Use these assessment tips for kidney injury

Pain and hemodynamic instability. These are the two most significant assessment finding related to kidney injuries, according to Katie Ryan, RN, BSN, director of the ED at St. Rose Dominican Hospitals — San Martin Campus in Las Vegas. Here are assessment tips:

Pain from kidney injuries might present as flank or back pain on the affected side if the bleeding from this injury has remained localized.

"If, however, the bleeding does not remain localized, the patient may complain of abdominal pain or generalized low back pain," says Ryan. "Hemodynamic instability is related to the amount of blood loss from the injury."

Injury to the kidney itself usually will become self-contained as the kidney capsule creates pressure allowing the bleeding to be controlled by a tamponade effect, she says.

Fluid resuscitation of 1 to 2 liters usually is enough to offset the initial blood loss.

"While the complaints of pain may continue for these patients, the vital signs will return to baseline and will remain adequate unless the bleeding returns," says Ryan.

If, however, there is injury to the capsule or the blood vessels supplying the kidney, the injury becomes much more potentially lethal, she says. "Because of their location deep in the renal pelvis, the kidneys are challenging in terms of bleeding control," says Ryan.

Patients may present with profound homodynamic instability and severe pain most likely in the abdomen or low back.

"These patients will most likely not respond to 1 to 2 liters of fluid, but rather, will require continued resuscitation with fluid and blood products until definitive measures such as surgery or interventional angiography can be performed," says Ryan.

A secondary finding for the patient with a kidney injury is blood in the urine.

"This may present as pink-tinged urine to frank bloody urine," Ryan says. "However, blood-tinged urine may also be present for other injuries, so this finding is not unique to kidney injuries alone."

The "gold star" diagnostic indicator for kidney injury is the contrast enhanced CT scan of the abdomen and pelvis.

"If the injury is believed to be vascular in nature, diagnostics will then include angiography to determine the exact location of the injury, as well as the best method of injury repair," says Ryan.

Immediate steps to take for kidney injuries

Do these interventions immediately if you suspect kidney injury in your patient, says Katie Ryan, RN, BSN, director of the ED at St. Rose Dominican Hospitals — San Martin Campus in Las Vegas:

  • Insert two large-bore intravenous lines, 16 gauge or greater.
  • Complete a head-to-toe assessment with the patient fully exposed.
  • Obtain a complete set of vitals, including the patient's temperature.
  • Keep the patient as warm as possible, to reduce the risk of hypothermia.
  • Monitor vital signs frequently, every five to 15 minutes, until the patient's diagnostic tests are complete and the extent of the injury is known.
  • Obtain baseline labs.
  • Insert a Foley catheter to closely monitor input and output, and keep the bladder and urethra free from blood clots.

Could the kidney injury be life-threatening?

Kidney injuries that are potentially life-threatening will present as profound hemodynamic instability, says Katie Ryan, RN, BSN, director of the ED at St. Rose Dominican Hospitals — San Martin Campus in Las Vegas.

"Although resuscitative measures may provide a brief return to normal, uncontrolled bleeding will again create a hypodynamic state," she says. "The patient may become hypothermic as well as coagulopathic, causing more potentially lethal problems."

The most significant sign that a patient has a life-threatening injury is hemodynamic instability that remains constant or that returns quickly after initial resuscitative measures have been tapered off, says Ryan. The patient's complete blood count might show a lower than normal hemoglobin or hematocrit. "However, this may not be evident on the initial set of lab results. Follow-up lab results may be more indicative of how much blood has been lost," she says.

Ryan says an equally important sign, however, is "How does your patient look?" "Nurses must always take the time to look at their patients and to listen to what they are saying," she says. "Pale, scared, diaphoretic, and a sense of impending doom have always helped me key in on patients in need of rapid lifesaving interventions."