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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
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
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