndrome and fluid volume imbalances are dangerous
• Early identification of disequilbrium issues (nausea/vomiting) critical
• Lower dialysate rate especially for older adults and those new to dialysis
• Fluid balance achieved with fluid replacement or lowering head of the bed
• Anemia is also risk factor and should stimulate RBC production with erythropoietin

Infections in Hemodialysis

• Blood transfusions and vein access increases risk of bloodborne infections like hepatitis B and C as well as HIV
• Use sterile sharps for skin prep and standard precautions

Peritoneal Dialysis

• Instillation of dialysate into peritoneal cavity and dwells for time required
• Peritoneum works as filtration membrane
• Waste products and excess fluid travel from high concentration in blood/low in dialysate Dialysate outflow is effluent which is drained into bag
• The client also needs intact peritoneal membrane without adhesions or surgeries

Peritoneal Indications

• Treatment for the elderly who require dialysis where the client has issues with anticoagulation, vascular issues, and are unstable

Peritoneal Considerations - Preprocedure

• Determine dry vital signs and LAB values such as blood creatinine and glucose
• Assess ability to perform sterile procedures
• Use standard precautions and technique while handling equipment
• Record abdominal girth and ensure dialysate matches room temperature

Intraperitoneal Nursing Actions

• Monitor vial signs and blood glucose levels; measure dialysate and color
• Watch for infection, drainage, and respiratory distress; check catheter site and follow schedule, and finally emotional support.

Nursing Actions - Postperitoneal

• Weigh the client and electrolytes; creatinine and urea are monitored

Peritoneal Client Education

• Perform care in the house with support

Peritoneal Complications

• Peritonitis can occur as effluence is contaminated; maintain surgical asepsis and assess for infection
• Notify provider for infection at access site
• Avoid glucose dialysate, and hyperlipidemia is a risk factor Causes of dialysate inflow/outflow are obstruction and constripaation

Peritoneal Interventions

• Reposition client/tubing, address constipation and treatment for APD is supine as needed

Acute and Chronic Kidney Disease

• Kidneys regulate fluid and remove wastes as acute kidney injury occurs when blood flow to kidneys is compromised
• Onset ends with oliguria 100-400ml in 24 hours which lasts from one to three weeks
• Diuresis also leads to dehydration by excreting 1000-2000ml
• Recovery and restoration can take 12 months
• Fluid intake is a great promotion tool, as decreased can cause complications

Factors of Renal Health

• Prerenal: Damage before kidney because volume and reducing nephrons
• Intrarenal is direct damage to glomeruli and nephrons and post renal is a bilateral obstruction
• Smoking is poor NSAIDs, and controlling diabetes preventions all
• AKI is rapid and the causes are vascular obstruction; shock and peripheral resistance as creatinine BUN increase
• Hypertension/fluid overload as well edema presents; the system and labs monitor all
• Hematuria and proteinuria are present for urine, but biopsy leads to diagnoses while restricting fluid is great and ECG does too

Nutrition and Renal Health

• Focus is less potassium, and intake, and fluid control as parenteral and dialysis are therapeutic for nephrology and consult nutritionist as progressive. Elderly and diabetic clients need increased attention

Nephritis and System Failure

• CKD has five stages where dialysis indicated and kidney disease leads towards high creatinine where electrolytes are affected; nephropathy and genetics lead to complications involving uremia

Polycystic Interventions

• Priority with treatment to control
• Hypertension as medication with management is needed along balanced food intake as kidney failure manifests with many infections

System Infections

• High in common; infections are in ureters in system or renal pelvis which in a female who is non-empty leads to high complications like shock
• Avoid hygiene sprays as high risk is present as estrogen is decreased with high alkalinity Elderly clients in those situations show confusion as hypotension and confusion is present; a urinalysis shows elevated results

Medications and Infections

• Sulfa is big risk but can flush medication. Educate proper practices
• Consult urological processes
• Acute can be treated but if in need of help refer specialist