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Introduction ⬇

An IVP, also known as an IV urogram or excretory urogram is an x-ray that visualizes the kidneys, ureters, and bladder and is one of the most frequently ordered tests in cases of suspected kidney disease or urinary tract dysfunction.

An IV radiopaque iodine contrast substance is injected and concentrates in the urine. Following this injection, a series of x-ray images is made at predetermined intervals over 20–30 minutes. A final postvoid film is taken after the patient empties the bladder.

These images demonstrate the size, shape, and structure of the kidneys, ureters, and bladder and the degree to which the bladder can empty. Kidney function is reflected by the length of time it takes the contrast material first to appear and then to be excreted by each kidney. Kidney disease, ureteral and bladder stones, and tumors can be detected with an IVP.

A CT also may be done in conjunction with an IVP to obtain better visualization of kidney lesions. This increases examination time. If kidney tomography or nephrotomograms are ordered separately, the procedure and preparation are the same as for an IVP.

Procedure ⬆ ⬇

  1. Take a preliminary abdominal x-ray (KUB) with the patient in a supine position to ensure that the bowel is empty and the kidney location can be visualized.

  2. Inject the IV contrast material, usually into the antecubital vein.

  3. Alert the patient that during and following the IV contrast injection, they may experience warmth, flushing of the face, salty taste, and nausea.

    1. Instruct the patient to take slow, deep breaths should these sensations occur. Have an emesis basin and tissue wipes available. Use standard precautions when handling secretions.

    2. Assess for other untoward signs, such as respiratory difficulty, diaphoresis, numbness, palpitations, or urticaria. Be prepared to respond with emergency drugs, equipment, and supplies. These items should be readily available whenever this procedure is performed.

  4. Take at least three x-ray images at predetermined intervals following injection of the contrast material.

  5. After these three images are taken, instruct the patient to void before the final image is made to determine the ability of the bladder to empty.

  6. Follow guidelines in Chapter 1 for safe, effective, informed intratest care.

Clinical Implications ⬆ ⬇

  1. Abnormal IVP findings may reveal the following conditions:

    1. Altered size, form, and position of the kidneys, ureters, and bladder

    2. Duplication of the pelvis or ureter

    3. Presence of only one kidney

    4. Hydronephrosis

    5. Supernumerary kidney

    6. Renal or ureteral calculi

    7. Tuberculosis of the urinary tract

    8. Cystic disease

    9. Tumors

    10. Degree of kidney injury subsequent to trauma

    11. Prostate enlargement

    12. Enlarged kidneys suggesting obstruction or polycystic disease kidney

    13. Evidence of kidney failure in the presence of normal-sized kidneys suggesting an acute rather than chronic disease process

    14. Irregular scarring of the kidney outlines, suggesting chronic pyelonephritis

  2. A time delay in radiopaque contrast visualization is indicative of kidney dysfunction. No contrast visualization may indicate very poor or no kidney function.

Interventions ⬆ ⬇

Pretest Patient Care

  1. Explain the purpose and procedure of the test. Written instructions may be helpful to the patient. Screen female patients for pregnancy status. If positive, advise the radiology department. If the patient has diabetes or takes metformin, special precautions may be necessary.

  2. Observe iodine contrast test precautions. Assess for all allergies and determine prior allergic reaction to contrast substances. Many radiology departments require a recent creatinine level for all patients older than 40 years before performing this procedure in order to ensure the absence of renal insufficiency.

  3. Because a relative state of dehydration is necessary for contrast material to concentrate in the urinary tract, instruct the patient to abstain from all food, liquid, and medication (if possible) for 12 hours before examination. Fasting after the evening meal the day before the test will meet this criterion.

  4. Do not give children younger than 7 years of age pretest cathartic drugs or enemas. Should the preliminary x-rays show intestinal gas obscuring the kidneys, a few ounces of carbonated beverage may relieve the concentration of gas at that particular location.

  5. Evaluate stool and check for abdominal distention to evaluate for possible barium retention if it has been used in previous studies. Additional bowel preparation may be necessary.

  6. Follow guidelines in Chapter 1 for safe, effective, informed pretest care.

Clinical Alert

Assess for latex allergy and inform the radiology department of any known or suspected sensitivities before study

Posttest Patient Care

  1. Review test results; report and record findings. Modify the nursing care plan as needed.

  2. Have the patient resume previous diet and activity after the examination.

  3. Teach and encourage the patient to drink sufficient fluids to replace those lost during the pretest phase.

  4. Encourage rest, as needed, following the examination.

  5. Observe and document mild reactions to the iodine material, which may include hives, skin rashes, nausea, or swelling of the parotid glands. Notify the healthcare provider if the signs and symptoms persist. Oral antihistamines may relieve more severe symptoms.

  6. Follow guidelines in Chapter 1 for safe, effective, informed posttest care.

Clinical Alert

  1. Contraindications to an IVP include the following conditions:

    1. Hypersensitivity or allergy to iodine preparations

    2. Combined kidney and hepatic disease

    3. Oliguria or anuria

    4. Kidney failure: Most radiology departments require recent creatinine test levels to determine whether to administer contrast materials. Generally, creatinine levels more than 1.5 mg/dL (more than 133 μmol/L) raise suspicion and signal the need for repeat laboratory work. A blood urea nitrogen level more than 25 mg/100 mL also may contraindicate the use of iodine contrast

    5. Multiple myeloma, unless the patient can be adequately hydrated during and after the study

    6. Advanced pulmonary tuberculosis

    7. Patients receiving drug therapy for chronic bronchitis, emphysema, or asthma

    8. Heart failure

    9. Pheochromocytoma

    10. Sickle cell anemia

    11. Diabetes

  2. If the patient has diabetes, assess whether they are taking metformin. Because of an increased risk for AKI and lactic acidosis, this medication regimen must be discontinued the day of and several days after administration of contrast media. Consult the radiology department for specific instructions.

  3. Some physiologic changes can be expected after radiopaque iodine injections. Hypertension, hypotension, tachycardia, arrhythmias, or other ECG changes may occur.

  4. An iodine-based contrast medium is given with caution in the presence of hyperthyroidism, asthma, and hay fever or other allergies.

  5. Observe for anaphylaxis or severe reactions to iodine, as evidenced by shock, respiratory distress, precipitous hypotension, fainting, convulsions, or actual cardiopulmonary arrest. Resuscitation supplies and equipment should be readily available.

  6. In all cases except emergencies, a contrast medium should not be injected sooner than 90 minutes after eating.

  7. IV iodine can be highly irritating to the intimal layer of the veins and may cause painful vascular spasm. If this occurs, a 1% procaine IV injection may relieve vascular spasm and pain. Sometimes, local vascular irritation is severe enough to induce thrombophlebitis. Warm or cold compresses to the area may relieve pain; however, these do not prevent sloughing. The attending primary provider should be notified. Anticoagulant therapy may need to be instituted.

  8. Local reactions to iodine may be evidenced by extensive redness, swelling, and pain at the injection site. Even a small amount of iodine contrast entering subcutaneous tissues can cause tissue sloughing, which may require skin grafting. X-ray evidence of iodine contrast leakage within soft tissues surrounding the injection site confirms extravasation.

Interfering Factors ⬆ ⬇

  1. Feces or intestinal gas will obscure urinary tract visualization.

  2. Retained barium can obscure optimal views of the kidneys. For this reason, barium tests should be scheduled after an IVP when possible.

Reference Values ⬆

Normal

  1. Normal size, shape, and position of the kidneys, ureters, and bladder. Normal kidneys measure approximately 4.5 inches in length and 2–3 inches in width. Therefore, kidney size is estimated in relation to this rule of thumb.

  2. Normal kidney function

    1. Two to 8 minutes after the injection of contrast material, the kidney outline appears on an x-ray film. Threadlike strands of contrast material appear in the calyces.

    2. When the second film is taken several minutes after contrast injection, the entire renal pelvis can be visualized.

    3. Later films show the ureters and bladder as the contrast material makes its way into the lower urinary tract.

    4. No evidence of residual urine should be found on the postvoid film.