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Journal of Nursing

Background of Assessment for the Registered Nurse and the Clinical Practitioner 

By: Dr. Gary D. Goldberg, PhD Clinical Professor of Medical Education, and Consultant Angeles College of Nursing, Los Angeles, California E-Mail: [email protected]


Abstract   


     The evaluation of impairment from the kidneys, as with the findings of proteinuria or an increased serum creatinine concentration, may be your first premises in the investigation pending diagnose.  In addition,   rushing to a conclusion can present as a variety of clinical syndromes.  In other instances, the presentation may reflect the impact of impaired renal function on other organ systems, such as edema or shortness of breath resulting from renal salt retention.   Still with other patients that are a-symptomatic, may simply have an abnormal urinalysis result on the routine examination.  Remember, in all of these situations, a- systematic approach will promote an efficient and accurate diagnosis.  


     First, the nurse practitioner along side of the clinician should determine the duration of the abnormal functioning kidneys.  Secondly, upon determining the degree of impairment, the clinician can classify and document the abnormal function as a disease.   Thirdly, the specific syndrome should be identified, based on information obtained through the history and physical examination, routine laboratory testing, and imaging of the kidneys. 


     Note:  The assessment of volume status deserves particular attention, because volume abnormalities are common in patients with renal disease and offer an important clue not only to the presence of renal failure but also to its management.  Approaching the case together in this manner will allow the clinician to establish the correct diagnosis and estimate the duration, course of action, and severity of the renal disease, as well as to the institute appropriate therapy programs.   


The Duration of the Disease – 


        Several tools can provide help in determining the disease duration.  The use of older medical records may be particularly valuable in dating the onset of an increased serum creatinine concentration, proteinuria, or hematuria.  [1]  In patients with impaired renal function, measurement of kidney size by renal sonography or plain film of the abdomen is quite useful.  Small kidneys (i.e., less than 8 cm in total length, in an adult), are an almost certain sign of chronic renal failure.  If the kidneys are normal in size, one cannot be certain whether the patient has acute or chronic renal disease.  Radiographic evidence of renal osteodystrophy in the distal clavicles, hands, ribs, skull, spine, and pelvis strongly suggest the presents and diagnosis of chronic renal disease.  [2]  


     Note:  However, patients in the early stages of chronic renal failure may not have detectable bone lesions even when the kidney size is small.   


     Therefore, the most precise way to differentiate acute renal disease from chronic is to have a renal biopsy perform.  This may not be practical or necessary in many cases.   Performing a renal biopsy is useful in patients who are suspected of having chronic renal failure because of their history and whose kidneys are normal in size on an ultrasound or plain films of the abdomen. 


     Assessment of Renal Function – 


     Once the disease is discovered, the presence or degree of renal dysfunction should be determined.  The glomerular filtration rate (GFR), is generally considered the best measurement of renal function.  Serial assessment of GFR can allow the clinician to determine the course of the underlying disease by demonstrating either rapid or slow rates of decline in renal function.  Accurate determination of renal function also helps the clinician to make adjustments in the dosing of pharmacologic agents so as to prevent the accumulation of drugs and metabolites and thereby, potential toxicities.  [3]


Assessment of Serum Creatinine –


     The measurement of the serum creatinine concentration is the most commonly used method for determining the level of renal function to date.  The creatinine concentration can be used to estimate GFR because creatinine varies inversely with the level of renal function.  Your base line or normal range of creatinine concentration is from 0.6 to 1.0 mg/dl in women and 0.8 to 1.3 mg/dl in men.  [4] 


      As an investigating nurse, you should be aware of its limitations regarding the serum creatinine level is its insensitivity to mild to moderate reductions in renal function.  The relationship between creatinine level and GFR is non-linear.  A change in creatinine from 0.6 mg/dl to 1.2 mg/dl reflects a decline in GFR of approximately 50%.  If a previous baseline value for creatinine does not exist for comparison, a creatinine of 1.2 mg/dl would not draw clinical attention to a potential reduction of GFR.  Likewise, the nephrologists’ are often consulted emergently when a patient’s creatinine concentration raises from 5 mg/dl to 8 mg/dl, which is far less critical, because GFR has fallen from approximately 20 ml/min to 15 ml/ min, a 25% decline. 


     Note:  As part of your total nursing evidence-based investigation process, it is important to detect and document changes in the GFR at relatively low creatinine values, when renal injury may still be reversible.    


      Changes in the serum creatinine concentration are usually slow to reflect acute changes in renal function; accumulation of creatinine in the blood and achievement of a new steady state occur gradually.  If acute renal failure occurs and the GFR suddenly falls from 100 ml/min to 10 ml/min, the serum creatinine would not rise correspondingly for approximately 6-7 days.  [5] 


     Basic Understanding of Creatinine Clearance – 


      Creatinine is an “endogenous marker” of filtration that is produced at a relatively constant rate.  Creatinine clearance (Ccr)  may be calculated by the following equation:   


Ccr(ml/min) = urine creatinine (mg/dl) x urine volume (ml/min)
                                   plasma creatinine (mg/dl) x 1,440  


     Usually the normal value or range of Ccr is approximately 95 ± 20 ml/min in women and 125 ± 25 ml/min in men.  Creatinine is freely filtered and is not reabsorbed; it is excreted primarily by filtration.  In addition, 15% to 20% of urinary creatinine is derived from tubular secretion via an organic acid pump in the proximal tubule. 


     Urea and creatinine kinetics are an attempt objectively to measure dialysis adequacy.  These measurements only reflect clearance of small molecular weight substances, so it is important to include a measure of protein intake, such as protein catabolic rate, to see assess appetite and nutritional status of your patients. 


     Body and Fluid Status – 


     As you continue to assess your patients on hemodialysis (HD), pay close attention to some common signs and symptoms such as: 


·     Subjectively, the presence of shortness of breath and oedema or oidema (i.e., an acute swelling). 


·     Objectively, presence of oedema, difference between acute and ‘dry’ weight, raised Jugular Venous Pressure (JVP) and a rise in blood pressure (B/P).


·     Aim for normality (e.g., within normal limits/or range), as sustained chronic fluid overload will increase the risk factor for hypertension (HTN) and left ventricular hypertrophy (LVH₃).  There are independent risk factors for cardiovascular morbidity. 


     Electrolyte and Acid-Base Balance Achievements -     


     As a nurse clinician, the primary goal should be to work with and by communicating directly and achieving patient understanding in order to bring into alignment the metabolic levels of balance: 


·     Aim for sodium, potassium, and bicarbonate into the normal range.


·     Patient calcium and phosphate levels should be brought into the normal range, but their levels are determined by factors other than dialysis.   


·     Look for any changes from the baseline of your patient and notation, notation, and notation must be current.  Also, look over the treating physician’s notes to check for changes that you could advise or alert the clinician too.     


     Imaging Studies Used in Evaluation – 


Ø      Radiograph of abdomen (kidneys, ureters, and bladder [KUB]) 


Ø      Ultrasonography and CT scanning


Ø      Intravenous pyelogram


Ø      Radionuclide studies


Ø      Renal arteriography


Ø      Voiding cystourethrogram


Ø      Retrograde or antegrade pyelography


Ø      Magnetic resonance imaging (MRI)


     Note:  The course of action will likely be taken depending on the assessments from the practitioner both nursing dept. and internal medicine dept.  The idea is to determine the kidney size and shape, possibly detection of nephrolithasis (i.e., deposits of calcium oxalate or calcium phosphate in the tubules of kidneys).  Also, distinguishing between simple and/or complex cysts.  In addition, early evaluation of polycystic kidney disease, and/possible renal mass and detection of renal vein thrombosis. [6] [7] 


As the investigating nurse/or practitioner approaches the patient with renal disease, he/or she must start thinking in forming a logical premise, building evidence-based findings toward a conclusion that will take the primary role in the “plane of action.”  For example, start with a basic logic tree (e.g., use a proven based nursing model and build from evidence that is already a “known”).   See Goldberg’s modified logic- tree based on Aristotle’s [8] logic of premise:  [9] 


A Modified Logic Tree for Nursing Assessment of Renal Disease – 


Abnormal Renal Function to Renal Disease Defined: 


{Determine Chronicity}  


{Assess level and Rate of Change from Renal Function} 


 {Categorize the Disorder into Specific Renal Syndromes} 


Ø      {Prerenal}   


Ø      {Intrinsic Renal } 


Ø      {Postrenal) 


{Acute Tubular Necrosis}  {Glomerular}  {Vascular}  {Tubulointerstitial} 


                                                 {Chronic glomerulonephritis, 


                                                   Nephrotic syndrome, acute glomerulonephritis. 


                                                       Rapidly progressive glomerulonephritis, asymptomatic  


                                                       Hematuria and/or proteinuria}.  


     Role of the Registered Nurse after Diagnosis -   


     The best hemodialysis (HD) units are managed by multidisciplinary teams whose members have different roles but are all regarded as equals.  The essential roles needed to function for the whole needs of the patient are as follows:  


·        Pre-dialysis education and assessment


·        Community assessment of the home and family


·        Assistance, if needed for re-housing


·        Assessment of other social and family needs


·        Psychological nursing, and medical support of patients as they reach End Stage Renal Failure (ESRF) and require catheter insertion


·        Psychological support of patients and family to be independent and manage their own dialysis life changes


·        Teaching on dietetic input regarding fluid and food intake


·        Assessment for long-term complications of dialysis


·        Assessment of dialysis adequacy


·        Guidance over problems with dialysis and assessment of alternative modalities (e.g., HD, APD, and if failing on CAPD)


     Conclusion – 


     In practice, most of the above issues will be carried out by a HD/or PD nurse clinician with back-up support from their medical staff.  Regular input will also be needed from social workers, dietitians, counselors (e.g., licensed psychologist/or medical psychiatrists), and on some occasions a physiotherapist or occupational therapists.  Many issues can be solved through regular meetings of the multidisciplinary team, but there will also be times when the patient will benefit from a case management meeting involving the appropriate care team members, themselves, and other family members. 


     Last Thoughts – 


     Note:  It is not uncommon for the patient or family to feel that the quality of life on dialysis is so poor that they would rather die.  Dialysis (HD) is a medical treatment and not a natural way of being kept alive.  Stopping dialysis treatment is also not the same as euthanasia; the patient should be allowed to die naturally and is not being given a toxic dose of a drug.  Withdrawal from HD accounts for almost 20% of mortality amongst American dialysis patients.  [10]  Therefore, it is important to have a system in place that helps the patient come to the ethical and correct decision that will support them through the whole process.  Having withdrawal the patient off dialysis will lead to death within 7-14 days in most cases.  [11]  


     Patient autonomy and the rights to self-determination will inevitably lead to some patients refusing treatment.  This may be appropriate and should engender a full and honest discussion between the care-team (e.g., physician, nurse clinician, technological care partners, plus the rest of the team, including the patient).  An Advanced Directive (living Will) will become a very important part of this discussion.  An example of some important ideas that should be discussed are: 


·        An assessment of the patient’s ability to make a decision 


·        Reversible factors should be addressed 


·        A full discussion with the dialysis team 


·        The full involvement of the family 


·        The full care and support of the patient after withdrawal 


     It is most vital that during this time of reflection and discussion that the compassion of nursing (art-of nursing) shines through.  Your humanity of science and art is all part of what makes a great care-giving nurse.     


Short Bio of Dr. Gary D. Goldberg, PhD 


Over 30 years experience in the Medical field, At UCLA and Pacific Hospital of the Valley, as a Chief Technologist and Analyst, Visiting Professor and Instructor for continuing education at UCLA School of Nursing and Writer/Speaker at the School of Medicine from 1995-2008.  


From 2003-2008 Dr. Goldberg has collaborated and published through Blackwell Publishing Co. (Medical Division), and Journal of American College of Cardiology plus 15, published abstracts through UCLA Dept. of Internal Medicine and the Dept. of Cardiology.  


 Current title:  Clinical Professor of Medical Education with Angeles College of Nursing, in Los Angeles, CA.   Funded through the State Dept. of California for Continuing Nursing Education.  


 Dr. Goldberg has written two major academic course textbooks for Angele College of Nursing and has represented advanced nursing education course curriculum approved by the ANA for CEU(s) and the AMA CMU Level 1 Credit for physicians. 


To reach Dr. Gary D. Goldberg, for comments and/or consultation, please use e-mail address: [email protected] or cell phone contact:  818-610-9017.  






[1] Shemesh O, Golbetz H, Kriss JP, et al:  Limitations of creatinine as a filtration marker in glomerulopathic patients.   Kidney Int. 28: 830, 1995.




[2] Palmer BF, Approaching the Patient with Renal Disease.  Kidney Int.  22: 654-660, 2001.




[3] Jones CA, McQuillan GM, Kusek JW, et al:  Serum creatinine levels in the US population:  third National Health and Nutrition Examination Survey.  Am. J. Kidney Dis. 35:  178-181, 2001




[4] Harrison, Braunwald, Fauci, Kasper, et al, Principles of Internal Medicine.  Nephrology, 166 14th edition 2006. McGraw Hill Publication Co. pp.  1961-1969.




[5] Jones CA, McQuillan GM, Kusek JW, et al:  Serum creatinine levels in the US population:  third National Health and Nutrition Examination Survey.  Am. J. Kidney Dis. 35:  178-181, 2001




[6] Lundqvist S, Holmberg G, Jakobsson G, et al:  Assessment of possible nephrotoxicity from iohexol in patients with normal and impaired renal function.  Acta Radiol. 39:362-363, 2000.




[7] Levey A, Coresh J, Balk E, et al:  National Kidney Foundation practice guidelines for chronic kidney disease:  evaluation, classification, and stratification.  Ann Intern Med 139: 137, 2004.




[8] Cooper DE.  World Philosophies:  An Historical Introduction. Second ed. Oxford, England: Blackwell Publishing Co.  2005.




[9] Tomassi P.  Logic and medicine (1-29), and Logic and scientific method (30-58).  In: Phillips CI, ed.  Logic in Medicine.  London, England: BMJ Publishing Group; 1999.




[10] U.S., Renal Data System:  USRDS 2008, Annual Data Report, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, April 2008.




[11] U.S., Renal Data System:  USRDS 2008, Annual Data Report…



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