1
Care of Patients with Renal Conditions:
● 3 things that a nurse should always do with renal patients
○ Check daily weight
■ Increased weight is a good indicator if the patient is retaining fluid or not
○ Have strict Intake and output measurements
■ if the output is less than 400 mL/ day or less than 30 ml/ hr on average, it is a good indicator that
a problems with the kidneys may be present
■ The intake and output should be relatively close in amount or fluid retention might be occurring
● Normal physical assessment of urinary system
○ no costovertebral angle (CVA) tenderness
○ nonpalpable kidney and bladder
○ No palpable masses
● Diagnostic testing
○ Urine studies
■ Urinalysis
■ Creatinine clearance
○ Lab studies
■ GFR
● Normal is 125 mL/Min
■ Creatinine
● normal is 0.6-1.3 mg/dL
■ BUN
● normal is 6 - 20 mg/dL
○ Urodynamics
■ Renal arteriogram
● Dye is administered and can show if the kidney’s blood supply has a blockage that is decreasing
the amount of the blood supply
● Visualizes renal blood vessels.
● Can assist in diagnosing renal artery stenosis, additional or missing renal blood vessels, and
renovascular hypertension. Can assist in differentiating between a renal cyst and a renal tumor.
Also included in workup of a potential renal transplant donor.
● A catheter is inserted into the femoral artery and passed up the aorta to the level of the renal
arteries.
● Contrast media is injected to outline the renal blood supply
■ Scopes
● Cystoscopic examination of the bladder
● Signs and symptoms of kidney disease
○ Decreased glomerular rate
○ Decreased urine output
○ Increased creatinine and BUN levels
● Urinary Tract Infection (UTI)
○ Second most common bacterial disease
○ Most common bacterial infection in women
, 2
○ Accounts for more than 8 million office visits per year
○ >100,000 people hospitalized annually because of UTI
■ UTI is a common cause of sepsis, urosepsis
■ the kidneys are in close proximity to the blood stream so the bacteria can easily cross into the
vascular system from the kidneys
○ >15% patients who develop gram-negative bacterial infection die.
■ gram negative bacteria release toxins which cause further harm to the host
■ many people get worse before they get better
○ Bladder and its contents are free of bacteria in most healthy patients.
○ Minority of healthy individuals have colonizing bacteria in bladder.
■ Called asymptomatic bacteriuria and does not justify treatment
○ an infection of the urinary system is diagnosed when bacterial invasion of the urinary tract
occurs.
○ most common cause of UTI is escherichia coli pathogen
○ Other causes include Fungal and parasitic infections
■ But these are uncommon
○ Urine analysis
■ Identify presence of nitrates, WBCs, and leukocyte esterase.
○ Patients at risk
■ Are immunosuppressed
■ Have diabetes
■ Have undergone multiple antibiotic courses
■ Have traveled to certain Third World countries
■ Had a recent foley catheter
○ Upper urinary tract infection
■ Upper tract
● Renal parenchyma, pelvis, and ureters
■ Symptoms
● Typically causes fever, chills, flank pain, and all over generalized pain
■ Example
● Pyelonephritis: inflammation of renal parenchyma and collecting system
○ Lower urinary tract infection
■ Lower urinary tract
■ Symptoms (Lower urinary tract symptoms: LUTS)
● Usually no systemic manifestations
● urinary frequency,
○ abnormally frequent with urinating more frequently
● urgent, and painful urination
● incontinence
○ loss or leakage of urine
● Bladder storage (cont’d)
○ Nocturia
■ Waking up ≥2 times at night to void
○ Nocturnal enuresis
, 3
■ Complaint of loss of urine during sleep
● Bladder emptying
○ Weak stream
○ Hesitancy
■ Difficulty starting the urine stream
○ Intermittency
■ Interruption of urinary stream while voiding
○ Postvoid dribbling
■ Urine loss after completion of voiding
○ Urinary retention
■ Inability to empty urine from bladder
○ Dysuria
■ Difficulty voiding
○ Pain on urination
● Older adults
○ Symptoms are often absent.
○ Experience nonlocalized abdominal discomfort rather than dysuria
○ May have cognitive impairment
○ Are less likely to have a fever
■ Example
● Cystitis—Inflammation of bladder wall
○ Diagnostic Studies
■ History and physical examination
■ Dipstick urinalysis (UA)
● Identify presence of nitrates, WBCs, and leukocyte esterase
■ Urine for culture and sensitivity(if indicated)
● A urine culture is indicated in complicated or HAI UTI, persistent bacteriuria, or frequently
recurring UTIs (more than two to three episodes per year). Urine also may be cultured when the
infection is unresponsive to empiric therapy, or when the diagnosis is questionable.
● Refrigerate urine immediately on collection.
● Clean-catch sample preferred
○ Teach women to spread the labia and wipe the periurethral area from front to back using a
moistened, clean gauze sponge (no antiseptic is used, as it could contaminate the specimen and
cause false-positives). Then tell them to keep the labia spread and to collect the specimen 1 to 2
seconds after voiding starts.
○ Instruct men to wipe the glans penis around the urethra. The specimen is collected 1 to 2 seconds
after voiding begins.
● Specimen by catheterization or suprapubic needle aspiration more accurate
● Determine susceptibility of bacteria to antibiotics
■ Imaging studies
● IVP or abdominal CT when obstruction suspected
● Renal ultrasound for recurrent UTIs
● Studies have shown that patients with symptoms can effectively diagnose their own UTIs and
can self-initiate treatment with the same success rate as physicians
Care of Patients with Renal Conditions:
● 3 things that a nurse should always do with renal patients
○ Check daily weight
■ Increased weight is a good indicator if the patient is retaining fluid or not
○ Have strict Intake and output measurements
■ if the output is less than 400 mL/ day or less than 30 ml/ hr on average, it is a good indicator that
a problems with the kidneys may be present
■ The intake and output should be relatively close in amount or fluid retention might be occurring
● Normal physical assessment of urinary system
○ no costovertebral angle (CVA) tenderness
○ nonpalpable kidney and bladder
○ No palpable masses
● Diagnostic testing
○ Urine studies
■ Urinalysis
■ Creatinine clearance
○ Lab studies
■ GFR
● Normal is 125 mL/Min
■ Creatinine
● normal is 0.6-1.3 mg/dL
■ BUN
● normal is 6 - 20 mg/dL
○ Urodynamics
■ Renal arteriogram
● Dye is administered and can show if the kidney’s blood supply has a blockage that is decreasing
the amount of the blood supply
● Visualizes renal blood vessels.
● Can assist in diagnosing renal artery stenosis, additional or missing renal blood vessels, and
renovascular hypertension. Can assist in differentiating between a renal cyst and a renal tumor.
Also included in workup of a potential renal transplant donor.
● A catheter is inserted into the femoral artery and passed up the aorta to the level of the renal
arteries.
● Contrast media is injected to outline the renal blood supply
■ Scopes
● Cystoscopic examination of the bladder
● Signs and symptoms of kidney disease
○ Decreased glomerular rate
○ Decreased urine output
○ Increased creatinine and BUN levels
● Urinary Tract Infection (UTI)
○ Second most common bacterial disease
○ Most common bacterial infection in women
, 2
○ Accounts for more than 8 million office visits per year
○ >100,000 people hospitalized annually because of UTI
■ UTI is a common cause of sepsis, urosepsis
■ the kidneys are in close proximity to the blood stream so the bacteria can easily cross into the
vascular system from the kidneys
○ >15% patients who develop gram-negative bacterial infection die.
■ gram negative bacteria release toxins which cause further harm to the host
■ many people get worse before they get better
○ Bladder and its contents are free of bacteria in most healthy patients.
○ Minority of healthy individuals have colonizing bacteria in bladder.
■ Called asymptomatic bacteriuria and does not justify treatment
○ an infection of the urinary system is diagnosed when bacterial invasion of the urinary tract
occurs.
○ most common cause of UTI is escherichia coli pathogen
○ Other causes include Fungal and parasitic infections
■ But these are uncommon
○ Urine analysis
■ Identify presence of nitrates, WBCs, and leukocyte esterase.
○ Patients at risk
■ Are immunosuppressed
■ Have diabetes
■ Have undergone multiple antibiotic courses
■ Have traveled to certain Third World countries
■ Had a recent foley catheter
○ Upper urinary tract infection
■ Upper tract
● Renal parenchyma, pelvis, and ureters
■ Symptoms
● Typically causes fever, chills, flank pain, and all over generalized pain
■ Example
● Pyelonephritis: inflammation of renal parenchyma and collecting system
○ Lower urinary tract infection
■ Lower urinary tract
■ Symptoms (Lower urinary tract symptoms: LUTS)
● Usually no systemic manifestations
● urinary frequency,
○ abnormally frequent with urinating more frequently
● urgent, and painful urination
● incontinence
○ loss or leakage of urine
● Bladder storage (cont’d)
○ Nocturia
■ Waking up ≥2 times at night to void
○ Nocturnal enuresis
, 3
■ Complaint of loss of urine during sleep
● Bladder emptying
○ Weak stream
○ Hesitancy
■ Difficulty starting the urine stream
○ Intermittency
■ Interruption of urinary stream while voiding
○ Postvoid dribbling
■ Urine loss after completion of voiding
○ Urinary retention
■ Inability to empty urine from bladder
○ Dysuria
■ Difficulty voiding
○ Pain on urination
● Older adults
○ Symptoms are often absent.
○ Experience nonlocalized abdominal discomfort rather than dysuria
○ May have cognitive impairment
○ Are less likely to have a fever
■ Example
● Cystitis—Inflammation of bladder wall
○ Diagnostic Studies
■ History and physical examination
■ Dipstick urinalysis (UA)
● Identify presence of nitrates, WBCs, and leukocyte esterase
■ Urine for culture and sensitivity(if indicated)
● A urine culture is indicated in complicated or HAI UTI, persistent bacteriuria, or frequently
recurring UTIs (more than two to three episodes per year). Urine also may be cultured when the
infection is unresponsive to empiric therapy, or when the diagnosis is questionable.
● Refrigerate urine immediately on collection.
● Clean-catch sample preferred
○ Teach women to spread the labia and wipe the periurethral area from front to back using a
moistened, clean gauze sponge (no antiseptic is used, as it could contaminate the specimen and
cause false-positives). Then tell them to keep the labia spread and to collect the specimen 1 to 2
seconds after voiding starts.
○ Instruct men to wipe the glans penis around the urethra. The specimen is collected 1 to 2 seconds
after voiding begins.
● Specimen by catheterization or suprapubic needle aspiration more accurate
● Determine susceptibility of bacteria to antibiotics
■ Imaging studies
● IVP or abdominal CT when obstruction suspected
● Renal ultrasound for recurrent UTIs
● Studies have shown that patients with symptoms can effectively diagnose their own UTIs and
can self-initiate treatment with the same success rate as physicians
