Fluids and Electrolytes: Balance and Disturbances

Fluid and electrolyte balance

Necessary for life and homeostasis
Nursing role is to help prevent and treat fluid and electrolyte
disturbances
Body Fluid Composition
Water
Primary component of fluids
Provides a medium for transport and exchange of nutrients and
other substances such as O2, CO2 and metabolic waste to and
from cells
Provides a medium for metabolic reactions within the cells
Assist in regulating body temperature through the evaporation of
perspiration
Provides form for body structure and acts as a shock absorber
Provides insulation
Acts as lubricants Total body water constitutes about 60% of the
total body weight but this amount varies with
age,
Gender
And the amount of body fat.
To maintain normal body balance, body water intake should be
approximately equal to body water output
Average fluid intake and output is about 2500ml/24hours
Urine production and excretion account for most water loss
Average of daily urine output is 1500ml in adults.
At least 400ml of highly concentrated urine/day is required to
excrete metabolic waste
Insensible water loss occurs through the skin, lungs and feces
Intracellular fluid (ICF)
Extracellular Fluid (ECF)

Extracellular fluid
Intravascular
Interstitial

 Trans cellular

Electrolytes
any of certain inorganic compounds, mainly sodium, potassium,
magnesium, calcium, chloride, and bicarbonate, that dissociate
in biological fluids into ions capable of conducting electrical
currents and constituting a major force in controlling fluid
balance within the body
Active chemicals that carry positive (cations) and negative
(anions) electrical charges
Assist in regulating water balance
Help regulate and maintain acid-base balance
Contribute to enzyme reactions
Essential for neuromuscular activity
Major cations:
An ion or group of ions having a positive charge and
characteristically moving toward the negative electrode in
electrolysis.
Sodium

142mEq/L

Potassium

5mEq/L

Calcium

5mEq/l

Magnesium

2mEq/L

Hydrogen ions
154mEq/L
Major anion
Chloride

103mEq/L

Bicarbonate

26mEq/L

Phosphate

2mEq/L

Sulfate

1mEq/L

Organic acids

5mEq/L

Proteinate

17mEq/L
154mEq/L

Sodium
Major cation outside the cell
Functions mainly
compartment

on

regulating

ECF

volume

including

vascular

 Loss and gain of Na is usually accompanied by loss/gains od water

Na also functions in establishing of electrochemical state necessary for
muscle contraction and the transmission of nerve impulses
Potassium
Major cation inside the cell
K influences both skeletal and cardiac function
Normal renal function is necessary for maintenance of K balance since
80% is excreted daily from the body by way of kidneys
Calcium
Major component of strong and durable teeth and bones
Ca helps hold body cells together
In addition, Ca exerts a sedative action on nerve cells and thus plays a
major role in transmission of impulses
It helps regulate muscle contractions and relaxation including normal
heart beat
Essential inactivating enzymes that stimulate many essential chemical
reactions and plays a role in blood coagulation
Magnesium
It acts as activator of many ICF enzymes and plays a role in both CHO
and CHON metabolism
Important in neuromuscular function
Also exerts effects on cardiovascular system acting peripherally to
produce vasodilation.
Chloride
Major anion found outside the cells and in the blood
Sea H2O has the same concentration of Cl ion as human body fluid
Helps maintain normal ECF osmolality
Affects body pH

Plays a vital role in maintaining acid-base balance

hydrogen ions to produce hydrochloric acid

combines with

Phosphate/Phosphorous
Critical constituent of all the bodys tissues
Essential to the function of muscle, RBC, nervous system, intermediary
metabolism of CHO, CHON and fats
CHLORIDE, BICARBONATE (HCO3), PHOSPHATE and SULPHATE all
contribute to maintain pH balance and regulating fluid in and out of the
cells

HCO3
Acts as a buffer to maintain the normal levels of acidity in blood and
other fluids
Use to measure the acidity of blood and body fluids

Electrolyte concentrations differ in the fluid compartments

Major cation in ECF
sodium
Major cation in ICF
potassium

Movement of fluid through capillary walls depends on:

Hydrostatic pressure pressure exerted on the walls of blood
vessels
Osmotic pressure pressure exerted by the protein in the plasma
Lymph drainage Osmosis
Diffusion
Filtration
Active transport
OSMOSIS movement of fluid trough a semi permeable membrane
from an area of low concentration to an area of
high
concentration of particles equalizing
concentration of both
sides of the membrane
DIFFUSION movement of molecules and ions from an area of higher
concentration to an area of lower concentration
FILTRATION movement of water and solutes from an area of higher
hydrostatic pressure to an area of lower
hydrostatic pressure
ACTIVE TRANSPORT movement of solutes across membranes,
requires expenditure of energy

Regulation of fluid
Homeostasis requires several regulatory mechanisms and processes to
maintain balance between fluid intake and excretion and these include:
Thirst
Kidneys the renin-angiotensin-aldosterone mechanism

 Antidiuretic hormone
Atrial natriuretic peptide
These mechanisms affect the volume, distribution and composition of body
fluids

Thirst
Primary regulator of water intake
Plays an important role in maintaining fluid balance and preventing
dehydration
Thirst is located in the brain and stimulated when the blood volume
drops because of water losses or when osmolality increases
Kidney
Primary responsible for regulating fluid volume and electrolyte balance
in the body
They regulate volume and osmolality of body fluids by controlling the
excretion of water and electrolytes
Renin-Angiotensin-Aldosterone System
Works to maintain intravascular fluid balance and blood pressure
A decrease in blood flow or blood pressure to the kidney stimulates
specialized receptors in the juxtaglomerular cells of the nephrons to
produce renin
Renin converts
angiotensin 1

angiotensinogen

on

the

circulating

blood

into

Angiotensin 1 travels through the blood steam to the lungs where it is

converted to angiotensin 2 by angiotensin converting enzyme (ACE)
Angiotensin 2 is a potent vasoconstrictor thus it raises blood pressure
Antidiuretic Hormone (ADH)
Released by the posterior pituitary gland, regulates water excretion
from the kidneys
Osmoreceptors in the hypothalamus respond to increases in serum
osmolality and decreases blood volume, stimulating ADH production
and release
ADH acts on the distal tubules of the kidney, making them more
permeable to water and thus increasing water reabsorption.
With increase water reabsorption, urine output falls and blood volume
is restored and serum osmolality drops as the water dilutes body fluids
Atrial Natriuretic Peptide
Released by atrial muscle cells in response to distention from fluid
overload

 ANP affects several body systems, including the cardiovascular, renal,

gastrointestinal and endocrine systems but it primarily affects the
renin-angiotensin-aldosterone system.
ANP opposes this system by inhibiting renin secretion and blocking the
secretion and sodium-retaining effects of aldosterone.
As a result, ANP promotes sodium wasting and diuresis and causes
vasodilation

Regulation of fluid volume

Regulation of body fluid volume
Hypervolemia
hypovolemia
Inhibits

stimulates

ADH release
Aldosterone release
release
Thirst inhibited

ADH release
Aldosterone
Thirst stimulated

Contribute to increase urination or diluted urine

urination or

contribute to decrease

concentrated urine

Fluid shifting
1st space shifting normal distribution of fluid in both the ICF and ECF
compartment
2nd space shifting- excess accumulation of interstitial fluid
3rd space shifting- fluid accumulation in areas that are normally have
no or little amounts of fluids
Routes of Gains and Losses
Gain
Dietary intake of fluid and food or enteral feeding
Parenteral fluids
Losses
Kidney: urine output
Skin loss: sensible and insensible losses
Lungs
GIT

 Others

Role of Atrial Natriuretic Peptide (ANP) in Maintenance of Fluid Balance

Fluid Volume Imbalances
Fluid Volume Deficit (FVD): Hypovolemia
Fluid Volume Excess (FVE): Hypervolemia

Electrolyte Imbalances
Sodium:

hyponatremia and hypernatremia

Potassium:

hypokalemia and hyperkalemia

Calcium:

hypocalcaemia and hypercalcaemia

Magnesium:

hypomagnesaemia and hypomagnesaemia

Phosphorus:

hypophosphatemia and hyperphosphatemia

Chloride:

hypochloremia and hyperchlororemia

Hyponatremia
Serum Na less than 135mEq/L
Causes: adrenal insufficiency, water intoxication ,SIADH and losses by
vomiting, diarrhea, sweating and diuretics
Manifestations: poor skin turgor, dry mucosa, headache, decreased
salivation, decreased BP, nausea. Abdominal cramping and neurologic
disorder
Nursing Management: assessment and prevention, monitoring of
dietary Na and fluid intake, identification and monitoring of at risk
patients and the effects of medication
Hypernatremia
Serum Na greater than 145mEq/L
Causes: excess water loss, excess Na administration, diabetes
insipidus, heat stroke and hypertonic IV solution
Manifestation: thirst, elevated temperature, dry swollen tongue, sticky
mucosa, neurologic symptoms, restlessness and weakness
Medical management: hypotonic electrolyte solution or D5W
Nursing Management: assessment and prevention, assess for over the
counter sources of Na, offer and encourage fluids to meet patients
needs and provide sufficient water with tube feedings
Hypokalemia

 Below normal serum K (<3.5 mEq/L) may occur with normal K levels in
alkalosis due to shift of serum K into cells
Causes: GI losses, medications, alterations of acid base balance,
hyperaldosteronism and poor dietary intake
Manifestations: fatigue, anorexia, nausea, vomiting, dysrhythmias,
muscle weakness, cramps, paresthesia's, glucose intolerance,
decreased muscle strength and deep tendon reflexes
Medical Management: increased dietary K, K replacement and IV for
severe deficit
Nursing Management: assessment, monitoring and providing nursing
care related to IV K administration
Hyperkalemia
Serum K is greater than 5.0 mEq/l
Causes: usually treatment related, impaired renal function,
hypoaldosteronism, tissue trauma and acidosis
Manifestation: cardiac changes and dysrhythmias, muscle weakness
with potential respiratory impairment, paresthesias, anxiety and GI
manifestations
Medical Management: monitor ECG, cation exchange resin. IV Na
bicarbonate, IV calcium cluconate, regular insulin and hypertonic
dextrose IV, and B-2 agonist, limit dietary K and perform dialysis
Nursing Management: assess serum K levels, mix well IVs containing K
monitor medication and initiate dietary K restriction and dietary
teaching for patients at risk
Hypocalcemia
Serum levels less than 8.5mg/dl must be considered in conjunction
with serum albumin level
Causes: hypoparathyroidism, malabsoption, pancreatitis, alkalosis,
massive transfusion of citrated blood , renal failure, medications
Manifestations: tetany, circumural numbness, paresthesias,
hyperactive DTRs trousseaus sign, chovteks sign, seizures, dyspnea
and laryngospasm, abnormal clotting and anxiety
Medical Management: IV Calcium gluconate, calcium and vitamin D
supplements , diet
Nursing Management: assessment, weight bearing exercises, health
teachings to diet and medication
Hypercalcemia
Serum level above 10.5 mg/dl
Causes: malignancy and hyperparathyroidism, bone loss related to
immobility

 manifestations: muscle weakness, incoordination, anorexia,

constipation, nausea and omitting, abdominal and bone pain, polyuria,
thrist, ECG changes and dysrhythmias
Medical management: treat underlying cause, administer fluids,
furosemide, phosphates, calcitonin and biphosphates
Nursing Management: assessment, ambulation, fluids of 3 to 4 L/day,
fluids containing Na unless contraindicated and fiber for constipation
Hypomagnesemia
Serum less than 1.8 mg/dl, evaluate in conjunction with serum albumin
Causes: alcoholism, GI losses, enteral or parenteral feeding deficient
in magnesium, medications, rapid administration of citrated blood,
contributing causes include DKA, sepsis, burns and hypothermia
Manifestations: neuromuscular irritability, muscle weakness,
tremors, athetoid movements, ECG changes and dysrhythmias and
alterations in mood and LOC
Medical Management: diet, oral mg, and MgSo4 IV
Nursing Management: assessment, ensure safety, health teachings
related to diet , medications, alcohol use
Hypermagnesemia
Serum level more than 2.7 mg/dl
Causes: renal failure, DKA and excessive administration of Mg
Manifestations: flushing, low BP, nausea and vomiting, hypoactive
reflexes, drowsiness, muscle weakness, depressed respirations, ECG
changes and dysrhythmias
Medical Management: IV calcium gluconate, loop diuretics, IV NS of
RL hemodialysis
Nursing Management: assessment, avoid administering medications
containing Mg and provide health teachings regarding Mg containing
OTC medications

Maintaining Acid-Base Balance

Normal plasma pH is 7.35 hydrogen ion concentration
Major ECF buffer system; bicarbonate-carbonic acid buffer system
Kidney regulate bicarbonate in ECF
Lungs under the control of the medulla regulate CO2 and therefore
carbonic acid in ECF
Types of acid base imbalances
Metabolic acidosis
Metabolic alkalosis

 Respiratory acidosis
Respiratory alkalosis
Metabolic Acidosis
Low pH ,<7.5
Low bicarbonate,< 22mEq/L
Most commonly due to renal failure
Manifestations include headache, confusion, drowsiness, increased
respiratory rate and depth, decreased blood pressure, decreased CO,
dysrhythmias, shock
Correct the underlying problem and correct the imbalance: bicarbonate
maybe administered
With acidosis hyperkalemia may occur as K shifts out of the cell
As acidosis is corrected, K shifts back into the cell and K levels
decreases
Serum calcium levels may be low with chronic metabolic acidosis and
must be corrected before treating acidosis
Metabolic Alkalosis
High pH, >7.45
High bicarbonate, >26mEq/L
Most commonly due to vomiting or gastric suction, may also be caused
by medications especially long term diuretic
Hypokalemia will produce alkalosis
Manifestations include symptoms related to decreased calcium,
tachycardia, symptoms of hypokalemia and respiratory depression
Correct underlying disorder, supply chloride t allow exertion of excess
bicarbonate and restore fluid with NaCl solutions
Respiratory Acidosis
Low pH, <7.35
PaCO2 > 42mmHg
Always due to respiratory problem with inadequate excretion of CO2
With chronic respiratory acidosis, the body may compensate and may
be asymptomatic, symptoms may include a suddenly increased pulse,
respiratory rate and BP, mental changes, feeling of fullness in the head
Potential increased ICP
Treatment is aimed at improving ventilation
Respiratory Alkalosis
High pH,> 7.45

 PaCO2 <35 mmHg

Always due to hyperventilation
Manifestations include lightheadedness, inability to concentrate,
numbness and tingling and sometimes loss of consciousness
Correct cause of hyperventilation
Arterial Blood Gases
pH 7.35 to 7.45
PaCO2 35 mmHg to 45 mmHg
HCO2 22 to 26 mEq/L
PaO2 80 to 100 mmHg
O2 saturation > 94%
Base excess/deficit +2 mEq/L

General nursing care of clients with fluid and electrolyte problems

Assessment

Obtain history to identify risk factors affecting fluid and

electrolyte status

Monitor vital signs

Evaluate skin turgor, hydration and temperature

Auscultate breath sounds

Weight client

Monitor I and O

Review laboratory test

Laboratory test
Urinary specific gravity
Serum pH and serum electrolytes
Hematocrit
Blood urea nitrogen (BUN)
Creatinine clearance
Nursing Diagnosis
Activity intolerance related to muscle weakness
Decreased CO related to cardiac dysrhythmias
Fluid volume deficit related to:
Diarrhea

 Loss of gastric contents

Diaphoresis
polyuria
Fluid volume excess related to:
Anuria
Decreased CO
Altered regulatory mechanism
Trapping of fluid in 3rd space where ECF accumulates and its
physiology unavailable to the body
Impaired gas exchange related to excessive secretions
Risk for injury related to sensory and perceptual alterations
Risk for impaired skin integrity related to poor skin turgor
Altered nutrition: less than body requirements related to
Anorexia
Nausea
Vomiting
Interventions
Manage F and E intake

Fluids maybe encourage to correct deficits

Nutritional intake can be increased or restricted to correct

electrolyte disturbances
o Na: table salt, dairy products, processed meats, soup,
canned foods
o Potassium: bananas, oranges, nuts, dark leafy greens,
dried fruits
o Calcium: milk, cheese yogurt
o

Administer IV therapy

Fluids
o Dextrose in water
o D5NaCl
o PNSS
o Ringers solution
Contains Na+ Cl- K+ Ca++
o LRS

 Contains Na+ Cl_ K+ Ca++ and lactate

Lactate is metabolized by liver and forms
bicarbonate ( HCO3
o Plasma expanders
Dextran and albumin
Monitor clients for complications (IV)

Infiltration

Phlebitis

Circulatory overload

Administer pharmacologic agents

Diuretics

Electrolyte replacement

Potassium removing resin

Provide care based on specific clinical findings

Skin care

Safe environment

Burns
Burn injuries
Most burns occur in home
Young children and the elderly are high risk for burn injuries
Nurses must play an active role in the prevention of burn injuries
by teaching prevention concepts and promoting safety legislation

Goals related to burns

Prevention
Institution of lifesaving measures for severely burned person
Prevention of disability and disfigurement through early specialized
and individualized care
Rehabilitation through reconstructive surgery and rehabilitation
program

Classification of Burns
Superficial partial thickness
Deep partial thickness
Full thickness
Factors to consider in determining Burn depth
How the injury occurred
Causative agent
Temperature of agent
Duration of contact with the agent
Thickness of the skin

Classification of Burns by extent of injury

Minor burn
Moderate, uncomplicated burn
Major burn
Methods to estimate total body surface area (TBSA) Burned
Rule of nine
Lund and Browder method
Palm method
Physiologic changes
Burns less than 25% TBSA produce a primarily local response
Burns more than 25% may produce a local and systemic response and
are considered major burns
Systemic response includes cytokines and other mediators into the
systemic circulation
Fluid shifts and shock result in tissue hypoperfusion and organ
hypofunction
Effects of major burn injury
Fluid and electrolyte shifts
Cardiovascular effects
Pulmonary injury
Inhalation blow the glottis
Upper airway
Carbon monoxide poisoning
Restrictive defects
Renal and GI alterations
Immunologic alterations
Effect upon thermoregulation
Phases of Burn injury
Emergent or resuscitative phase onset of injury to completion of fluid
resuscitation
Acute or intermediate phase- from beginning of diuresis to wound
closure
Rehabilitation phase- from wound closure to return to optimal physical
and psychosocial adjustment
Emergent or Resuscitative phase

 Prevent injury to rescuer

Stop injury: extinguish flames, cool the burn, irrigate chemical burns
ABCs: establish airway breathing and circulation
Start O2 and large bore IVs
Remove restricted objects and cover the wound
Do assessment, surveying all body systems, obtain a hx of the incident
and pertinent data
Patient is transported to emergency department
Fluid resuscitation is begun
Foley catheter is inserted
Patients with burns exceeding 20-25% should have an NGT inserted
and placed to suction
Patient is stabilized and condition is continually monitored
Patients with electrical burns should have ECG
Address pain: only IV medication should be administered
Psychosocial consideration and emotional support should be given to
patient and family
Fluid and Electrolyte Shifts: Emergent
Generalized dehydration
Reduced blood volume and hemoconcentration
Decreased urine output
Trauma causes release of K into ECF: hyperkalemia
Na traps in edema fluid shifts into cells as K is released: hyponatremia
Metabolic acidosis
Care of patient in the Emergent Phase: Diagnosis
Impaired gas exchanged
Ineffective airway clearance
Fluid volume deficit
Hypothermia
Acute pain
anxiety
Potential complications/collaborative problems
Acute respiratory failure
Distributive shock

 Acute renal failure

Compartment syndrome
Acute pain
Anxiety
Acute or Intermediate Phase
48-72 hours after injury
Continue assessment and maintain respiratory and circulatory support
Prevention of infection, wound care, pain management and nutritional
support are priorities in this stage
Fluid and Electrolyte Shifts: Acute phase
Fluid re-enters the vascular space from interstitial space
Hemodilution
Increased urine output
Na is lost with diuresis and due to dilution as fluid enters vascular
space: hyponatremia
Potassium shifts from ECF into cells: potential hypokalemia
Metabolic acidosis
Care of patient in the Acute Phase: Diagnosis
Excessive fluid volume
Risk for infection
Imbalanced nutrition
Acute pain
Impaired physical mobility
Ineffective coping
Interrupted family processes
Deficient knowledge
Collaborative problems/potential complications
Heart failure and pulmonary edema
Sepsis
Acute respiratory failure
Visceral damage ( electrical burns)
Rehabilitation Phase
Rehabilitation is begun as early as possible in the emergent phase and
extends for a long period after the injury

 Focus is upon the wound healing, psychosocial support, self image,

lifestyle and restoring maximal functional abilities so patient can have
the best quality life, both personally and socially
Patient may need reconstructive surgery to improve function and
appearance
Vocational counseling and support groups may assist patient
Burn wound care
Wound cleaning
Use of topical agents
Wound debridement
Natural debridement
Mechanical debridement
Surgical debridement
Wound dressing, dressing changes and skin grafting
Pain Management
Burn pain has been described as one of the most severe forms of acute
pain
Pain accompanies care and treatments such as wound cleaning and
dressing changes
TYPES OF BURN PAIN
Background or resting
Procedural
breakthrough
Analgesics
IV use during emergent and acute phase
Morphine
Fentanyl
Role of anxiety in pain
Effect of sleep derivation on pain
Nonpharmacologic measures
Nutritional Support
Burn injuries produce profound metabolic abnormalities
Goal of nutritional support is to promote a state of nitrogen balance
and match nutrient utilization
Nutritional support is based on patients' preborn status and % TBSA
burned

 Enteral route is preferred

Home care instructions
Mental health
Skin and wound care
Exercise and activity
Nutrition
Pain management
Thermoregulation and clothing
Sexual issues

Alterations in the Renal and Genitourinary System

Kidney (Structure and Function)
Nephron functional units of kidney, consist of glomerulus where
blood is filtered and a tubular component
Glomerulus consists of capillaries encased in Bowmans capsule.
Where water soluble nutrients, wastes and other small particles are
filtered from the blood

The Nephron (Tubular components of the Nephron)

Proximal convoluted tubule coiled segment that drains the
Bowmans capsule
Loop of Henle thin looped structure
Distal convoluted tubule
Collecting tubule which joins with several tubules to collect the filtrate
Tubular Structure
These process the glomerular (urine) filtrate selectively reabsorbing
substances from the tubular fluid into the peritubular capillaries and
secreting substances from the peritubular cappilaries into the urine
filtrate
Tubular Reabsorption and Secretion
Water and urea are passively absorbed along concentration grandients
Na+, K+, Ca+, phosphates ions, urate, glucose, amino acids
reabsorbed through active transport
H+, K+, urate ions secreted into the tubular fluid
Na+ reabsorption is dependent on presence of aldosterone, hormone
secreted by the adrenal gland
Urine volume is controlled hormonally by mechanism that regulate the
amount of water reabsorbed by the kidney tubules; only under
abnormal conditions does the glomerular filtration rate influence urine
volume
Renal Blood Flow

 In adults, kidneys are perfused with 1000 to 1300 ml of blood per

minute, or 20% to 25% of CO mainly to ensure sufficient GFR for the
removal of waste products from the blood
Regulation of Renal Blood Flow
Natural and humoral control mechanism sympathetic nervous
system and humoral substances: angiotensin II, ADH and endothelins
produce vasoconstriction of renal vessels
Autoregulation occurs when the resistance to blood flow through
the kidneys must be varied in direct proportion to arterial pressure
Juxtaglomerular complex represents a feedback control system
that links changes in the GFR with renal blood flow
Functions of the Kidneys
Focus: elimination of water, waste products, excess electrolytes,
unwanted substances from the blood
Regulation of pH: by conserving base bicarbonate and eliminating H+
Regulation of Na and K elimination
Urea and uric acid elimination
Endocrine function of the kidney
Long term regulation of blood pressure is facilitated through the
kidneys activation of renin-angiotensin system and the regulation of
Na and water balance
Activation of vitamin D
Kidney stimulates erythropoietin
Common urine test
Urine analysis
Culture and sensitivity test of urine
Specific gravity
Diagnostics related to urinary system
Common urine test
Urine analysis
Culture and sensitivity test of urine
Specific gravity
Cystoscopy visualization of the bladder through a tube
with a fiberoptic end
IVP (intravenous pyelogram) x-ray examination of the
kidney, ureters and bladder after injection
of a contrast medium into an antecubital
vein

 Blood chemistry: BUN, creatine, BUA

CBC
KUB ultrasound

General Nursing Diagnoses for clients with Urinary/Reproductive system

Disorders
Anxiety r/t reduced urine output
Body image disturbance r/t :
Dependency on technology
Alterations in structure
Loss of functions
Constipation r/t pressure on colon
Fluid volume excess r/t inability to secrete urine
Anticipatory grieving r/t:
Loss of independence
Concerns about dying
Infertility
Incontinence r/t diseases process
Risk for infection r/t :

 Altered immune response

Knowledge deficit
Knowledge deficit r/t prevention/treatment protocols
Altered nutrition: less than body requirements related to anorexia
Pain r/t:
Inflammation
Obstruction of urine
pressure
Impaired physical mobility r/t:
Pain
inflammation
Altered role performance r/t:
Inference with sexual functioning
Chronic debilitation
Self-esteem disturbance related to chronic debilitation
Sensory perceptual alteration related to chemical toxins
Sexual dysfunction r/t
Altered body image
Inadequate tissue perfusion
Surgery
Imposed restrictions
Altered sexuality patterns r/t:
Fear of transmission of infection
Loss of function
Impaired skin integrity r/t:
Presence of irritants
Presence of lesions
Social isolation r/t social stigma
Altered urinary elimination r/t:
Microbiology irritants
Physical obstruction
trauma
Urinary retention r/t physical obstruction

 Altered thought processes related to chemical toxins

Obstructive Disorders (Urolithiasis and Nephrolithiasis)

Formation of stones in the urinary tract, stones may be composed of
calcium phosphate, uric acid or oxalate.
They tend to recur and may cause obstruction, infection and or
hydronephrosis
Clinical Findings
Subjective
Severe pain in kidney area radiating down the flank to the pubic
area
Frequency or urgency of urination
History of prior or associated health problems
nausea
Objective
Diaphoresis, pallor, nausea, vomiting
Hematuria, pyuria may occur if infection is present
Therapeutic Interventions
Narcotics
Antispasmodics
Allopurinol or sulfinpyrazone
Antibiotics
Monitor I and O
Diet therapy
Large fluid intake
Surgical intervention if stone is not passed or complications are
present
Percutaneous ultrasonic lithotripsy
Nephroscope is inserted through skin into kidney
Extracorporeal shock-wave lithotripsy
Evaluation/Outcome
Express relief of pain
Establishes normal urine flow
Describes strategies for prevention of stone formation

Urinary Tract Infection

UTI involves both the lower and upper urinary tract structures
In lower UTIs ( cystitis), the infecting pathogens tend to propagate in
the urine and cause irritative voiding, symptoms often with minimal
systemic signs of infection
Upper UTIs (pyelonephritis) tend to invade the tissues of the kidney
pelvis, inciting an acute inflammatory response with marked systemic
manifestations of infection
Etiologic Factors
Pathogens: Escherichia coli, staphylococcus saprophyticus, proteus
mirabilis, klebsiella pneumonia, enterococcus species
Host defenses and Pathogen virulence
Obstruction and reflux
Urethrovesical reflux
Vesicoureteral reflux
Manifestations
For lower UTI:
Frequency of urination
Lower abdominal or back discomfort
Burning and pain on urination

 Urine is cloudy and foul smelling

For upper UTI: (pyelonephritis)
Shaking
Chills
Fever
Constant ache in the loin area of the back
Dysuria
Frequency and urgency
Malaise
Nausea and vomiting with abdominal pain

Inflammatory Problems (Glomerulonephritis)

Involves damage to both kidneys resulting from filtration and trapping
of antibody-antigen complexes within glomeruli
As a result, inflammatory and degenerative changes affect all renal
tissue
Often follows some forms of streptococcal infection such as tonsillitis
May be acute or chronic in nature: decreases life expectancy if
progressive renal damage occurs
Complications include hypertensive encephalopathy, heart failure and
infection
Assessment

 History of recent upper respiratory or skin infections or invasive

procedures
Blood pressure for baseline data
Urine for color
History of dyspnea and edema
Neck veins for engorgement
Clinical Findings
Subjective
Flank pain, costovertebral tenderness
Headache
Malaise
Dyspnea due to salt and fluid retention
Weakness
Visual disturbances
Objective
Hematuria
Periorbital and facial edema
Oliguria
Fever
Tachycardia; hypertension
Urinalysis reveals protein and casts
Elevated plasma BUN and creatinine
anemia
Therapeutic Interventions
Antibiotics such as penicillin to treat underlying infection
Dietary restriction of Na, fluids and protein based on clinical status
Diuretics and antihypertensive to control blood pressure
Rest, regular activity may be resumed when hematuria and proteinuria
resolve
Interventions
Monitor I and O
Assess specific gravity of urine
Weigh client daily
Monitor V/S

 Special prophylactic skin care

Protect client from infection
Observe for complications such as renal failure, cardiac failure and
hypertensive encephalopathy
Evaluate laboratory results ( BUN, creatinine, urinalysis)
Encourage continued medical supervision
Refer to social service as needed
Evaluations/Outcome
Complies w/ medical regimen
Stabilizes fluid volume to w/n acceptable limits
Maintains adequate nutritional status
Identifies signs of complications