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Assessment of Kidney and Urinary Function

When the total number of functioning nephrons is less than 20%, renal replacement
therapy needs to be considered. Dialysis is an example of a renal replacement therapy.
Prior to the loss of about 80% of the nephron functioning ability, the patient may have
mild symptoms of compromised renal function, but symptom management is often
obtained through dietary modifications and drug therapy. The listed creatinine and BUN
levels are within reference ranges.
The three narrowed areas of each ureter are the ureteropelvic junction, the ureteral
segment near the sacroiliac junction, and the ureterovescial junction. These three areas of
the ureters have a propensity for obstruction by renal calculi or stricture. Obstruction of
the ureteropelvic junction is most serious because of its close proximity to the kidney and
the risk of associated kidney dysfunction. The urethra is not part of the ureter.
To calculate creatinine clearance, a 24-hour urine specimen is collected. Midway through
the collection, the serum creatinine level is measured.
Dullness to percussion of the bladder following voiding indicates incomplete bladder
emptying. Enlargement of the kidneys can be attributed to numerous conditions such as
polycystic kidney disease or hydronephrosis and is not related to bladder fullness.
Dehydration and ureteral obstruction are not related to bladder fullness; in fact, these
conditions result in decreased flow of urine to the bladder.
Ultrasonography requires a full bladder; therefore, fluid intake should be encouraged
before the procedures. The administration of a radiopaque contrast agent is required to
perform IV urography studies, such as an IV pyelogram. Ultrasonography is a quick and
painless diagnostic test and does not require sedation or intubation. The injection of a
radioisotope is required for nuclear scan and ultrasonography is not in this category of
diagnostic studies.
Urine specific gravity depends largely on hydration status. A decrease in fluid intake will
lead to an increase in the urine specific gravity. With high fluid intake, specific gravity
decreases. In patients with kidney disease, urine specific gravity does not vary with fluid

intake, and the patients urine is said to have a fixed specific gravity.
Many age-related changes in the renal and urinary systems should be taken into
consideration when taking a health history of the older adult. One change includes a
decreased glomerular surface area resulting in a decreased glomerular filtration rate.
Other changes include the decreased ability to concentrate urine and a decreased bladder
capacity. It also should be understood that urinary incontinence is not a normal agerelated change, but is common in older adults, especially in women because of the loss of
pelvic muscle tone.
After a cystoscopic examination, the patient with obstructive pathology may experience
urine retention if the instruments used during the examination caused edema. The nurse
will carefully monitor the patient with prostatic hyperplasia for urine retention. Postprocedure, the patient will experience some hematuria, but is not at great risk for

Assessment of Kidney and Urinary Function


hemorrhage. Unless the condition is associated with another disorder, nausea is not

commonly associated with this diagnostic study. Bladder perforation is rare.


Retention of potassium is the most life-threatening effect of renal failure. Aldosterone
causes the kidney to excrete potassium, in contrast to aldosterones effects on sodium
described previously. Acid/base balance, the amount of dietary potassium intake, and the
flow rate of the filtrate in the distal tubule also influence the amount of potassium
secreted into the urine. Hypocalcemia, the accumulation of wastes, and lack of BP control
are complications associated with renal failure, but do not have same level of threat to the
patients well-being as hyperkalemia.
Biopsy of the kidney is used in diagnosing and evaluating the extent of kidney disease.
Indications for biopsy include unexplained acute renal failure, persistent proteinuria or
hematuria, transplant rejection, and glomerulopathies.
The various substances normally filtered by the glomerulus, reabsorbed by the tubules,
and excreted in the urine include sodium, chloride, bicarbonate, potassium, glucose, urea,
creatinine, and uric acid. Within the tubule, some of these substances are selectively
reabsorbed into the blood. Glucose is completely reabsorbed in the tubule and normally
does not appear in the urine. However, glucose is found in the urine if the amount of
glucose in the blood and glomerular filtrate exceeds the amount that the tubules are able
to reabsorb. Protein molecules are also generally not found in the urine because amino
acids are also filtered at the level of the glomerulus and reabsorbed so that it is not
excreted in the urine.
An increase in body weight commonly accompanies edema. To calculate the approximate
weight gain from fluid retention, remember that 1 kg of weight gain equals approximately
1,000 mL of fluid. Five lbs = 2.27 kg = 2,270 mL.
The costovertebral angle is the angle formed by the lower border of the 12th rib and the
spine. Renal dysfunction may produce tenderness over the costovertebral angle.
There are several contraindications to a kidney biopsy, including bleeding tendencies,
uncontrolled hypertension, a solitary kidney, and morbid obesity. Indications for a renal
biopsy include unexplained acute renal failure, persistent proteinuria or hematuria,

transplant rejection, and glomerulopathies.


Increased urinary urgency and frequency coupled with decreasing urine volumes strongly
suggest urine retention. Hematuria may be an accompanying symptom, but is likely
related to a urinary tract infection secondary to the retention of urine. Dehydration and
renal failure both result in a decrease in urine output, but the patient with these conditions
does not have normal urine production and decreased or minimal flow of urine to the
bladder. The symptoms of urgency and frequency do not accompany renal failure and

dehydration due to decreased urine production.


When the vasa recta detect a decrease in BP, specialized juxtaglomerular cells near the
afferent arteriole, distal tubule, and efferent arteriole secrete the hormone renin. Renin

Assessment of Kidney and Urinary Function


converts angiotensinogen to angiotensin I, which is then converted to angiotensin II. The
vasoconstriction causes the BP to increase. The adrenal cortex secretes aldosterone in
response to stimulation by the pituitary gland, which in turn is in response to poor

perfusion or increasing serum osmolality. The result is an increase in BP.


An obstruction of the bladder outlet, such as in advanced benign prostatic hyperplasia,
results in abnormally high voiding pressure with a slow, prolonged flow of urine. The
urine may remain in the bladder, which increases the potential of a urinary tract infection.
Older male patients are at risk for prostatic enlargement, which causes urethral
obstruction and can result in hydronephrosis, renal failure, and urinary tract infections.
Ultrasonography is a noninvasive procedure that passes sound waves into the body
through a transducer to detect abnormalities of internal tissues and organs. Structures of
the urinary system create characteristic ultrasonographic images. Because of its
sensitivity, ultrasonography has replaced many other diagnostic tests as the initial
diagnostic procedure.
Ureteral pain is characterized as a dull continuous pain that may be intense with voiding.
The pain may be described as sharp or stabbing if the bladder is full. This type of pain is
inconsistent with a stone being present in the bladder. Stones are not normally situated in

the urethra or meatus.


Hematuria and renal colic are common and expected findings after the performance of a
renal brush biopsy. The physician should be notified of the patients body temperature,
which likely indicates the onset of an infectious process. IV infiltration does not warrant
notification of the primary care physician.
Some burning on voiding, blood-tinged urine, and urinary frequency from trauma to the
mucous membranes can be expected after cystoscopy. The nurse should explain this to
the patient and ensure that the bleeding resolves. No clear need exists to report this
finding and it does not warrant insertion of a Foley catheter or vitamin K administration.
Following cystoscopy, moist heat to the lower abdomen and warm sitz baths are helpful
in relieving pain and relaxing the muscles. Ice, lidocaine, and mobilization are not
recommended interventions.
Preparation for an open biopsy is similar to that for any major abdominal surgery. When
preparing the patient for an open biopsy you would keep the patient NPO. You may
discuss the diagnosis with the family, but that is not a preparation for the procedure. A
pre-procedure wash is not normally ordered and antivirals are not administered in
anticipation of a biopsy.
Before the procedure, a laxative may be prescribed to evacuate the colon so that
unobstructed x-rays can be obtained. A 24-hour urine test is not necessary prior to the
procedure. Gastrografin and potassium chloride are not administered prior to renal
angiography.
Renal glycosuria can occur on its own as a benign condition. It also occurs in poorly
controlled diabetes, the most common condition that causes the blood glucose level to

Assessment of Kidney and Urinary Function

exceed the kidneys reabsorption capacity. Glycosuria is not associated with SIADH,
diabetes insipidus, or renal carcinoma.
The kidney performs two major functions to assist in acid/base balance. The first is to
reabsorb and return to the bodys circulation any bicarbonate from the urinary filtrate; the
second is to excrete acid in the urine. Retaining bicarbonate will counteract an acidotic
state. The nephrons do not sequester free hydrogen ions.
The adult GFR can vary from a normal of approximately 125 mL/min (1.67 to 2.0
mL/sec) to a high of 200 mL/min. A low GFR is associated with increased levels of BUN,
creatinine, and potassium.
To replace any lost bicarbonate, the renal tubular cells generate new bicarbonate through
a variety of chemical reactions. This newly generated bicarbonate is then reabsorbed by
the tubules and returned to the body. The lungs and adrenal glands do not synthesize
bicarbonate. Excretion of acid compensates for a lack of bicarbonate, but it does not
actively replace it.
The nurse emphasizes the need to drink throughout the day even if the patient does not
feel thirsty, because the thirst stimulation is decreased. Four liters of daily fluid intake is
excessive and fluids other than water are acceptable in most cases. Additional salt intake
is not recommended as a prompt for increased fluid intake.
Patient preparation should include teaching relaxation techniques because the patient
needs to remain still during an MRI. The patient does not normally need to be NPO or

fluid-restricted before the test and conscious sedation is not usually implemented.
Osmolality is the most accurate measurement of the kidneys ability to dilute and
concentrate urine. Osmolality is not a direct indicator of renal function as it relates to
erythropoietin synthesis or maintenance of acid/base balance. It does not indicate the
maintenance of healthy levels of potassium, the vast majority of which is excreted.
Dysfunction of the kidney can produce a complex array of symptoms throughout the
body. Pain, changes in voiding, and gastrointestinal symptoms are particularly suggestive
of urinary tract disease. Jaundice and petechiae are not associated with genitourinary
health problems.
The proximity of the right kidney to the colon, duodenum, head of the pancreas, common
bile duct, liver, and gallbladder may cause GI disturbances. The proximity of the left
kidney to the colon (splenic flexure), stomach, pancreas, and spleen may also result in
intestinal symptoms. Digestive enzymes do not affect renal function and the left kidney is
not connected to the common bile duct.
Although historically hematocrit has been the blood test of choice when assessing a
patient for anemia, use of the hemoglobin level rather than hematocrit is currently
recommended, because that measurement is a better assessment of the oxygen transport
ability of the blood. ESR and creatinine levels are not indicative of oxygen transport
ability.
The deep tendon reflexes of the knee are examined for quality and symmetry. This is an
important part of testing for neurologic causes of bladder dysfunction, because the sacral
area, which innervates the lower extremities, is in the same peripheral nerve area

Assessment of Kidney and Urinary Function

responsible for urinary continence. Neurologic function does not directly influence the
course of renal calculi, BPH or UTIs.
Voiding in the presence of others can frequently cause guarding, a natural reflex that
inhibits voiding due to situational anxiety. Because the outcomes of these studies
determine the plan of care, the nurse must help the patient relax by providing as much
privacy and explanation about the procedure as possible. Diuretics and increased fluid
intake would not address the patients anxiety. It would be inappropriate and anxietyprovoking to discuss test results during the performance of the test.
Drinking fluids can help to clear hematuria. Diuretics are not used for this purpose.
Activity limitation and massage are unlikely to resolve this expected consequence of
testing.
Urine testing includes testing for specific gravity, glucose, RBCs, and casts. BUN and
creatinine are components of serum, not urine.
A dipstick examination, which can detect from 30 to 1000 mg/dL of protein, should be
used as a screening test only, because urine concentration, pH, hematuria, and
radiocontrast materials all affect the results. Proteinuria is not diagnostic of diabetes and

it is neither an age-related change nor a risk factor for incontinence.


The nurse should ensure that the patient understands the results that are presented by the
physician. Informing the patient of a diagnosis is normally the primary care providers
responsibility. Withholding fluids or medications is not normally required after testing.