1114

SECTION 9 Problems of Urinary Function

The accuracy of these diagnostic studies is influenced by (1)

adherence to the proper procedures and (2) cooperation of the
patient in terms of fluid restriction, urine specimen collection,
study preparations procedures, ability to remain positioned on
examination table, or following other instructions.
Many radiologic studies require the use of a bowel preparation the evening before the study to clear the lower GI tract
TABLE 45-8

of feces and flatus. Because the kidneys lie in a retroperitoneal

location, the contents of the colon may obstruct visualization
of the urinary tract. If the bowel preparation fails to adequately
evacuate the lower tract, the study may be unsuccessful and
have to be rescheduled. Commonly used bowel preparations
include enemas, castor oil, magnesium citrate, and bisacodyl
(Dulcolax) tablets or suppositories. Some bowel preparations,

DIAGNOSTIC STUDIES

Urinary System
STUDY
Urine Studies

DESCRIPTION AND PURPOSE

NURSING RESPONSIBILITY

Urinalysis

General examination of urine to establish baseline information or

provide data to establish a tentative diagnosis and determine
whether further studies are to be ordered (see Table 45-9).
Creatinine is a waste product of protein breakdown (primarily body muscle mass). Clearance of creatinine by kidney approximates the GFR.
Creatinine clearance is calculated as follows:

Try to obtain first urinated morning specimen. Ensure

specimen is examined within 1 hr of urinating. Wash
perineal area if soiled with menses or fecal material.
Collect 24-hr urine specimen. Discard first urination
when test is started. Save urine from all subsequent
urinations for 24 hr. Instruct patient to urinate at end
of 24 hr and add specimen to collection. Ensure that
serum creatinine is determined during 24-hr period.

Creatinine
clearance

Creatinine = Urine creatinine (mg/dL) Urine volume (mL/min)

clearance
Serum creatinine (mg/dL)

Composite urine
collection

Reference interval: 70-135 mL/min/1.73 m2 (corrected for body

surface area).
Measures specific components, such as electrolytes, glucose,
protein, 17-ketosteroids, catecholamines, creatinine, and minerals.
Composite urine specimens are collected over a period that may
range from 2 to 24 hr.

Urine culture
(clean catch,
midstream)

Confirms suspected urinary tract infection and identifies causative

organisms. Normally, bladder is sterile, but urethra contains
bacteria and a few WBCs. If properly collected, stored, and
handled: <103 organisms/mL usually indicates no infection;
103-105/mL is usually not diagnostic, and test may have to be
repeated; >105/mL indicates infection.

Concentration test

Evaluates renal concentration ability. Measured by specific gravity

readings.
Reference interval: 1.003-1.030.
Determines amount of urine left in bladder after urinating. Finding
may be abnormal in problems with bladder innervation, sphincter
impairment, BPH, or urethral strictures.
Reference interval: 50 mL urine (increases with age).

Residual urine

Protein determination
Dipstick (Albustix,
Test detects protein (primarily albumin) in urine.
Combistix)
Reference interval: 0-trace.

Quantitative
protein test

Urine cytology

A 24-hr collection gives a more accurate indication of amount

of protein in urine. Persistent proteinuria usually indicates
glomerular renal disease.
Reference interval: <150 mg/24 hr (mainly albumin).
Identifies abnormal cellular structures that occur with bladder
cancer and to follow the progress of bladder cancer.

BPH, Benign prostatic hyperplasia; GFR, glomerular filtration rate; WBCs, white blood cells.

Instruct the patient to urinate and discard this first urine

specimen. This time is noted as the start of the test.
Save all urine from subsequent urinations in a container
for designated period. At end of period, ask patient to
urinate, and this urine is added to container. Remind
patient to save all urine during study period. Specimens
may have to be refrigerated, or preservatives may have
to be added to container used for collecting urine.
Use sterile container for collection of urine. Touch only
outside of container. For women, separate labia with
one hand and clean meatus with other hand, using at
least three sponges (saturated with cleansing solution)
in a front-to-back motion. For men, retract foreskin (if
present) and cleanse glans with at least three cleansing
sponges. After cleaning, instruct patient to start
urinating and then continue voiding in sterile container.
(The initial voided urine flushes out most contaminants
in the urethra and perineal area.) Catheterization may be
needed if patient is unable to cooperate with procedure.
Instruct patient to fast after given time in evening (in
usual procedure). Collect three urine specimens at
hourly intervals in morning.
If residual urine test is ordered, catheterize patient immediately after urinating or use bladder ultrasound equipment.
If a large amount of residual urine is obtained, health care
provider may want catheter left in bladder.
Dip end of stick in urine and read result by comparison
with color chart on label as directed. Grading is from
0 to 4+. Interpret with caution. Positive result may not
indicate significant proteinuria; some medications may
give false-positive readings.
Perform 24-hr urine collection as above.

Specimens may be obtained by voiding, catheterization,

or bladder irrigation. Mornings first voided specimen
should not be used because epithelial cells may change
in appearance in urine held in bladder overnight. As
with urinalysis, the specimen should be fresh or
brought to laboratory within the hour. An alcohol-based
fixative is then added to preserve the cellular structure.

1115

CHAPTER 45 Urinary System

TABLE 45-8

DIAGNOSTIC STUDIEScontd

Urinary System
STUDY
Blood Studies

DESCRIPTION AND PURPOSE

NURSING RESPONSIBILITY

Urea nitrogen
(BUN)

Used to identify presence of renal problems. Concentration

of urea in blood is regulated by rate at which kidney excretes urea.
Reference interval: 6-20 mg/dL (2.1-7.1 mmol/L).

Creatinine

More reliable than BUN as a determinant of renal function.

Creatinine is end product of muscle and protein metabolism
and is liberated at a constant rate.
Reference interval: 0.6-1.3 mg/dL (53-115 mol/L).
Reference interval: 12:1 to 20:1.

Be aware that when interpreting BUN, nonrenal factors

may cause increase (e.g., rapid cell destruction from
infections, fever, GI bleeding, trauma, athletic activity and
excessive muscle breakdown, corticosteroid therapy).
Explain test and watch for postpuncture bleeding.

BUN/creatinine
ratio
Uric acid

Sodium

Potassium

Calcium (total)

Phosphorus

Bicarbonate

Used as screening test primarily for disorders of purine metabolism

but can also indicate kidney disease. Values depend on renal
function, rate of purine metabolism, and dietary intake of food
rich in purines.
Female: 2.3-6.6 mg/dL (137-393 mol/L).
Male: 4.4-7.6 mg/dL (262-452 mol/L).
Main extracellular electrolyte determining blood volume. Usually
values stay within normal range until late stages of renal failure.
Reference interval: 135-145 mEq/L (135-145 mmol/L).
Kidneys are responsible for excreting majority of bodys potassium.
In renal disease, K+ determinations are critical because K+ is one of
the first electrolytes to become abnormal. Elevated K+ levels of
>6 mEq/L can lead to muscle weakness and cardiac dysrhythmias.
Reference interval: 3.5-5.0 mEq/L (3.5-5.0 mmol/L).
Main mineral in bone and aids in muscle contraction, neurotransmission, and clotting. In renal disease, decreased reabsorption of Ca2+
leads to renal osteodystrophy.
Reference interval: 8.6-10.2 mg/dL (2.15-2.55 mmol/L).
Phosphorus balance is inversely related to Ca2+ balance. In renal
disease, phosphorus levels are elevated because the kidney is the
primary excretory organ.
Reference interval: 2.4-4.4 mg/dL (0.78-1.42 mmol/L).
Most patients in renal failure have metabolic acidosis and low serum
HCO3 levels.
Reference interval: 22-26 mEq/L (22-26 mmol/L).

Explain test and watch for postpuncture bleeding.

Explain test and watch for postpuncture bleeding.

Explain test and watch for postpuncture bleeding.

Explain test and watch for postpuncture bleeding.

Explain test and watch for postpuncture bleeding.

Explain test and watch for postpuncture bleeding.

Radiologic Procedures
Kidneys, ureters,
bladder (KUB)
Intravenous
pyelogram (IVP)

Antegrade
pyelogram
(nephrostogram)

Retrograde
pyelogram

Involves x-ray examination of abdomen and pelvis and delineates

size, shape, and position of kidneys. Radiopaque stones and
foreign bodies can be seen.
Visualizes urinary tract after IV injection of contrast media. Presence,
position, size, and shape of kidneys, ureters, and bladder can
be evaluated. Cysts, tumors, lesions, and obstructions cause a
distortion in normal appearance of these structures. Patient with
significantly decreased renal function should not have IVP, because
contrast media can be nephrotoxic and worsen renal function.*

Evaluates upper urinary tract when there is allergy to contrast media

or decreased renal function and when abnormalities prevent
passage of a ureteral catheter. Contrast media may be injected
percutaneously into renal pelvis or via a nephrostomy tube that
is already in place when determining tube function or ureteral
integrity after trauma or surgery.*
X-ray of urinary tract taken after injection of contrast material into
kidneys. It may be done if an IVP does not visualize the urinary
tract or if patient is allergic to contrast media or has decreased
renal function. A cystoscope is inserted and ureteral catheters
are inserted through it into renal pelvis. Contrast media is injected
through catheters.*

Perform bowel preparation (if ordered).

Evening before procedure, give cathartic or enema to

empty colon of feces and gas. Before procedure,
assess patient for iodine sensitivity to avoid anaphylactic reaction. Inform patient that procedure involves
lying on table and having serial x-rays taken. Advise
patient that warmth, a flushed face, and a salty taste
during injection of contrast material may occur. After
procedure, force fluids (if permitted) to flush out
contrast media.
Explain procedure and prepare patient as for IVP.
Watch for signs of complications (e.g., hematuria,
infection, hematoma).

Prepare patient as for IVP. Inform patient that pain may

be experienced from distention of pelvis and discomfort from cystoscope. Inform patient that anesthesia
may be given for procedure.
Complications are similar to those for cystoscopy (see
cystoscopy later in table).

BUN, Blood urea nitrogen; Ca2+, calcium ions; GI, gastrointestinal; HCO3, bicarbonate; IV, intravenous; K+, potassium ions.
*N-acetylcysteine (Mucomyst), a renal vasodilator and antioxidant, is sometimes administered to reduce the incidence of contrast-induced nephropathy; can be given by oral or
intravenous route. Source: Kohtz C: Preventing contrast medium-induced nephropathy, Am J Nurs 107(9):40, 2007.

Continued

1116

SECTION 9 Problems of Urinary Function

TABLE 45-8

DIAGNOSTIC STUDIEScontd

Urinary System
STUDY
DESCRIPTION AND PURPOSE
Radiologic Procedurescontd

NURSING RESPONSIBILITY

Renal arteriogram
(angiogram)

Visualizes renal blood vessels. Can assist in diagnosing renal artery

stenosis (Fig. 45-8), additional or missing renal blood vessels, and
renovascular hypertension. Can assist in differentiating between a
renal cyst and a renal tumor. Also included in workup of a potential
renal transplant donor. A catheter is inserted into the femoral artery
and passed up the aorta to the level of the renal arteries (Fig. 45-9).
Contrast media is injected to outline the renal blood supply.*

Renal ultrasound

Used to detect renal or perirenal masses, differential diagnosis of

renal cysts, solid masses, and identification of obstructions. Small
external ultrasound probe is placed on patients skin. Conductive
gel is applied to skin. Noninvasive procedure involves passing
sound waves into body structures and recording images as they
are reflected back. Computer interprets tissue density based on
sound waves and displays it in picture form. It can be used safely
in patients with renal failure.
Provides excellent visualization of kidneys. Kidney size can be evaluated;
tumors, abscesses, suprarenal masses (e.g., adrenal tumors,
pheochromocytomas), and obstructions can be detected. Advantage
of CT over ultrasound is its ability to distinguish subtle differences in
density. Use of IV-administered contrast media during CT accentuates
density of renal tissue and helps differentiate masses.*
Useful for visualization of kidneys. Not proven useful for detecting
urinary calculi or calcified tumors. Computer-generated films rely
on radiofrequency waves and alteration in magnetic field.

Before procedure: Prepare patient the prior evening by

giving cathartic or enema. Before injection of contrast
material, test for iodine sensitivity. The patient may
experience a transient warm feeling along the course
of the blood vessel when contrast media is injected.
After procedure: Place a pressure dressing over femoral
artery injection site. Observe site for bleeding. Have
patient maintain bed rest with affected leg straight.
Take peripheral pulses in the involved leg every
30-60 min to detect occlusion of blood flow caused
by a thrombus. Observe for complications including
thrombus, embolus, local inflammation, and hematoma.
Explain procedure to patient. Because radiation exposure
is avoided, a number of images can be obtained and
repeat studies can be done over a brief period of time.
Images can be obtained from both prone and supine
positions. A bowel preparation is not required.

Computed
tomography
(CT) scan

Magnetic
resonance
imaging (MRI)

Magnetic
resonance
angiography
Cystogram

Allows visualization of renal vasculature. Gadolinium-enhanced

studies allow visualization of the renal artery. Contraindications:
same as above.
Visualizes bladder and evaluates vesicoureteral reflux. Also used to
evaluate patients with neurogenic bladder and recurrent urinary
tract infections. Can also delineate abnormalities of the bladder
(e.g., diverticula, calculi, and tumors). Contrast media is instilled
into bladder via cystoscope or catheter.

Explain procedure to patient. Ask patient about iodine

sensitivity. The patient is instructed to lie very still
during the procedure while the machine takes precise
transaxial images. Sedation may be required if patient
is unable to cooperate.
Explain procedure to patient. Have patient remove all
metal objects. Patients with a history of claustrophobia
may need to be sedated. Contraindications: presence
of implanted magnetic clips or prosthesis and
pacemakers.
Same as above. Does not require femoral artery
puncture.
Explain procedure to patient. If done via cystoscope,
follow nursing care related to cystoscopy.

IV, Intravenous.
*N-acetylcysteine (Mucomyst), a renal vasodilator and antioxidant, is sometimes administered to reduce the incidence of contrast-induced nephropathy; can be given by oral or
intravenous route. Source: Kohtz C: Preventing contrast medium-induced nephropathy, Am J Nurs 107(9):40, 2007.

FIG. 45-8

Renal arteriogram showing stenosis of the right renal artery.

FIG. 45-9 Catheter insertion for a renal arteriogram.

1117

CHAPTER 45 Urinary System

DIAGNOSTIC STUDIEScontd

TABLE 45-8
Urinary System

STUDY
DESCRIPTION AND PURPOSE
Radiologic Procedurescontd
Urethrogram

Voiding cystourethrogram (VCUG)

Loopogram

NURSING RESPONSIBILITY

Similar to a cystogram. Contrast media is injected retrograde into

the urethra to identify strictures, diverticula, or other urethral
pathologic conditions. When urethral trauma is suspected, a
urethrogram is done before catheterization.
Voiding study of the bladder opening (bladder neck) and urethra. The
bladder is filled with contrast media. Fluoroscopic films are taken
to visualize the bladder and urethra. After urination, another film is
taken to assess for residual urine. Can detect abnormalities of the
lower urinary tract, urethral stenosis, bladder neck obstruction, and
prostatic enlargement.
Used to detect obstructions, anastomotic leaks, stones, reflux, and
other uropathologic features when patient has a urinary pouch or
ileal conduit. Because urinary diversions are created with bowel,
there is risk of absorption of contrast media.

Explain procedure to patient.

Inspects interior of bladder with a tubular lighted scope (cystoscope)

(Fig. 45-10). Can be used to insert ureteral catheters, remove
calculi, obtain biopsy specimens of bladder lesions, and treat
bleeding lesions. Lithotomy position is used. Procedure may
be done using local or general anesthesia, depending on needs
and condition of patient. Complications include urinary retention,
urinary tract hemorrhage, bladder infection, and perforation of the
bladder.

Before procedure: Force fluids or give IV fluids if general

anesthesia is to be used. Ensure consent form is
signed. Explain procedure to patient. Give preoperative
medication.
After procedure: Explain that burning on urination,
pink-tinged urine, and urinary frequency are expected
effects. Observe for bright red bleeding which is not
normal. Do not let patient walk alone immediately after
procedure because orthostatic hypotension may occur.
Offer warm sitz baths, heat, mild analgesics to relieve
discomfort.

Measures urine volume in a single voiding expelled in a period of

time. This test is used to (1) assess the degree of outflow obstruction caused by such conditions as BPH or stricture, (2) assess
bladder or sphincter dysfunction effects on voiding, and (3) evaluate effects of treatment for lower urinary tract problems. Graphic
displays can illustrate straining and intermittent flow patterns or
other abnormal voiding disorders.
Normal maximum flow rate: men: 20-25 mL/sec; women: 25-30 mL/
sec. Volume voided and the patients age can affect the flow rate.
Evaluates bladder tone, sensations of filling, and bladder (detrusor)
stability. Involves insertion of catheter and instillation of water or
saline solution into bladder. Measurements of pressure exerted
against bladder wall are recorded. If abdominal pressure is measured,
a second tube is inserted into the rectum or vagina. This tube is
attached to a small fluid-filled balloon to allow pressure recording.

Explain procedure to patient. The patient is asked to

start the test with a comfortably full bladder, urinate
into a special container, and try to empty completely.
Measure residual urine volume immediately after a
urinary flow study because this will help to identify
the degree of chronic urinary retention that is often
associated with abnormal flow patterns.

Explain procedure to patient.

Explain procedure to patient. The patient should be

closely monitored for reactions to the contrast media.

Endoscopy
Cystoscopy

Urodynamics
Urine flow study
(uroflow)

Cystometrogram

Explain procedure to patient. During the infusion, patient

is asked about sensations of bladder filling, usually
including the first desire (urge) to urinate, a strong
desire to urinate, and perception of bladder fullness.
Observe patient for manifestations of urinary infection
after procedure.

IV, intravenous.
Source: Digesu GA, Athanasiou S, Chaliha C, et al: Urethral retroresistance pressure and urodynamic diagnoses in women with lower urinary tract symptoms,
BJOG: Inter J Obstet Gynaecol 11(1):34, 2006.

Continued

FIG. 45-10 Cystoscopic examination of the bladder in a man. A, Flexible Cysto nephroscope. B, Scope
inserted into bladder.

1118

SECTION 9 Problems of Urinary Function

TABLE 45-8

DIAGNOSTIC STUDIEScontd

Urinary System
STUDY
DESCRIPTION AND PURPOSE
Urodynamicscontd

NURSING RESPONSIBILITY

Sphincter electromyography
(EMG)

Explain procedure to patient.

Voiding pressure
flow study

Videourodynamics

Radionuclide
cystography
(RNC)
Whitaker study

Recording of electrical activity created when nervous system stimulates motor units within a muscle. By placing needles, percutaneous wires, or patches near the urethra, the pelvic floor muscle
activity can be assessed. During the filling cystometrogram,
sphincter EMG is used to identify voluntary pelvic floor muscle
contractions and the response of these muscles to bladder filling,
coughing, and other provocative maneuvers.
Combines a urinary flow rate, cystometric pressures (intravesical,
abdominal, and detrusor pressures), and a sphincter EMG for
detailed evaluation of micturition. It is completed by assisting the
patient to a specialized toilet and allowing the person to urinate
while the various pressure tubes and EMG apparatus remain in
place.
Combination of the filling cystometrogram, sphincter EMG, and/
or urinary flow study with anatomic imaging of the lower urinary
tract, typically via fluoroscopy. Used in selected cases to identify
an obstructive lesion and characterize anatomic changes in the
bladder and lower urinary tract.
Used to detect and grade vesicoureteral reflux. Similar to VCUG with
a small dose of radioisotope tracer instilled into the bladder via
urethral catheter. More sensitive than VCUG and radiation dose is
1/1000 that of the VCUG.
Used to measure the pressure differential between the renal pelvis
and the bladder. Ureteral obstruction can be assessed. Percutaneous access is gained to the renal pelvis by placing a catheter in
the renal pelvis. A catheter is also placed in the bladder. Fluid is
perfused through the percutaneous tube or needle at a rate of
10 mL/min. Pressure data are then collected. Pressure measurements are combined with fluoroscopic imaging to identify the level
of obstruction.

Explain procedure to patient.

Explain procedure to patient.

Explain procedure to patient as in VCUG.

Explain procedure to patient.

Renal Radionuclide Imaging

Renal scan

Renal biopsy

Evaluates anatomic structures, perfusion, and function of kidneys.

Radioactive isotopes are injected IV. Radiation detector probes are
placed over kidney, and scintillation counter monitors radioactive
material in kidney. Radioisotope distribution in kidney is scanned
and mapped. Shows location, size, and shape of kidney and, in
general, assesses blood flow, glomerular filtration, tubular function,
and urinary excretion. Abscesses, cysts, and tumors may appear
as cold spots because of presence of nonfunctioning tissue. Also
used to monitor function of a transplanted kidney.
Obtains renal tissue for examination to determine type of renal
disease or to follow progress of renal disease. Technique is usually
done as a skin (percutaneous) biopsy through needle insertion
into lower lobe of kidney. Can be performed with CT or ultrasound
guidance. Absolute contraindications are bleeding disorders, single
kidney, and uncontrolled hypertension. Relative contraindications
include suspected renal infection, hydronephrosis, and possible
vascular lesions.

Requires no dietary or activity restriction. Inform patient

that no pain or discomfort should be felt during test.

Type and crossmatch patient for blood. Ensure consent

form is signed.
Before procedure: Ascertain coagulation status through
patient history, medication history, CBC, hematocrit, prothrombin time, and bleeding and clotting
time. Patient should not be taking aspirin or warfarin
(Coumadin).
After procedure: Apply pressure dressing and keep on
affected side for 30-60 min; bed rest for 24 hr. Vital
signs every 5-10 min, first hour. Assess for flank pain,
hypotension, decreasing hematocrit, temperature,
chills, urinary frequency, dysuria, and serial urine specimens (gross/microscopic hematuria). Urine dipstick can
be used to test for bleeding in urine. Inspect biopsy
site for bleeding. Instruct patient to avoid lifting heavy
objects for 5-7 days and to not take anticoagulant drugs
until allowed by health care provider.

*CBC, Complete blood count.

Source: Goldfarb CR, Srivastava NC, Grotas AB, et al: Radionuclide imaging in urology, Urol Clin North Am 33(3):319, 2006.

CHAPTER 45 Urinary System

TABLE 45-9

1119

DIAGNOSTIC STUDIES

Urinalysis
TEST

NORMAL

ABNORMAL FINDING

POSSIBLE ETIOLOGY AND SIGNIFICANCE

Color

Amber yellow

Odor

Aromatic

Protein

Random protein (dipstick):

0-trace
24-hr protein (quantitative):
<150 mg/day

Dark, smoky color

Yellow-brown to olive green
Orange-red or orange-brown
Cloudiness of freshly voided urine
Colorless urine
Urine allowed to stand
Unpleasant odor
Persistent proteinuria

Glucose

None

Glycosuria

Ketones

None

Present

Bilirubin

None

Present

Specific
gravity

Low
High
Fixed at about 1.010

pH

1.003-1.030
Maximum concentrating
ability of kidney in morning
urine (1.025-1.030)
300-1300 mOsm/kg
(300-1300 mmol/kg)
4.0-8.0 (average, 6.0)

Hematuria
Excessive bilirubin
phenazopyridine (Pyridium)
Infection
Excessive fluid intake, renal disease, or diabetes insipidus
Becomes ammonia-like in odor
Urinary tract infection
Characteristic of acute and chronic renal disease, especially
involving glomeruli; heart failure
In absence of disease: high-protein diet, strenuous exercise,
dehydration, fever, emotional stress, contamination by vaginal
secretions
Diabetes mellitus, low renal threshold for glucose reabsorption
(if blood glucose level is normal); pituitary disorders
Altered carbohydrate and fat metabolism in diabetes mellitus and
starvation; dehydration, vomiting, severe diarrhea
Liver disorders
May appear before jaundice is visible (see Chapter 44)
Dilute urine; excessive diuresis; diabetes insipidus
Dehydration, albuminuria, glycosuria
Renal inability to concentrate urine; end-stage renal disease

RBCs

0-4/hpf

WBCs
Casts

0-5/hpf
None
Occasional hyaline

>5/hpf
Present

Culture for
organisms

No organisms in bladder;
<104 organisms/mL result
of normal urethral flora

Bacteria counts >105/mL

Osmolality

<300 mOsm/kg
>1300 mOsm/kg
>8.0
<4.0
>4/hpf

Tubular dysfunction; kidney lost ability to concentrate or dilute

urine (not part of routine urinalysis)
Urinary tract infection; urine allowed to stand at room
temperature (bacteria decompose urea to ammonia)
Respiratory or metabolic acidosis
Calculi, cystitis, neoplasm, glomerulonephritis, tuberculosis,
kidney biopsy, trauma
Urinary tract infection or inflammation
Molds of the renal tubules that may contain protein, WBCs,
RBCs, or bacteria; noncellular casts (hyaline in appearance)
occasionally found in normal urine
Urinary tract infection; most common organisms are Escherichia
coli, enterococci, Klebsiella, Proteus, and streptococci

hpf, High-powered field; RBCs, red blood cells; WBCs, white blood cells.

such as magnesium citrate and Fleet enema, are contraindicated

because magnesium cannot be excreted by patients with renal
failure (see Chapter 47).
When a patient has diagnostic studies on consecutive days, it
is important to prevent dehydration. It is not uncommon to have
a patient take nothing by mouth (NPO) after midnight, spend
all morning in the x-ray department, be too tired to eat, sleep all
afternoon, and be NPO after midnight again because of studies
scheduled for the next day. Severe dehydration, especially in a
diabetic, debilitated, or older patient, may lead to acute renal
failure. When a patient is scheduled for diagnostic studies, you
are responsible for ensuring that the patient is properly hydrated
and given adequate nourishment between studies. You should
also check with the health care provider regarding insulin dosage for diabetic patients who are placed on NPO status.

Urine Studies
Urinalysis. Urinalysis (see Tables 45-8 and 45-9) is one of the
first studies completed to evaluate disorders of the urinary tract.
Results from the urinalysis may indicate possible abnormalities,
suggest the need for further studies, or provide evidence of progression in a previously diagnosed disorder.

Although a specimen may be collected at any time of the day

for a routine urinalysis, it is best to obtain the first specimen
urinated in the morning. This concentrated specimen is more
likely to contain abnormal constituents if they are present in the
urine. The specimen should be examined within 1 hour of urinating. If not examined within 1 hour, bacteria multiply rapidly,
RBCs hemolyze, casts (molds of renal tubules) disintegrate, and
the urine becomes alkaline as a result of urea-splitting bacteria. If it is not possible to send the specimen to the laboratory
immediately, it should be refrigerated. However, to obtain the
best results, you should coordinate specimen collection with
routine laboratory hours.
Creatinine Clearance. One of the most common composite indicators used to analyze urinary system disorders is creatinine clearance. Creatinine is a waste product produced by
muscle breakdown. Urinary excretion of creatinine is a measure of the amount of active muscle tissue in the body, not of
body weight. Therefore individuals with larger muscle mass
have higher values. Because almost all creatinine in the blood
is normally excreted by the kidneys, creatinine clearance is the
most accurate indicator of renal function. The result of a creatinine clearance test closely approximates that of the GFR.3