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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:  g.goldberg@live.com

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]

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