Synonym/Acronym
Antegrade pyelography, excretory urography (EUG), intravenous urography (IVU, IUG), IVP.
Rationale
To assess urinary tract dysfunction or evaluate progression of kidney disease such as stones, bleeding, and congenital anomalies.
Patient Preparation
There are no activity restrictions unless by medical direction. Instruct the patient to fast and restrict fluids for 8 hr, or as ordered, prior to the procedure. Fasting may be ordered as a precaution against aspiration related to possible nausea and vomiting. The American Society of Anesthesiologists has fasting guidelines for risk levels according to patient status. More information can be located at www.asahq.org.The Canadian Anesthesiologists’ Society has fasting guidelines for preprocedural fasting. Related information can be located at https://www.cas.ca/English/Page/Files/97_Appendix%206.pdf.
Instruct the patient to take a laxative or a cathartic, as ordered, on the evening before the examination; the bowel must be cleansed to achieve good visualization of the kidneys.
Pediatric and Older Adult Considerations: Special considerations regarding fluid restrictions may apply to patients experiencing chronic dehydration, including older adult patients in whom dehydration is common; considerations may also be given to pediatric patients. Fluid restrictions for pediatric patients may be adjusted based on age and weight.
Note: Protocols regarding the use of iodinated contrast medium in patients with impaired kidney function and who are receiving metformin or drugs containing metformin for type 2 diabetes may vary by facility; the drug may be discontinued on the day of the test and continue to be withheld for 48 hr after the test. Kidney function should be assessed per facility protocol before use of metformin is resumed (e.g., Cr, eGFR, hydration or clinical assessment).
Regarding the patient’s risk for bleeding, the patient should be instructed to avoid taking natural products and medications with known anticoagulant, antiplatelet, or thrombolytic properties or to reduce dosage, as ordered, prior to the procedure. Number of days to withhold medication is dependent on the type of anticoagulant. Note the last time and dose of medication taken. Protocols may vary among facilities.
Normal Findings
- Normal size and shape of kidneys, ureters, and bladder.
- Normal bladder and absence of masses or renal calculi, with prompt visualization of contrast medium through the urinary system.
Study type: X-ray, special/contrast; related body system: Urinary system.
Intravenous pyelography (IVP) is most commonly performed to determine urinary tract dysfunction or kidney disease. IVP uses IV iodinated radiopaque contrast medium to visualize the kidneys, ureters, bladder, and renal pelvis. The contrast medium concentrates in the blood and is filtered out by the glomeruli passing out through the renal tubules and concentrated in the urine. Renal function is reflected by the length of time it takes the contrast medium to appear and to be excreted by each kidney. A series of images is performed over a 30-min period to view passage of the contrast through the kidneys and ureters into the bladder. Tomography may be employed during the IVP to permit the examination of an individual layer or plane of the organ that may be obscured by surrounding overlying structures. Many facilities have replaced the IVP with computed tomography (CT) studies. CT provides detail of the anatomical structures in the urinary system and therefore greater sensitivity in the identification of renal pathology.
Contraindications
Pregnancy is a general contraindication to procedures involving radiation.
Patients with conditions associated with adverse reactions to contrast medium (e.g., asthma, food allergies, or allergy to contrast medium). Although patients are asked specifically if they have a known allergy to iodine or shellfish (shellfish contain high levels of iodine), it has been well established that the reaction is not to iodine; an actual iodine allergy would be problematic because iodine is required for the production of thyroid hormones. In the case of shellfish, the reaction is to a muscle protein called tropomyosin; in the case of iodinated contrast medium, the reaction is to the noniodinated part of the contrast molecule. Patients with a known hypersensitivity to the medium may benefit from premedication with corticosteroids and diphenhydramine; the use of nonionic contrast or an alternative noncontrast imaging study, if available, may be considered for patients who have severe asthma or who have experienced moderate to severe reactions to ionic contrast medium.
Patients with moderate to marked renal impairment (glomerular filtration rate less than 30 mL/min/1.73 m2), or with conditions associated with preexisting renal insufficiency (e.g., chronic kidney disease, single kidney transplant, nephrectomy, diabetes, multiple myeloma, treatment with aminoglycosides and NSAIDs), because iodinated contrast is nephrotoxic.
Patients with moderate to marked renal impairment (glomerular filtration rate less than 30 mL/min/1.73 m2) and who are also taking metformin, which may put them at risk for development of drug-induced lactic acidosis, a dangerous and sometimes fatal adverse effect of metformin (related to renal impairment that does not support sufficient excretion of metformin)
Patients with bleeding disorders or receiving anticoagulant therapy, because the puncture site may not stop bleeding.
Factors That May Alter the Results of the Study
- Gas or feces in the gastrointestinal tract resulting from inadequate cleansing or failure to restrict food intake before the study.
- Retained barium from a previous radiological procedure.
- Metallic objects (e.g., jewelry, body rings) within the examination field, which may inhibit organ visualization and cause unclear images.
- Inability of the patient to cooperate or remain still during the procedure because movement can produce blurred or otherwise unclear images.
Abnormal Findings Related to
Potential Nursing Problems: Assessment & Nursing Diagnosis
| Problems | Signs and Symptoms |
|---|
| Fluid volume (deficit—related to vomiting, nausea) | Dry mucous membranes, low blood pressure, increased heart rate, slow capillary refill, diminished skin turgor, diminished urine output | | Infection (related to stones, urinary stasis, invasive procedure, postoperative change in skin condition [incision]) | Fever; chills; changes in laboratory studies (WBC count, CRP, urine culture); diaphoresis; increased heart rate; urine frequency and burning; cloudy, foul-smelling urine; red indurated incision; draining incision | | Pain (related to stones, obstruction and/or anomalies, spasm) | Self-report of pain in flank area, facial grimace, moaning, crying, abdominal guarding |
|
Before the Study: Planning and Implementation
Teaching the Patient What to Expect
- Inform the patient this procedure can assist in assessing the kidneys, ureters, and bladder.
- Explain that the procedure takes about 30 to 60 min and is performed in a radiology department.
- Review the procedure with the patient.
- Explain that pregnancy testing may be required.
- Explain that prior to the procedure, laboratory testing may be required to determine the possibility of bleeding risk (coagulation testing) or to assess for impaired kidney function (serum Cr or eGFR) if use of iodinated contrast medium is anticipated.
- Discuss how there may be moments of discomfort or pain when the IV line is inserted, allowing for infusion of fluids such as saline, anesthetics, sedatives, medications used in the procedure, or emergency medications.
- Explain that contrast medium will be injected, by catheter, at a separate site from the IV line.
- Advise that a burning and flushing sensation may be felt throughout the body during injection of the contrast medium and the patient may experience an urge to cough, flushing, nausea, or a salty or metallic taste.
Procedural Information
- Policies regarding breastfeeding before and after an imaging procedure may vary among facilities. For additional information see Appendix A: Patient Preparation and Specimen Collection, subsection: Potential Contraindications and Complications Associated with Diagnostic Procedures.
- Baseline vital signs will be recorded and monitored throughout the procedure.
- Positioning for this study will be in the supine position on an examination table.
- Prior to the procedure a KUB or plain film is taken to ensure that no barium or stool obscures visualization of the urinary system.
- The patient is advised to take slow, deep breaths if nausea occurs during the procedure.
- An ordered antiemetic drug is administered, as needed.
- An emesis basin is available for use, as needed.
- Images are taken at 1, 5, 10, 15, 20, and 30 min following injection of the contrast medium into a vein in the arm; after which the contrast circulates into the urinary system.
- The patient is asked to exhale deeply and to hold his or her breath while each image is taken.
- Patients are instructed to void if a post-voiding exposure is required to visualize the empty bladder.
- Once the study is completed, the needle or catheter is removed, and a pressure dressing is applied over the puncture site.
Potential Nursing Actions
Make sure a written and informed consent has been signed prior to the procedure and before administering any medications.
Safety Considerations
- Anticoagulants, aspirin, and other salicylates should be discontinued by medical direction for the appropriate number of days prior to a procedure in which bleeding is a potential complication.
- Older Adult Considerations: The combination of fluid restrictions and administration of laxatives may cause increased injury risk from falling for older adult patients, related to weakness. Additional monitoring and assistance while ambulating may be required.
After the Study: Implementation & Evaluation Potential Nursing Actions
Avoiding Complications
- Monitor the patient for complications related to the procedure.
- Establishing an IV site and injection of contrast are invasive procedures that can cause rare complications. For additional information see Appendix A: Patient Preparation and Specimen Collection, subsection: Potential Contraindications and Complications Associated with Diagnostic Procedures.
- Explain the importance of immediately reporting symptoms such as difficulty breathing, chest pain, fever, hyperpnea, hypertension, nausea, palpitations, pruritus, rash, tachycardia, urticaria, or vomiting to the appropriate HCP.
- Administer ordered antihistamines or prophylactic steroids if the patient has an allergic reaction.
- Observe/assess the needle insertion site for bleeding, inflammation, or hematoma formation.
Treatment Considerations
- Follow post-procedure vital sign and assessment protocol.
- Resume usual diet, fluids, medications, or activity, as directed by the HCP.
- Monitor urinary output after the procedure. Decreased urine output may indicate acute kidney injury.
- Instruct the patient in the care and assessment of the injection site and to apply cold compresses as needed, to reduce discomfort or edema.
Fluid Volume
- Observation and assessment for dehydration is important when fluids are insufficient.
- Monitor and trend vital signs, urine color, intake and output, and strain urine for stones.
- Monitor and trend laboratory studies: BUN, Ca, Cr, electrolytes, uric acid, and WBC count.
- Administer ordered parenteral fluids, encourage oral fluid intake, and administer ordered antiemetics.
Infection
- Treatment includes administration of ordered antibiotics and antipyretics.
- Monitor and trend laboratory results and vital signs.
- Monitor catheter insertion site for redness, induration, and drainage.
- Assess urine characteristics, color, odor, and for the presence of blood.
Pain
- Management of pain should be individualized.
- Some interventions are to assess pain character, location, duration, and intensity.
- Use an easily understood pain rating scale.
- Consider alternate measures for pain management (imagery, relaxation, music, etc.).
- Place the patient in a position of comfort (knees to chest).
- Administer ordered analgesics.
Clinical Judgement
- Consider which method of instruction will assist in adherence to therapeutic regime and pain management strategies.
Follow-Up and Desired Outcomes
- Collaborates with the HCP to devise a plan of care that supports kidney health.