Renal ArteriogramRenal BiopsyCT Scan/MRI of the Kidneys/Urinary Bladder

RENAL ARTERIOGRAM

A renal arteriogram is also commonly called renal angiogram

An arteriogram is a x-ray image of the arteries or blood vessels of the kidneys (renal).

A fluoroscopic image of the kidneys can also be done to see the movement of the kidneys.

The catheter is inserted into the femoral artery and is passed upward through the iliac artery and the aorta to the renal artery.

This tests permits visualization of the renal vessels and the parenchyma.

An aortogram is sometimes made with real angiography to detect any vessel abnormality and to show the relationship of the renal arteries to the aorta.

Indications/Purposes (RA)

To detect renal artery stenosis

Renal thrombus or embolous

Space-occupying lesions (tumors, cysts)

Aneurysms

To determine the causative factor of hypertension

To evaluate renal circulation

Procedure (RA)

A consent form should be signed by the client or a designated family member.

The client should be NPO for 8-12 hours before the test. Antocoagulants (heparin) are usually discontinued.

Record V/S. have client void before the test. Dentures and metallic objects should be removed

before the test. The access site should be shaved.

Premedications (i.e., sedative or narcotic analgesic), if ordered, are administered an hour before the test. If the client has a hx of severe allergic reactions to various substances or drugs, the health care provider may order steroids or antihistamines before and after the procedure as a prophylactic measure.

Intravenous fluid may be started before the procedure so that emergency drugs, if needed, may be administered.

The client lies in supine position on an x-ray table. A local anesthetic is administered to the injection incisional site.

The test takes approximately 1-2 hours. Laxative or cleansing enema is usually ordered the

evening before the test.

Nursing Implication: Pretest Obtain history of hypersensitivity to iodine, seafood, or

contrast dye from other x-ray procedures (e.g., IVP). The health care provider should also know if the client is highly sensitive to other substances. Skin testing could be done before the test, or prophylactic medications (i.e., steroids, antihistamines) may be given prior to and/or following the test.

Record baseline vital signs.

Give laxative or cleansing enema, if ordered. This will cleanse the lower intestinal tract, allowing better visualization.

Have the client void, wear a gown, and remove dentures.

Administer premedications (sedative and narcotic analgesic) as ordered. Check that the consent form has been signed before giving premedications. The client should be in bed with the bed sides up after premedications are given.

Nursing Implication: Post-test Apply pressure on the injection site for 5-10 minutes or longer

(venous access) or 30 minutes or longer (arterial access) until bleeding has stopped. Check the injection site for bleeding when taking vital signs.

Monitor vital signs as ordered, such as every 15 min for the first hour, every 30 min fir the next 2hours, and then every hour for the next 4 hours, or until stable. Temperature should be taken every 4 hours for 24-48 hours or as ordered.

Enforce bed rest for 5 hours for venous access or 6-8 hours for arterial access or as ordered. Activities should be restricted for a day.

Assess injection site for swelling and for hematoma.

Check peripheral pulses in the extremities. Absence or weakness in pulse volume should be reported immediately

Note the temperature and color of the extremity. Report changes (e.g., color-pale, pain in the extremity, especially distal to access site) to the health care provider immediately. Arterial occlusion to the extremity may occur.

Apply cold compress or an ice pack to the injection site for edeme or pain, if ordered.

Monitor ECG tracings, urine output, and IV fluids. IV fluids and cardiac monitoring may be discontinued after the angiography.

Observe for a delayed allergic reaction to the contrast dye (i.e., tachycardia, dyspnea, skin rash, urticarial [hives], decreasing systolic BP, and decreased urine output)

Nursing and Patient Care Consideration

Clear liquids only after midnight before the examination; adequate hydration is essential

Continue oral medications (especially orders needed for diabetic patients)

IV access required May not be done on the same day as other studies

requiring barium or contrast material Maintain bed rest for 8 hours after the examination, with

the leg kept straight on the side used for groin access Observe frequently for hematoma or bleeding at access

site. Keep sandbag at bedside for use if bleeding occurs

RENAL BIOPSY

Renal biopsy is the excision of a tissue sample from the kidney for microscopic analysis to determine cell morphology and the presence of tissue abnormalities.

The test assists in confirming a diagnosis of cancer found on x-ray or ultrasound or to diagnose certain inflammatory or immunologic conditions.

Biopsy specimen is usually obtained either percutaneously or after surgical incision.

Indication (RB)

Confirming suspected renal malignancy

Cause of renal disease

Systemic lupus erythematosus or other immunologic

disorders

Monitor progression of nephrotic syndrome

Renal function after transplantation

Contraindication (RB)

Bleeding disorders

Advanced renal disease

Uncontrolled hypertension

Solitary kidney (except transplanted kidney)

Obesity

Severe spinal deformity

Nursing Implication: Pretest

Obtain a history of the patient’s genitourinary and immune system including list of known allergens.

Obtain history of bleeding disorders, as well as result of previously performed tests and procedures, especially bleeding time, clotting time, CBC, partial thromboplastin time, platelets and prothombin time.

Obtain a list of medications the patient takes, including anticoagulant therapy, acetylsalicylic acid, and herbals known to affect coagulation. These products should be discontinued 14 days before dental or surgical procedures.

The requesting health care practitioner and laboratory should be advised if the patient regularly uses such products so their effect can be taken into consideration when reviewing results.

There are no medication restrictions unless by medical direction.

Instruct the patient that nothing should be taken by mouth beginning the night before the procedure.

Review the procedure with the patient. Sensitivity to cultural and social issues, as well as concern for modesty is important in proving psychological support.

Address concerns about pain r/t the procedure. Explain that a sedative may be administered to promote relaxation during the procedure.

Assess if the patient has an allergy to local anesthetics and to inform health care practitioner accordingly.

Confirm nonallergy to anesthesia before open biopsy procedure performed under general anesthesia.

Obtain written and informed consent before administering any medications prior to the procedures.

Inform the patient that the procedure is performed by the surgeon under sterile conditions using local anesthetic (e.g., lidocaine) and that specimen collection takes approximately 40-60 min.

Nursing Implication: Intratest

Ensure that the patient has complied with dietary restrictions before open biopsy.

Direct patient to breathe normally and to avoid unnecessary movement.

Observe standard precautions Administer ordered premedication.

Record baseline v/s. after administration of anesthesia, a surgical incision is made, suspicious areas located, and tissue sample collected.

Percutaneous needle biopsy:

Assist the patient into a prone position. Cleanse the site antiseptic. A local anthesthetic is injected and a sterile field is prepared, a sandbag may be placed under the abdomen to aid in moving the kidneys to the desired position. Instruct patient to take deep breath and hold it while the needle is inserted. As the needle enters the kidney, instruct the patient to exhale. The needle is rotated to obtain a plug of tissue, and then removed.

Place the specimens in the appropriate containers. Label the specimen, indicating site location, especially left or right; promptly transport specimen to the laboratory.

Apply manual pressure for 5-20 min, and apply pressure dressing.

Nursing Implication: Post-test

Instruct the patient to resume usual diet as directed by the health care practitioner.

After open biopsy, monitor v/s every 15 min for 1 hr, then every 2 hr for 4 hr and as ordered. Take temperature every 4 hr for 24 hr.

After local anesthesia, monitor v/s and compare with baseline values.

Inform the patient that blood may be seen in the urine after the first or second postprocedural voiding.

Monitor fluid I&O for 24 hr.

Instruct the patient to report any changes in urinary pattern or volume or any unusual appearance of the urine. If the urine volume is less than 200 mL in the first 8 hr, encourage the patient to increase fluid intake unless contraindicated by another medical condition.

Instruct px to immediately report symptoms such as backache, flank pain, shoulder pain, lightheadedness, burning on urination, hematoria, chills or fever, which may indicate presence of infection, haemorrhage, or inadvertent puncture of other organs.

Observe the needle site or incision for bleeding. Observe the patient for other signs of distress

including hypotension and tachycardia. After percutaneous biopsy, instruct patient to stay in

bed lying on the affected side at least 30 min with a pillow or sandbag under the site to prevent bleeding. The patient also needs to remain on bed rest for 24 hr.

Instruct patient to avoid strenuous activity, sports, and heavy lifting for 2 weeks after the procedure.

Recognize anxiety r/t test results and offer support. Provide teaching and information of the test results, as appropriate. Educate the patient regarding access to counselling services.

Evaluate test results in relation to the patient’s symptoms and other test performed. Related laboratory include albumin, aldosterone, antiglomerular basement membrane antibody, β2-macroglobulin, creatinine clearance, osmolality, potassium, urine potassium, protein, urine protein, renin, sodium, urine sodium, urea nitrogen, urinalysis and urine cytology.

CT SCAN OF THE KIDNEYS AND BLADDER Computed tomography (CT or CAT scan) is a noninvasive

diagnostic imaging procedure that uses a combination of X-rays and computer technology to produce horizontal, or axial, images (often called slices) of the body. A CT scan shows detailed images of any part of the body, including the bones, muscles, fat, and organs. CT scans are more detailed than standard X-rays.

CT scans of the kidneys can provide more detailed information about the kidneys than standard kidney, ureter, and bladder (KUB) X-rays, thus providing more information related to injuries and/or diseases of the kidneys.

Indication (CT Scan)

Tumors or other lesions

Kidney stones

Congenital anomalies

Polycystic kidney disease

Accumulation of fluid around the kidneys

Location of abscesses

Contraindication (CT Scan)

Allergies to shellfish or iodinated dye

Px w/ known hypersensitivity to the medium may benefit

from premedication w/ corticosteriods

Claustrophobic

Pregnant

Elderly & Chronically dehydrated

Renal failure

Outweigh the risk of exposure to high levels of radiation

Nursing Implication

Obtain history of the px’s complaints or clinical sx, including

allergens, especially allergies or sensitivities to iodine, seafood,

or other contrast mediums

Obtain a history of results of previously performed diagnostic

procedures, & laboratory tests

Note any recent barium or other radiologic contrast procedures.

Record the date of the last menstrual period & determine the

posibility of pregnancy in permenopausal women

Obtain a list of the medications the px is taking

Nursing Implication: Pretest

In case contrast is used, px receiving metformin

(glucophage) for non-insulin-dependent (type 2) diabetes

should the drug on the day of the test & continue to withhold

it for 48 hrs after the test

Review the pocedure w/ the px

Provide psychological support before, during, & after the

procedure

Explain that an IV line may be inserted to allow infusion of IV

fluids, contrast medium, dye, or sedatives.

Inform the px that he/she may experience nausea, a

feeling of warmth, a salty or metallic taste, or a

transient headache after injection of contrast medium,

if given

The px should fast & restrict fluids for 6-8 hrs prior to

the procedure. Instruct the px to avoid taking

anticoagulant medication or to reduce dosage as

ordered prior to procedure

Instruct the px to remove jewelry, credit cards, keys,

coins, pagers, cellphone & other metallic objects

Make sure a written & informed consent has been

signed prior to the procedure & before administering

any medications

Nursing Implication: Intratest

Ensure that the px has complied w/ dietary, fluids, &

medication restrictions & pretesting preperations,

assure that food has been restricted for atleast 6hrs

prior to the procedure. Ensure that the px has removed

all external metalic objects prior to the procedure

Have emergency equipment readily available

If the px has a history of severe allergic reactions to

any substance or drug. Administer ordered prophylactic

steroids or antihistamines before the procedure.

Px are given a gown, robe, & foot coverings to wear &

instructed to void prior to the procedure

Observe standard precautions

Instruct the px to cooperate fully & to follow directions

Establish an IV line for the injection of contrast, emergency

drugs, & sedatives

Administer an antianxiety agent, as ordered, if the px has

claustrophobia. Administer a sedative to a child or to an

uncooperative adult, as ordered

Place the px in the supine position on an exam table

If contrast is used, the contrast medium is injected, & a

rapid series of images is taken during & after the filling of

the vessels to be examined. Delayed images may be taken

to examine the vessels after a time to monitor the venous

phase of the procedure Ask the px to inhale deeply & hold his/her breath while the

x-ray images are taken, & then to exhale after the images

are taken Instruct the px to take slow, deep breaths if nausea occurs

during the procedure. Monitor & administer an antiemetic

agent if ordered. Ready an emesis basin for use

Monitor the px for complications related to the procedure

(eg. Allergic reaction, anaphylaxis, bronchospasm) if

contrast is used

The needle or vascular catheter is removed, & a pressure

dressing is applied over the puncture site

The results are recorded on film, or by automated equipment

in a computerized system for recall & post procedure

interpretation by the appropriate health care practitioner

Nursing Implication: Post-test

Instruct the px to resume usual diet, fluids,

medications, or activity, as directed by the health care

practitioner. Renal function should be assessed before

metformin is resumed, if contrast was used

Monitor vital signs & neurologic status every 15 mins

for 30 mins.

If contrast was used delayed allergic reactions

If contrast was used, advise the px to immediately report

sx such as heart rate, difficulty breathing , skin rash,

itching, or decreased urinary output

Observe the needle/ catheter insertion site for bleeding,

inflammation, or hematoma formation

Instruct the client to apply cold compress to the puncture

site, as needed, to reduce discomfort or edema

Instruct the px to increase fluid intake to help

eliminate the contrast medium, if used

Inform the px that diarrhea may occur after ingestion

of oral contrast medium

A written report of the examination will be completed

by health care practitioner

MRI OF THE KIDNEYS AND BLADDER MRI uses a magnetic radio waves to produce

an energy field that can be displayed as imaged

Indication (MRI)

At risk of contrast nephropathy.

Allergy to contrast agents.

Renal cell carcinoma.

Women with chronic urinary tract infections

Contraindication (MRI)

Px w/ certain ferrous metal prostheses, valves, aneurysm

clips, inner ear prostheses, or other metallic objects

Px w/ metal in their body, such as ferrous metal in the eye

Px w/ intrauterine devices

Px w/ iron pigments tattoos

Px who is claustrophobic

Px who is pregnant