FLUID AND ELECTROLYTES IMBALANCES Manifestations of fluid volume excess: Coma

Body Fluids Weight gain Third space fluid shifts

Water weight percentage in:
Men: 60-70% of body weight is water Crackles (rales)
Manifestations:
Women: 50-55% body weight is water in BP and PR
Depends on degree of fluid loss
Infants: 75-80% body weight is water Headache Acute weight loss
Elderly: 47% of body weight is water skin turgor
Late signs: Oliguria

Electrolyte Functions: Neck vein distention Concentrated urine
1. Promotes neuromuscular irritability
2. Maintains Fluid Volume Tachycardia Postural hypotension
3. Regulate Acid-Base Balance Pitting edema (lower extremities)
Manifestations:
Solution Types: Interventions: Weak, rapid heart rate
Isotonic: 0.9% NaCl Flattened neck veins

Weigh client daily

Hypertonic: 3.0% NaCl temperature

Hypotonic: .45% NaCl
Restrict fluids
Central venous pressure
Monitor I/O Cool, clammy skin
Assessment of Fluids: Provide skin care Thirst
Daily weight Nausea

Skin turgor Fluid Volume Disturbances Lassitude

Input and output Fluid Volume Deficit (Hypovolemia)

Muscle weakness
Fontanel in infants loss of extracellular fluid volume >

Cramps
Orbits of the eyes intake of fluid
Urine specific gravity Water & electrolytes are lost in the Nursing Interventions:

same amount
Measure I/O
Causes of Fluid Volume Weigh daily
Deficit: Causes:
Vomiting Monitor vital signs
Fever
Diarrhea fluid intake
Vomiting

Diarrhea GI suctioning
Nursing Interventions:
urine output Sweating
Administer an antiemetic if patient is
Decreased intake nauseated
Causes of Fluid Volume Nausea Enteral or parenteral nutrition
Excess:
Congestive Heart Failure Risk Factors: Fluid Volume Excess (Hypervolemia)
Excessive edema Diabetes Insipidus Isotonic expansion of the ECF
Excessive IV fluids Adrenal insufficiency Abnormal retention of water and
Osmotic diuresis sodium
Hemorrhage
Causes: Diarrhea, NPO Flat P wave
Fluid overload insulin Muscular weakness
Heart failure Paresthesia
Renal failure Manifestations: Diarrhea

Weak irregular pulses
Cirrhosis of the liver
ECG: Management:
Excess salts
QT prolonged Monitor vital signs
Diminished function of the Inverted T waves

homeostatic mechanisms Restrict K rich foods

Altered LOC
Shallow respiration Discontinue K supplements
Manifestations: Weakness If no renal disease: diuretics
Edema Hyporeflexia Prep for dialysis
Distended neck veins Constipation Administer NaHCO3
Crackles 10% glucose with insulin 50 units
Tachycardia Management: induce transfer of K serum to the ICF
BP Monitor vital signs, RR Ca2+ gluconate antidote for Mg toxicity

Pulse pressure
Monitor serum K levels has an antagonistic effect on Ca2+

Bed rest Serum Na 135 145meq/L

Central venous pressure
Encourage K-rich foods
weight fiber diet HYPONATREMIA
urine output Use of K-sparing diuretics Na is less than 135meq/L
Shortness of breath Oral Potassium
Wheezing IV potassium Causes:
NEVER give via IV, IM or SC Diuretics

Management: Hyperkalemia
Diaphoresis
Monitor vital signs K is more than 5.5 meq/L
Addison s Disease
I&O
SIADH
Restrict fluid and Na intake Causes:
Excessive K intake NPO
Weigh daily pre-breakfast
Adrenal insufficiency salt diet
Monitor electrolytes
K sparing diuretics Freshwater drowning

Addison s disease
Electrolyte Imbalances Assessment:
CRF
Normal K 3.5 5.0 meq/L pulse rate
Metabolic Acidosis
Shallow respiration
HYPOKALEMIA Tissue damage and injury
headache
K is less than 3.5 meg/L
Altered LOC
Assessment:

Irregular, weak pulses Seizures

Causes:
Diuretics, digitalis & steroids BP Weakness

Cushing s syndrome ECG: Polyuria

Metabolic Alkalosis Tall T wave < 1.010 sp. Gravity
 Excessive intake of Ca & Vit. D
Management: Normal serum Calcium Use of thiazides, Lithium

Monitor vital signs 4.5 5.5 meq/L

Hyperparathydroidism
Monitor LOC Malignancy
intake of Na rich foods HYPOCALCEMIA

Ca is less than 4.5meq/L Immobility, Fracture

Hypovolemia: IVF NSS
Kidney Disease
Fluid excess: osmotic diuretics
Causes: Multiple Myeloma
SIADH: Lithium & Demeclocycline intake of Ca & Vit. D
Seizure precautions Lactose Intolerance Manifestations:
Parathydroidectomy Irregular CR
HYPERNATREMIA CRF Cardiac arrest
Na is more than 145meq/L Diuretics
Altered LOC
Peritonitis
Muscle weakness
Causes: Pancreatitis

Steroids Colic pain renal stones

Diarrhea
Na intake Constipation
water intake Manifestations:
Irregular pulses Management:
Cushing s syndrome
Paresthesia Monitor vital signs, CR
CRF
numbness Restrict Ca rich foods
Manifestations: Discontinue PO and IV Ca
Weakness Give prescribed diuretics
PR
Tetany fluid intake
Cramping
Carpopedal spasm
Calcitonin: biphosphates
Convulsions (+) trosseaus sign

Shallow respiration ASA and NSAIDS

(+) chvostek sign
inhibit Ca resorption from bones
Weakness Convulsion
Dry, flaky skin Prep for dialysis

Altered LOC Management: Mithrozine: serum Ca in the body

Oliguria < 30cc Q hr Monitor vital signs

Monitor serum Ca & Mg RENAL FAILURE

> 1.025 sp. Gravity

Encourage Ca-rich foods Loss of kidney function

Dry mucus membranes
Oral Ca supplement
Management:
CaCO3 (calci-aid) Imbalance of electrolytes

Monitor vital signs

IV Ca
given very slowly
Retention of wastes, fluids
Restrict Na and fluids never thru IV, IM or SQ
Diuretics Types:

Hypovolemia: D5W and Hypotonic IVF HYPERCALCEMIA ACUTE RENAL FAILURE (ARF)
Ca is less than 4.5meq/L

Causes:
CHRONIC RENAL FAILURE (CRF)
Acute Renal Failure (ARF)
Hypertension; DM (Most common) Monitor LOC
Recurrent ARF
Sudden loss of kidney function Chronic urinary obstruction
Reverse isolation

Temporary; Reversible
Autoimmune disorders Wear mask
Assessment:
Does not require dialysis BP (Hypertension)
Diet: CHON K Ca

Irregular pulses Restrict Na intake

Causes:
PRE-RENAL UO (Oliguria) Limit fluid intake
INTRA-RENAL
POST-RENAL
Edema Administer Na Kayexalate
Stages: Pallor Avoid nephrotoxic drugs
1st: OLIGURIC PHASE
Weakness and fatigue
UO ( 400 ml/day) Prepare for dialysis
Anorexia and vomiting
BUN Creatinine
Hypertension Altered LOC
HEMODIALYSIS
Altered LOC
Fluid overload; edema Kussmauls breathing Diffusion of dissolved particles across a
semi-permeable membrane
2nd: DIURETIC PHASE Complications:
UO 4-5 L/day Hypertension Functions:
BUN and creatinine (gradual) Fluid imbalance Cleanses the blood of waste products
Improvement in LOC K, Ca
Hypotension Metabolic Acidosis Removes excessive fluids
Azotemia/ Uremia Maintains bodys buffer system
3rd: CONVALESCENCE: Anemia
Normal Urine output Infection and bleeding
Maintains electrolyte balance
Normal BUN/Creatinine
LOC Stages: Access:
Complete recovery: I: Diminished renal Reserve Subclavian Vein Catheter
1-2 years II: Renal Insufficiency Femoral Vein Catheter
III: End-Stage Renal Disease Arteriovenous Shunt (AV Shunt)
(ESRD) Chronic dialysis clients
Chronic Renal Failure (CRF) Maturity: 1-2 weeks before use
Management:
Irreversible; permanent damage Management:
End-stage renal disease (ESRD)
Monitor VS; BP and PR
Monitor VS; BP
Requires dialysis or kidney transplant
Assess I and O Check patency blood access device

Weigh OD pre-breakfast WEIGH client before and after dialysis

Causes: Check BUN, creatinine; Serum K and Ca
For ABG monitoring
Hold antihypertensive drugs
 Complications:
Provide adequate nutrition Hypotension; shock Management
Peritonitis Relieve obstruction by:
Complications: draining the bladder
Hypotension and shock HYDRONEPHROSIS relieve pressure via percutaneous
Disequilibrium syndrome
nephrostomy tube
Blood diseases Enlargement of the pelvis of the kidney with
urine
Treat the underlying disorder
PERITONEAL DIALYSIS surgery
Result of back pressure in the ureter caused
Dialyzing membrane: Peritoneum by an obstruction
GLOMERULONEPHRITIS
Insertion of siliconized catheter into the PATHOPHYSIOLOGY Destruction and inflammation of the
abdomen develops when the pelvis and calyces (the glomeruli capillaries in kidneys
3- 5 cm below umbilicus urine-collecting structures of the kidneys)
of both kidneys become distended because Causes:
Contraindications: urine is unable to drain from the kidney
Peritonitis down the ureters into the bladder. (Bilateral Immunological
means both sides.)
Recent abdominal surgery
Hydronephrosis is not itself a disease, but
Streptococcal infection
rather a physical result of whatever disease (URTI or wound 2-3 wks prior)
Nursing care:
is keeping urine from draining out of the Group A beta hemolytic
Monitor VS; BP kidneys, ureters, and bladder.
Assessment:
Obtain weight Causes:
Disorders associated with hydronephrosis
Hematuria
Have the client VOID
Monitor I and O accurately
include: Proteinuria
acute bilateral obstructive uropathy
Check BUN and creatinine chronic bilateral obstructive uropathy Edema (periorbital, facial)
Assess serum K, Ca and glucose
uteropelvic junction obstruction
Maintain strict aseptic posterior ureteral valves
Hypertension

neurogenic bladder Fever

technique
Anorexia and vomiting
bladder outlet obstruction
Assess catheter dressing site
prune belly syndrome
Fatigue and weakness
Oliguria ( UO)
Watch for signs of infection;
respiratory distress Pathophysiology
Manifestations:
Turn client from side to side Signs of hydronephrosis is generally Antigen (Group A beta-hemolytic
observed during fetal ultrasound streptococcus)
Monitor exchange cycle:
Infusion
BP Antigen-antibody product
Repeated UTI s
Indwelling (Do not extend)
Flank or abdominal pain Deposition of antigen-antibody complex in
Draining (Color and amount) the glomerulus
Abdominal mass
 Increased production of epithelial cells Diet: Calorie, CHON
lining the glomerulus Administer Medical Management
Leukocytes infiltrate the glomerulus Antibiotics
Steroids
Objective is to preserve renal function.

Thickening of the glomerular filtration Antihypertensive Diuretics for edema

Diuretics
membrane ACE inhibitors for proteinuria
Scarring and loss of glomerular filtration NEPHROTIC SYNDROME Antineoplastic inhibitors (cyclophospamide)
membrane
Primary glomerular disease characterized Immunosuppresant medications
Diagnostics:
by the following: (azathioprine)
Throat/ wound culture proteinuria Corticosteroid
ASO (Anti-Streptolysin O)
hypoalbuminemia
edema
Nursing Management:
ESR (Erythrocyte Sedimentation Rate) hyperlipidemia
Monitor VS
BUN and Creatinine This syndrome is apparent in any condition
tha seriously damage the glomerular Assess Input and Outpu
capillary and results in increased glomerular
permeability
Bed rest
Medical Management
Management consists of primarily treating Assessment:
Weigh OD pre breakfast

the symptoms Proteinuria Diet: Calorie, CHON

Pharmacologic therapy depends on the
Hypoalbumenia Restrict Na intake
cause of AGE
Streptococcal = penicillin Edema Limit fluids
Other antibiotic agents may be prescribed
Hyperlipidemia Administer as prescribed:
Diuretics
Nursing Management: Steroids
Monitor VS; BP and Temp Pathophysiolgy Plasma expanders
Albumin, dextran
I and O
Nephrotic syndrome can occur with almost any Anticoagulants

Monitor urine intrinsic renal disease or systemic disease

Restrict fluid as prescribed
Restrict Na intake
Weigh OD and pre breakfast
Bed rest and limited activities
that affects the glomerulus.
It is characterized by the loss of plasma
protein, particularly albumin, in the urine. Wilms Tumor
Although the liver is capable of increasing What is Wilms Tumor?
the production of albumin, it cannot keep
up with the daily loss of albumin through o cancer of the kidney that primarily affects
the kidneys, thus hypoalbuminemia results.
children
o Also known as nephroblastoma
o most common malignant tumor of the
kidney in children
o peak time of Wilms' tumor occurrence is at
age 3, and it occurs only rarely after age 8
Pathophysiology
o cancer arises when cells destined to form
the kidney fail to develop and instead
multiply in their primitive state
o tumor usually becomes evident between
ages 1 and 5
o mass often distorts the kidney and can
compress normal tissue into a thin rim
o may cause bleeding and can result in
blood in the urine
Cause
o Most Cancers occur after damage to genes
o Genes program cells to develop, grow,
mature and die
o Cancer results when changes (mutations)
arise in genes that control growth,
allowing cells to multiply without restraint
o In rare cases, genetic defects pass from
parent to child
o Some cases of Wilms' tumor are related to
defects in one of two genes on
chromosome 11 (WT1 and WT2)
Signs and Symptoms
o Partial nephrectomy - removal of the
tumor and part of the kidney tissue
o Palpable mass in childs abdomen surrounding it ; usually performed when
the other kidney is damaged or has
o Fever
already been removed
o Blood in the urine o Radical nephrectomy - doctors remove the
o Reduced appetite kidney and surrounding tissues.
Neighboring lymph nodes also may be
o Weight loss removed.
o
High blood pressure
o Treatment regimens by stage:
o Constipation
o Stomach pain
Stage I or II cancer
o cancer is restricted to the kidney or nearby
o Nausea structures
o Vomiting o removal of the affected kidney and tissues
o General discomfort (malaise)
and some of the lymph nodes near the
kidney, followed by chemotherapy
Nursing Management Stage III or IV cancer
o Provide emotional support o cancer has spread within the abdomen and
o Encourage family to verbalize feelings
can't be completely removed without
jeopardizing structures such as major
o Inform family about all the alternative
blood vessels
forms of treatment o radiation will be added to surgery and
o Prepare patient for surgery
chemotherapy
Stage V cancer
Medical Management o tumor cells are in both kidneys
o Chemotherapy o part of the cancer from both kidneys will
be removed during surgery and
o Radiation therapy
neighboring lymph nodes taken to see if
o Surgery
they contain tumor cells
o Simple nephrectomy - surgeon removes
o Chemotherapy is used to shrink the
remaining tumor
the entire kidney

o Surgery is repeated to remove as much
tumor as possible while leaving functioning
kidney tissue
o More chemotherapy and radiation therapy
may follow.
Urolithiasis
What is Urolithiasis?
The process of forming stones in the
kidney, bladder, and/or urethra
development of the stones is related to
decreased urine volume or increased
excretion of stone-forming components
such as calcium, oxalate, urate, cystine,
xanthine, and phosphate
The stones form in the urine collecting
area (the pelvis) of the kidney and may
range in size from tiny to staghorn stones
the size of the renal pelvis itself
Pathophysiology
Renal, urologic, endocrine, and metabolic
disorders may lead to the development of
crystallized material in the urinary system
Stones are most often classified into
groups based on their chemical
components
In fluids contained within the urinary
system, interaction between factors that
promote and factors that inhibit
crystallization is continuous.
When solutes in solution are at
concentrations below their solubility
product (subsaturation of stone-forming
compounds in the urine), added crystals
dissolve (undersaturated region)
Spontaneous precipitation can occur when
concentration of constituents is above the
formation product
Materials that produce stones in the
urinary tract include
(1) calcium with phosphate or oxalate
(2) purine derivatives
(3) magnesium ammonium phosphate
(struvite)
(4) cysteine
(5) combinations of the preceding items
(6) drugs or their metabolites (eg,
phenytoin, triamterene).
Causes
Supersaturation of stone-forming
compounds in urine
Presence of chemical or physical stimuli in
urine that promote stone formation
Inadequate amount of compounds in urine
that inhibit stone formation (eg,
magnesium, citrate)
Factors such as developmental
abnormalities of the urinary tract, urinary
obstruction, urinary stasis, and infection
with urea-splitting microorganisms may
also be important.
Additional risk factors include the following
Habitually low urine volume
High urine excretion of calcium
High urine excretion of uric acid
High urine excretion of oxalate
Low urine pH: Uric acid and cysteine are
less soluble in acid urine.
Medication
High urine pH: Struvite and calcium
phosphate are less soluble in alkaline
urine.
Nidus for crystal precipitation: A nidus for
crystal precipitation (eg, uroepithelial
surface properties that affect crystal
retention) occurs when the crystalline
lattice structure of one crystal is similar to
another crystal and the second crystal
grows on the first
Signs and Symptoms
Sudden onset of excruciating pain in the
buttocks area
Abdominal pain
Nausea and vomiting
You are constantly moving to relieve the
pain
Pain in the genital area as the stone
moves
Fever and chills
Nursing Management
Advise patient to drink at least six to eight
glasses of water a day, plus one at
bedtime and another during the night to
enable the stone to pass more easily
Patient may need to urinate through a
strainer to collect the stone and give it to
your health care provider for analysis
Acid Ash diet for Calcium stones
Alkaline Ash diet for oxalate stones
Medical Management
Narcotics to control severe pain
 Allopurinol, 100 to 300 mg daily to control
hyperuricemia
Potassium citrate, 100 mEq tablets twice
daily to raise urinary pH
Hydrochlorothiazide, 25 to 50 mg daily for
calcium type I stones
Cellulose sodium phosphate 10 g daily for
calcium type I stones; to decrease bowel
absorption
Orthophosphates for calcium type III
stones; to inhibit vitamin B synthesis
Surgical and Other Procedures
Urethroscopya diagnostic proceedure for
identifying stones in lower third of ureter
Extracorporeal Shock Wave Lithotripsy
(ESWI)an outpatient proceedure in
which shock waves are used to shatter
stones under 2 cm
Percutaneous nephrolithotripsya surgical
proceedure for removing large or dense
kidney stones; instruments are inserted
into the kidney to break up stones
Urinary Incontinence
What is Urinary Incontinence?
more common in women than in men
o o
o Mild leakage affects most women at some
time in their lives
o Severe leakage is less common and affects
about one in ten women
o More than one half of women who have
symptoms do not seek medical care
Pathophysiology
o Leaks in women can occur with certain
physical activities or with other stress,
such as coughing
Some may lose urine when they hear the
o the body
sound of running water or when their
hands are in water
o Some feel the urge to urinate and cannot
control it
o Others leak urine only while they are o Neuromuscular Disorders
pregnant
o Medication
5 types of urinary incontinence:
Signs and Symptoms
Stress o Urgency: A strong urge to urinate whether
o most common type of urinary incontinence or not the bladder is full, often with pelvic
in younger women pressure.
o occurs when the pressure in the bladder is o Frequency
greater than the pressure in the urethra o Nocturia
o Occurs when a woman coughs, laughs, or o Dysuria
sneezes o Enuresis: Bed-wetting or leaking while
sleeping.
Nursing Management
Leaks o Inform patient that incontinence is not
normal and advise him/her to seek
o also can happen when a woman
professional help
walks, runs, or does aerobics
o Help patient know why leaks occur (type
Urge
of incontinence) and how to avoid them
o sudden strong urge to void and leaks urine
before she can get to the bathroom
o Teach Patient Kegel exercises
o sometimes called overactive bladder
Medical Management
Mixed
o Pseudoephedrine
o has both stress and urge symptoms
o Overflow
Imipramine
o bladder does not empty all the way during
voiding o Anticholinergics
o bladder muscle is not active enough or
urethra is blocked o hormone treatment
Functional
Urinary Tract Infection
o Incontinence due to other health problems
What is UTI?
o serious health problem affecting millions of
Causes
people each year
o Urinary Tract Infection
o second most common type of infection in
.
o Pelvic Support Problems
o Women are more prone to UTI than men
o One woman in five develops a UTI during
o Urinary Tract Abnormalities
her lifetime

Pathophysiology
o infection occurs when tiny organisms,
usually bacteria from the digestive
tract, cling to the opening of the
urethra and begin to multiply
o Most infections arise from one type of
bacteria, Escherichia coli (E. coli),
which normally lives in the colon
o An infection limited to the urethra is
called urethritis
o If bacteria move to the bladder and
multiply, a bladder infection, called
cystitis, results
o If the infection is not treated
promptly, bacteria may then travel
further up the ureters to multiply and
infect the kidneys causing
pyelonephritis.
o Chlamydia and Mycoplasma may also
cause UTIs in both men and women,
but these infections tend to remain
limited to the urethra and
reproductive system
o Chlamydia and Mycoplasma may be
sexually transmitted
Signs and Symptoms
o Urinary frequency
o Dysuria
o Weakness
o Women may feel uncomfortable
pressure above the pubic bone
o Man may feel a fullness in the rectum
o Oliguria
o Heamaturia
o Milky or cloudy urine
o Fever
o pain in the back or side below the ribs
o Nausea and vomiting
Nursing Management
o Drink plenty of water every day.
o Urinate when you feel the need; don't
resist the urge to urinate.
o Wipe from front to back to prevent
bacteria around the anus from entering
the vagina or urethra.
o Take showers instead of tub baths.
o Cleanse the genital area before sexual
intercourse.
o Avoid using feminine hygiene sprays and
scented douches, which may irritate the
urethra.
Medical Management
o Sulfonamides
o Quinolones
Neurogenic Bladder
What is a Neurologic Disorder?
o malfunctioning urinary bladder due to
neurologic dysfunction
o Could also result from insult
emanating from internal or external
trauma, disease, or injury
o Pathophysiology
o If a problem occurs within the nervous
system, the entire voiding cycle is
affected
o Any part of the nervous system may
be affected, including the brain, pons,
spinal cord, sacral cord, and
peripheral nerves
o A dysfunctional voiding condition
results in different symptoms, ranging
from acute urinary retention to an
overactive bladder or to a combination
of both
Brain Lesion
o Lesions of the brain above the pons
destroy the master control center
o Causes complete loss of voiding
control
o voiding reflexes of the lower urinary
tractthe primitive voiding reflex
remain intact
o Includes stroke, brain tumor,
Parkinson disease, Hydrocephalus,
cerebral palsy, and Shy-Drager
syndrome Spinal Cord lesion
Spinal Cord lesion
o Diseases or injuries of the spinal cord
between the pons and the sacral
spinal cord
o result in spastic bladder or overactive
bladder
o causes include motor vehicle and
diving accidents, Multiple sclerosis
(MS), and myelomeningocele
Sacral cord injury
o injuries of the sacral cord and the
corresponding nerve roots arising
from the sacral cord
o If a sensory neurogenic bladder is
present, affected individual may not
be able to sense when the bladder is
full
o In the case of a motor neurogenic
bladder, the individual will sense the
 bladder is full and the detrusor may
not contract, a condition known as
detrusor areflexia Medical Management
o Typical causes are a sacral cord tumor, o insertion of a catheter or hollow tube
herniated disc, and injuries that crush (to empty the bladder at regular
the pelvis intervals)
o prophylactic (preventive) antibiotic
Peripheral nerve injury therapy (to reduce the incidence of
o Often caused by Diabetes mellitus and infection)
AIDS o artificial sphincter
o Causes peripheral neuropathy o surgery
resulting in urinary retention
o diseases destroy the nerves to the
bladder and may lead to silent,
painless distention of the bladder
o Patients with chronic diabetes lose the
sensation of bladder filling first, before
the bladder decompensates

Signs and Symptoms

o urinary tract infection
o kidney stones
o chills
o shivering
o fever
o urinary incontinence
o small urine volume during voiding
o urinary frequency and urgency
o dribbling urine
o loss of sensation of bladder fullness

Nursing Management
o Assess patients age, overall health,
and medical history
o Assess patients severity of symptoms
o Help patient to determine the type of
voiding dysfunction that results
o Assess patients tolerance for specific
medications, procedures, or therapies
o Encourage the patient to verbalize
opinion or preference for the type of
treatment