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Chapter 46 • Magnesium — metabolism of carbohydrates
Fluid, Electrolyte, and Acid-Base Balance
FUNCTIONS OF WATER IN THE BODY
• Transporting nutrients to cells and wastes
from cells
• Transporting hormones, enzymes, blood
platelets, and
red and white blood cells
• Facilitating cellular metabolism and proper
cellular
chemical functioning
• Acting as a solvent for electrolytes and
nonelectrolytes
• Helping maintain normal body temperature
• Facilitating digestion and promoting
elimination
• Acting as a tissue lubricant
TWO COMPARTMENTS OF FLUID IN THE BODY
• Intracellular fluid (ICF) — fluid within cells
(70%)
• Extracellular fluid (ECF) — fluid outside
cells (30%)
– Includes intravascular and interstitial fluids
VARIATIONS IN FLUID CONTENT
• Healthy person — total body water is 50% to
60% of
body weight
• An infant has considerably more body fluid
and ECF than an adult
– More prone to fluid volume deficits
• Sex and amount of fat cells affect body water
– Women and obese people have less body
water
FLUID BALANCE
• Solvents — liquids that hold a substance in
solution
(water)
• Solutes — substances dissolved in a solution
(electrolytes and non-electrolytes)
MAJOR ELECTROLYTES/CHIEF FUNCTION
• Sodium — controls and regulates volume of
body fluids
• Potassium — chief regulator of cellular
enzyme activity and
water content
• Calcium — nerve impulse, blood clotting,
muscle
contraction, B12 absorption
and proteins, vital actions involving enzymes
• Chloride — maintains osmotic pressure in
blood, produces hydrochloric acid
• Bicarbonate — body’s primary buffer system
• Phosphate — involved in important chemical
reactions in body, cell division and hereditary
traits
TRANSPORTING BODY FLUIDS
• Osmosis — water passes from area of lesser
solute concentration to greater concentration
until equilibrium is established
• Diffusion — tendency of solutes to move
freely throughout a solvent (“downhill”)
• Active transport — requires energy for
movement of substances through cell
membrane from lesser solute concentration to
higher solute concentration
• Filtration — passage of fluid through
permeable membrane from area of higher to
lower pressure
OSMOLARITY OF A SOLUTION
• Isotonic — same concentration of particles
as plasma
• Hypertonic — greater concentration of
particles than plasma
• Hypotonic — lesser concentration of
particles than Plasma
SOURCE OF FLUIDS FOR THE BODY
• Ingested liquids
• Food
• Metabolism
Fluid Losses
• Kidneys — urine
• Intestinal tract — feces
• Skin — perspiration
• Insensible water loss
PRIMARY ORGANS OF HOMEOSTASIS
• Kidneys normally filter 170 L plasma, excrete
1.5 L urine.
• Cardiovascular system pumps and carries
nutrients and
water in body.
• Lungs regulate oxygen and carbon dioxide
levels of
blood.
• Adrenal glands help body conserve sodium,
save chloride
and water, and excrete potassium.
• Thyroid gland increases blood flow in body
and increases renal circulation

• Parathyroid glands regulate the level of
calcium in ECF.
• GI tract absorbs water and nutrients that
enter body
though this route.
• Nervous system is a switchboard to inhibit
and stimulate
fluid balance (thirst center and ADH storage).
ACID-BASE BALANCE (PH)
• Acid — substance containing hydrogen ions
that can be
liberated or released
• Base — substance that can trap hydrogen
ions
ASSESSMENT
Nursing Care Management 103
Concept: Nursing Care of Patients with
Problems in Fluid and Electrolytes Balance
HEALTH HISTORY
1.The nurse must query for disorders such
as: as URINARY CALCULI, FREQUENT
URINARY TRACT INFECTIONS, congenital
disorders, and stroke
2. history of cancer with radiation or
chemotherapy.
3. history of any hospitalizations and surgical
history.
4. General health questions: current health
status, nutrition, and work history.
5. Symptoms significantly suggestive of
decreased kidney function: reduced energy
level, METALLIC TASTE IN THE MOUTH,
anorexia, nausea, PRURITUS,
decreasedability to concentrate, decreased
urine output, and related weight gain from fluid
retention.
6. ask the patient if he or she smokes, which
makes individuals more susceptible to bladder
cancer.
ASSESSMENT OF URINARY PATTERNS
QUESTIONS TO ASK
• Have you noticed a change in VOIDING
PATTERNS? • Do you have a history of
incontinence,
urgency, or frequency of urination?
• Do you have difficulty with starting the
voiding process? • Do you feel burning when
you urinate?
ASSESSMENT OF URINARY PATTERNS
QUESTIONS TO ASK
• What COLOR is your urine?
• Has there ever been any indication of
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HEMATURIA (blood in the urine)?
• Do you feel full after you void?
• Is your urinary stream full, or are you able
to void only in DRIBBLES?
MEDICATION HISTORY
• Renal system has a direct relationship with
the metabolism of many meds, and the health
of the renal system is vital to the patient’s use
of meds.
• Amount and duration of nonsteroidalanti-
inflammatory medication usage.
• Potential for damage increases in the
presence of HTN or exposure to other
nephrotoxic drugs
POTENTIALLY NEPHROTOXIC DRUGS AND
OTHER AGENTS
1. Amikacin
2. Chemotherapeutic agents
3. Gentamicin
4. Contrast medium
5. Amphotericin B Ethylene glycol
6. Gentamicin Gold and other
heavy metals
7. Sulfonamides
8. Nonsteroidal anti-inflammatory drugs
PHYSICAL ASSESSMENT
SKIN
• Note skin turgor - hydration status.
• Skin could be dry and lack turgor or grossly
edematous, depending on the dysfunctions
etiology within the urinary system.
• Persistent scratching - phosphorus or calcium
imbalances of renal failure
• pallor or the yellow-gray cast - sometimes
seen in renal failure.
MOUTH
• Check mucous membranes for signs of
irritation or dryness and note breath smell.
• The smell of ammonia is common with
uremia (accumulation of end-products of
protein metabolism in the blood)
ABDOMEN
• Inspect and palpate for bladder distension,
masses, or enlarged kidneys -found with renal
cell cancer or polycystic renal disease within
an organ
KIDNEYS
• Palpate the kidneys at the Costovertebral
angle (Normally, the left kidney is not
palpable)
• A normal right kidney may be palpable during
deep inhalation.
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• Check for Tenderness - common finding in functions. They help diagnose problemsrelated
kidney infection, pyelonephritis, and polycystic to urine control. These can be
kidneys. incontinence,difficulty emptying the bladder,
overactive bladder, obstructions or frequent
infections.

LUNGS
• A fluid-overloaded pulmonary capillary bed
easily infiltrates the lungs with fluid, which is
evidenced by crackles on auscultation and wet
lung fields on a chest X-ray.
BLADDER
• palpate bladder for shape, size, and
Consistency
• An empty bladder is not usually palpable.
• A moderately full bladder is smooth and
round, and it is palpable above the symphysis
pubis. Before the test, you will be asked to empty
• A full bladder is palpated above the your bladder as much as you can.
symphysis pubis, and it may be close to the  A small soft tube (called a catheter) is
umbilicus. inserted into the urethra until it reaches
BLADDER ABNORMALITIES your bladder.
• A bladder that is nodular or asymmetrical to  The catheter allows the bladder to be
palpation. A nodular bladder may indicate a emptied completely. It is also used to
malignancy. An asymmetrical bladder may measure the amount of urine remaining in
result from a tumor in the bladder or the bladder after you go. Plus, it measures
anabdominal tumor that is compressing the the strength of your bladder by recording
bladder. pressure.
•Men with BENIGN PROSTATIC
HYPERPLASIA may be unable to completely
empty their bladder because of the pressure
that the enlarged prostate places on the
bladder.
• Various types of urinary incontinence, due to
altered mental status, muscle
function,medications, and other causes can
lead to incomplete bladder emptying.
DIAGNOSTIC STUDIES URINE STUDIES
• Urine culture- A bacterial count greater than
100,000 indicates a treatable infection
• Timed urine collection - the most common is
the 24-hour creatinineclearance to determine
renal filtering efficiency. Normal clearance
range is 70–140 mL/minute.
URINE STUDIES
 Voiding Cystometrogram
• A graphic recording of bladder filling pressure
and abdominal pressure during the filling and
voiding cycle. A urinary catheter is inserted into
the urinary bladder for filling and emptying
during the procedure.
• This tests measure how well the bladder
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URINE STUDIES
Cystography
• Radiopaque dye is instilled via a catheter
directly into the bladder. As with the voiding
cystometrogram, pressure recordings can be
obtained.
• Check for allergies to contrast media.
Postprocedural hydration, unless
contraindicated, is important for nephrotoxic
dye excretion.
RENAL FUNCTION TESTS

RADIOGRAPHIC
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Disturbances in Fluids & Electrolytes Assessment
 Fluid Volume Excess • PRIORITY: ABCs
 Fluid Volume Deficit • Health History
 Hyper / Hypocalcemia
 Hyper / Hypokalemia MILD MODERATE SEVERE
 Hyper / Hyponatremia
• intravascular • intravascular • IV losses 40%
FLUID VOLUME DEFICIT fluid 10% 15% fluid 25% loss •marked
• Hyperosmolar Imbalance (DHN) losses • rapid, thready tachycardia
• in intravascular & interstitial fluid • slight pulse • hypotension
tachycardia • urine output > •Weak / absent
Etiology • increased CRT 10 to peripheral pulses
1. fluid intake • urine output > 30 cc/hr • cool, cyanotic
2. Excess fluid losses 30cc/hr •supine skin
3. Failure of regulatory mechanism • cool, pale skin hypotension •Urine output <
4. Failure to absorb & reabsorb water • anxious • cool truncal skin 10
• severe thirst cc/hr
Causes of Fluid loss •unconsciousness
• Hemmorrhage
• Excessive sweating • Physical examination
• Renal failure with polyuria • Diagnostic test results
• Abdominal surgery Serum osmolality
• Vomiting / diarrhea HCT
• Nasogastric drainage Urine specific gravity
• DM CV
• Fistulas ESTIMATING FLUID LOSS
• Excessive use of laxatives Degree of Dehydration
• Excessive diuretic therapy
• Fever 1. Mild - 1-2L of water lost or 2% of BW
• Reduced fluid intake 2. Moderate - 3-5L of water lost or 8% of BW
• Fluid shifts 3. Severe - 5-10L of water lost or 9% of BW

Chief signs & symptoms Types of Dehydration

• Orthostatic hypotension 1. Isotonic Dehydration - equal losses between
• Tachycardia fluid & electrolyte
• Thirst 2. Hypertonic Dehydration - waterloss is >
• Flattened neck veins electrolyte loss
• Sunken eyeballs 3. Hypotonic Dehydration - waterloss is <
• Dry mucous membranes electrolyte loss; rare and difficult to treat
• Acute weight loss
• Decreased urine output Nursing Diagnosis
• Prolonged capillary refill time • Fluid Volume Deficit
• Altered tissue perfusion
Pointers in Hypovolemia • Altered oral mucous membrane
• Infants and elderly at increased risk • High risk for impaired skin integrity
• Hypovolemic clients are at risk for • High risk for injury
hypovolemic shock • Knowledge deficit Planning
• Multiple diagnostic test necessary
• Early warning sign for hypovolemia • If FVD,
• Hemodynamics affected - Maintain normal urine output
• Remember the ABCs - Maintain stable weight
• Improper correction may lead to - Monitor laboratory values
Hypervolemia - Monitor BP levels
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• Crackles
• Rapid bounding pulse
• If Altered Tissue perfusion, • Hypertension
- Exhibit warm, dry skin • Distended neck veins
- CR 60 to 100 bpm • Acute weight gain
- Capillary refill time (3 sec) • Edema
- Strong peripheral pulses
POINTERS IN HYPERVOLEMIA
• If Altered mucous membrane, • Elderly patients with heart or renal problems
- No infection • Serum potassium and blood ureanitrogen
- Verbalization of comfort (BUN) decline
- Intact skin • May cause acute pulmonary edema
• Overcorrection: hypovolemia
• If High Risk for injury,
- Safety precautions ASSESSMENT
- No injury incurred during hospital stay • Rapidly assess patient’s ABC
• Health history
• If Knowledge Deficit, • Physical examination
- State understanding of treatment • Diagnostic test result:
- Formulate a personal plan of action  Serum osmolality
 HCT
Nursing Interventions  Urine specific gravity
• Prevent bleeding - elevate  CVP
• Postural elevation for hypotension  Chest x-ray shows congestion
• Maintain an IV line
• Monitor urine output 1.Anasarca
• Blood transfusion as necessary 2.Periorbital edema
• Increase OFI 3.Peripheral edema (pitting)
• Turn to sides
• Daily weights
• Explain to client accordingly and provide
emotional support

Evaluation
• Explain nature of hypovolemia
• List warning signs of hypovolemia
• Describe all prescribed medications

FLUID VOLUME EXCESS

• Overhydration or water intoxication
CAUSES:
1. CHF
2. Rapid administration of hypertonic
solution
3. Hyperaldosteronism - aldosterone NURSING DIAGNOSIS
4. Renal disease • Fluid volume excess
5. Cirrhosis of the liver • Impaired gas exchange
6. Low intake of dietary protein • High risk for impaired skin integrity
7. Dietary intake of NaCl and other • Anxiety
sodium salts PLANNING
8. Fluid shifts • Return to baseline weight
Chief signs & symptoms • Maintain urine output 30 - 60cc/hr
• Tachypnea • BP, CR, RR, within normal limits
• Dyspnea • If Impaired gas exchange,

- O2 @ 90% or more
- PaCO2, pH, PaO2 within normal limits
- Clear breath sounds
• If impaired skin integrity
- no tissue breakdwon
• If anxiety
- Use available support systems
- Reports of less anxiety
IMPLEMENTATION
• Monitor VS
• Assess breath sounds (RR, pattern)
• Assess for venous distention
• Monitor I & O
• Monitor ABG levels
• Oral care
• Administer diuretics as ordered
• Elevate head of bed
• Pursed-lip breathing
• O2 as necessary
• Watch for signs of edema
• Rate and document existing edema
• Prevent skin breakdown
EVALUATION
• If warranted, teach client about
need for sodium / fluid restriction
• Discuss underlying cause
• Explain treatment regimen
• Encourage daily weighing
 SODIUM
• Found in ECF
• Directs osmolality
• Normal levels : 135 - 145 mEq/L
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• For impulse transmission in nerve and
muscle fibers
• Regulates acid-base balance
• Minimum daily requirement: 2g
• Influenced by ADH and Aldosterone
 HYPONATREMIA
• A common electrolyte imbalance
• Less than 135mEq/L
• Leads to seizure, coma and permanent
neurologic damange
Causes:
• Sodium intake restriction
• Excess sodium loss (vomiting, diarrhea)
• Fluid shifts (edema, burn, ascites)
• SIADH
Chief signs & symptoms
• Abdominal cramps
• Nausea
• Headache
• Altered LOC
• Signs of hypovolemia
• Signs of hypervolemia
POINTERS IN HYPONATREMIA
• Varies among patients
• Common imbalance in hospitalized patients
• Hypervolemia may result to hyponatremia
• Hyponatremia always results indecreased
serum osmolality
• Altered LOC usually accompanies serum
sodium level below 125 mEq/L
ASSESSMENT
• Health history
• Medication history
• Physical examination
- Dry and poor skin turgor
- Weak, rapid pulse
- BP and CVP or (DHN / overHdn)
• Diagnostic results
- Serum osmolality
- Serum sodium (< 135 mEq/L)
- Urine sp. Gr. < 1.010
NURSING DIAGNOSIS
• Altered thought processes
• High risk for injury
• Knowledge deficit
PLANNING
• Regain orientation to person, place, and time
• Remain free from injury
• Show no evidence of permanent neurologic
damage
• Express willingness to learn
IMPLEMENTATION
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• Restrict Na intake (for dilutionalhyponatremia) • Infants and comatose patients at
if prescribed increased risk
• Administer oral sodium supplements • Correction of imbalance should be
• IVF of hypertonic sodium chloridesolution gradual
• Monitor VS • Always results in increased osmolality
• Assess skin integrity every shift ASSESSMENT
• Provide safe environemnt • Health history
• Diet: high in sodium (smoked fish, buttermilk, - Determine if risk factors for hypernatremia
crabs, salted popcorn, etc.) are present. E.g. OTC Medications (antacids,
EVALUATION bicarbonates)
• can the patient, - Mental status - changes in activity level
- identify the causes of hyponatremia? - Intense sweating
- State the importance of seeking medical • Physical examination
treatment for signs of hyponatremia? - Disorientation, agitation
- Explain the treatment regimen? • Diagnostic Tests
• Continued physical assessment - Serum Na > 145mEq/L
• Oriented - Urine sp. Gr. > 1.030
• Absence of injury - Serum osmolality 300 mOsm/kg
• Normal Na levels NURSING DIAGNOSIS
• Absence of permanent neurologic • Altered thought processes
Deficits • High risk for injury
 HYPERNATREMIA • Knowledge deficit
PLANNING
• Serum sodium level > 145 mEq/L • Regain orientation
• May lead to seizure, coma, and permanent • Remain injury-free
neurologic damage. • No permanent neurologic deficits
• Thirst - primary compensation to combat • Willingness to learn and seek information
hypernatremia regarding Hypernatremia
Causes: • Maintenance within normal range
• H2O deprivation -
• Excessive water loss (severe vomiting)
• Excessive sodium intake  POTASSIUM
• Near-drowning in sea water
• Hyperaldosteronism • Maitaining cells’ electrical neutrality and
• Diabetes Insipidus osmolality
• High protein feedings without adequate • Facilitates cardiac muscle contraction
water supplement • Aid in neuromuscular transmission of
• Excessive administration of high sodium nerve impulses
content such as sodium polysytrene sulfonate • Affecting acid-base imbalance (H+)
(Kayexalate) • Normal serum levels 3.5 - 5 mEq/L
Chief Signs And Symptoms: • Required intake 60 to 100mEq or 3.5g
• Restless or agitation progressing to seizures • Kidneys eliminate 80% of ingested
or coma potassium
• Flushed skin DIETARY SOURCES OF POTASSIUM
• Intense thirst • Beef
• Low-grade fever • Chicken
• Signs of hypervolemia / hypovolemia • Beans
• Underlying mechanisms • Broccoli
- Water loss • Carrots
- Inadequate water intake • Banana
- Sodium gain • Cantaloupe
POINTER FOR HYPERNATREMIA • Baked potatoes
• Rarely results from ineffective thirst • spinach
mechanism
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NURSING DIAGNOSIS
 HYPOKALEMIA • Decreased cardiac output related to
arrythmias
• Abnormally low potassium (<3.5mEq/L) • Constipation related to decreased GI motility
• Causes: • Activity intolerance related to muscle
- Prolonged diuretic therapy weakness
- Severe GI fluid depletion by suctioning, PLANNING
laxative abuse • Regain potassium levels with normal range
- Diarrhea or vomiting • Regain normal ECG pattern
- Severe diaphoresis • Report increased tolerance for activity
- Stress: • Consume a high-fiber diet
Chief Signs and Symptoms IMPLEMENTATION
• Decreased muscle tone and muscle • Monitor potassium levels
weakness • Monitor fluid intake
• Decreased bowel sounds • Monitor for overhydration
• Paresthesia • Monitor respiratory rate and depth
• Weak irregular pulse • Potassium replacement therapy (IV)
POINTERS • 200 to 250 mEq / 24hours of K unless
• One of the most common electrolyte prescribed of IV infusion or 40 to 60 mEq/L
imbalance EVALUATION
• Commonly accompanies metabolic alkalosis • Normal serum levels
• Serum potassium levels and elctrocardiogram • Normal ECG tracings
tracings are the best clinical indicators. • Normal bowel elimination
• Major concerns: Arrythmias, respiratory  HYPERKALEMIA
muscle weakness
ASSESSMENT • Abnormally high potassium levels
• Health history CAUSES:
- Behavioral changes • Inadequate excretion
- Vomiting • Excessively high intake of potassium
- Constipation, leg cramps • Excessive infusion of IV with potassium
• Physical examination • Injury to cells
- Lethargy • Lysis of malignant cells from chemotherapy
- Diminished tendon reflex • Blood transfusion of large quantities
- Dilute urine Chief signs and symptoms
- Polyuria • Irritability
- Hypotension • Abdominal cramping, diarrhea
- paralysis • Paresthesia
• Diagnostic test • Muscle weakness
- Serum K less than 3.5 mEq/L • Irregular pulse arte
- Elevated pH and bicarbonate levels POINTERS
• Most dangersous of electrolyte disorders
above 7 mEq/L may cause cardiac
arrythmias
• Best clinical indicator: ECG tracings
ASSESSMENT
• Health history
- GI symptoms
- Renal failure
- Paresthesia
- Vague muscle weakness
• Physical examination
- Irregular pulse
- Hypotension
- Muscle weakness

- Flaccid paralysis
• Diagnostic tests
- Serum potassium level elevated
- Decreased arterial pH
- ECG tracings
NURSING DIAGNOSIS
• Decreased cardiac output related to
arrhythmias secondary to hyperkalemia
• Activity intolerance related to muscle
weakness secondary to hyperkalemia
• Diarrhea related to increased GI motility
secondary to hyperkalemia
PLANNING
• Regain normal cardiac output thru stable VS
• Regain normal ECG pattern
•Perform ADLs, bowel elimination
IMPLEMENTATION
• Monitor serum potassium and other
electrolyte levels
• Monitor intake and output
• Anticipate cardiac monitoring andperitoneal
dialysis or hemodialysis
• Administration of calcium gluconate to
counteract mycardial depressant effects of
hyperkalemia
• Kayexalate administration
• Implement safety measures
• Limit foods high in potassium
EVALUATION
• Normal potassium levels
• Stable vital signs
• Normal ECG tracing
• Increased tolerance for activity
• Normal bowel elimination patterns
• Relief from abdominal discomforts
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 CALCIUM
• Involved in structure and function of bones
• Concentrated on bone and teeth (99%)
• Enhances bone strength
• Stabilizes cell membrane and reduces
permeability to sodium
• Facilitates contraction of cardiac and skeletal
muscle
• Participates in neurotransmitter in synapses
• Activator in blood coagulation
• 8.9 - 10.1 mg/dl dietary intake: 1000mg
 REGULATION OF CALCIUM
• Vitamin D
- Calcium absorption in the intestine
• Phosphorus
- Inhibits calcium absorption
• PTH
- Regulate extracellular calcium concentration
- Ca, released PTH to increase Ca by bone
resorption (Ca from bone to plasma)
• Calcitonin
- Regulates extracellular calcium concentration
- Ca, released Calcitonin to decrease Ca
release from bone, also decreases PTH
 HYPERCALCEMIA
• Increased calcium resorption from bone
• Excessive intake of calcium supplements
• Multiple fractures, imbbolization
• Thiazide diuretics
ASSESSMENT
• Health history
- Intake of calcium supplements
- Hyperparathyroidism
• Physical examination
- Nausea restlessness
– Anorexia lethargy
– Abdominal pain bone pain
• Increased heart rate
• Increased blood pressure
• Polyuria, polydipsia, dehydration
NURSING DIAGNOSIS
• Altered urinary elimination related to polyuria
and renal calculi
• High risk for injury related to CNS dysfunction,
muscle weakness
• Decreased cardiac output related to
decreased electrical conduction through
cardiac muscle
INTERVENTION
• Monitor serum electrolyte levels
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• Provide safe environment (side rails)
• Assess LOC NURSING DIAGNOSIS
• Assess GI status • Altered nutrition: less than bodyrequirements
• Monitor VS related to inadequate intakeof calcium
• Note nutritional intake and pattern of • Pain related to muscle cramps secondaryto
elimination hypocalcemia
EVALUATION • Inability to sustain spontaneous ventilation
• Calcium levels within normal range laryngospasm
• Balance between fluid intake and output IMPLEMENTATION
• Baseline muscle strength • Provide a quiet, safe stress-free environment
 HYPOCALCEMIA • Monitor serum calcium levels
• Assess nutritional intake
• Below normal levels • Administer IV calcium for severe hypoCa
CAUSES: • Diet (alcohol restrictions)
• Alcoholism • Vitamin D supplements
• People with low intake of calcium • Encourage exercise is applicable
• Less active, immobilized • Discourage laxative use
• Severe infection or burn EVALUATION
• Renal failure • Absence of muscle cramps
• Blood transfusion • Absence of injury
• hypoparathyroidism • Normal rate, depth, pattern and rhythm of
ASSESSMENT respiration
• Health history • Normal VS
- Seizures, tremors or cramps
- Irritability or anxiety
- Paresthesia of fingers
• Physical examination
- Hyperactive deep tendon reflexes
- Positive Trousseaus’ sign and a positive
Chvostek’s sign
Trousseau’s Sign
Chvostek’s Sign
• Diagnostic tests
- Slight precipitation of calcium
- Prothrombin time and thromboplastin time are
prolonged
 URINARY SYSTEM: QUICK REVIEW URETERS, BLADDER,URETHRA
REVIEW OF URINARY ANATOMY &
PHYSIOLOGY
• Located:
– Under back muscles
– Behind peritoneum
• Thus: retroperitoneal
– Below level 2of lowest ribs
– Right lower than left
– Adrenal gland on top of
kidney
• Medulla
– Contains Pyramids &
Papilla
• Pelvis
– Calyx = division of pelvis  Bladder capacity 400 - 500 mL
• Pleural = calyces  smooth muscle
• Cortex  Urethral sphincter
 Micturition
 Efflux of urine
URINE FORMATION
 1- Glomerular filtration 2-Tubular reabsorption, 3-
Tubularsecretion
 Amino acids and glucose are usually filtered at the
level of the glomerulus and reabsorbed
 renal glycosuria
 Proteinuria (usually lowmolecular weight proteins)

 Each kidney has 1 million

 If total number of functioning nephronsis less than
20% of normal renal replacement therapy needed
 Nephrons
 Cortical nephrons- 80% to 85%
 Juxtamedullary nephrons- 15% to GLOMERULAR FILTRATION
 20%
 normal blood flow through the kidney1000 and
 Glomerulus
1,300mL/min
 Bowman’s Capsule
 99% of filtrate is Glomerular Filtration reabsorbed

ADH (Antidiuretic Hormone)

 Made in hypothalamus; water conservation
hormone
 Stored in posterior pituitary gland
 Acts on renal collecting tubule to regulate
reabsorption or elimination of water
 If blood volume decreases, then ADH is
released & water is reabsorbed by kidney. Urine
 output will be lower but concentration will be
increased.
RENIN
 Released by kidneys in response to decreased
blood volume
 Causes angiotensinogen (plasma protein) to split &
produce angiotensin I
 Lungs convert angiotensin I to angiotensinII
 Angiotensin II stimulates adrenal gland to release
aldosterone & causes an increase in peripheral
vasoconstriction
Volume of urine also controlled by glomerular
filtration rate
 Unique arrangment of blood vessels
– Afferent arteriole -----to----capillary bed-----to----
efferent arteriole -----to-----capillary bed ----to---- veins
 First capillary bed = glomerular capillaries
 Second capillary bed = peritubular capillaries
 Purpose of this = to control the pressure in the
glomerular capillaries & consequently the
glomerular filtration pressure
3 factors control this:
(1) autoregulation
 Local feedback from muscle tension in afferent
arteriole
 Local feedback from DCT at JGA
 Mediated via endothelial secretions of glomerular
capillaries
(2) sympathetic nervous system
(3) Renin

Regulation of Red Blood Cell Production

 kidneys detect a decrease inthe oxygen tension-
release ERYTHROPOIETIN.
Vitamin D Synthesis • B = increase fluid volume; overhydration; high output
 kidneys are responsible forthe final conversion of heart
inactive vitamin D to its activeform, 1,25 failure
dihydroxycholecalciferol. • C = kidney pathology
Secretion of Prostaglandins • D = hypertension; arteriolar spasm
 kidneys produce prostaglandin E and prostacyclin,
which have a vasodilatory effect and are important
in maintaining renal blood flow.
Excretion of Waste Products
 kidneys eliminate the body’s metabolic waste
products.
 The major waste product ofprotein metabolism:
urea, of (about 25 to 30 g)
 Other wastes: creatinine,phosphates, and sulfates,
uricacid, drug metabolites
Urine storage
 filling and emptying of the bladder are mediated by
coordinated sympathetic and parasympathetic
nervous system
 parasympathetic pelvic nerves at the level of S1
through S4
 150 to 200 mL- sensation of fullness
 300 mL to 500 mL - strong desired to void
Bladder Emptying – Hormones help control the volume of urine via fluid &
 Initiation of voiding - efferent pelvic nerve, which electrolyte balance
originates in the S1 to S4 area • The concentration factor essentially deals with urine
 micturition- mediated by muscarinic an cholinergic volume
receptors within the detrusor – Usually more the volume = more the dilution [a direct
 pressure during micturition 20 40 cm H2O proportion]
 • engorged neck veins
• pulmonary edema and cardiomegaly
ASSESSMENT AND DIAGNOSTIC FINDINGS
• enlargement of kidneys
• elevated IgA
• biopsy
COMPLICATIONS
• hypertensive encephalopathy
• rapid decline leads to ESRD
• Prognosis : excellent
NURSING MANAGEMENT
1. Aldosterone • intake and output monitoring
 From adrenal cortex • patient education of the disease and
 Works on distal convoluted tubule Treatment
 Causes H2O & Na+ retention CHRONIC GLOMERULONEPHRITIS
2. Atrial natriuretic hormone(ANH)
 From atrial wall of heart • repeated occurrence of acute nephriticsyndrome,
 Works on distal convoluted tubule nephrosclerosis, glomerular sclerosis
 Works in opposition to aldosterone CLINICAL MANIFESTATIONS
 Causes H2O & Na+ loss • poorly nourished
3. Antidiuretic hormone • yellow-gray pigmentation of the skin
 From posterior pituitary •Peripheral and periorbital edema
 Works on collecting tubules • BP maybe normal or elevated
 Causes reabsorption of H2O (Na+ goes with it) • cardiomegaly may be present
• crackles and rale
•Peripheral neuropathy and diminished DTR
RENAL DISORDERS ASSESSMENT AND DIAGNOSTIC FINDINGS
• urine sg 1.010
NEPHROSCLEROSIS • presence of urinary casts
•GFR of 50 ml/min
 hardening of renalarteries due toprolonged • chest x-ray : cardiac enlargement
 hypertension or DM • MRI : decreased size of of renal cortex
TWO FORMS MEDICAL MANAGEMENT
• Malignant • diuretic medications
- occurs in young adults (2x in men than women) • Sodium and water restrictions
- associated with hypertension • weight monitoring
• Benign • early dialysis
- occurs in older adults NURSING MANAGEMENT
- Associated with atherosclerosis and hypertension • relieve anxiety
ASSESSMENT FINDINGS • provide emotional support
◦ Hematocrit • self-care needs
◦ Creatinine •Follow-up evaluations
◦ Serum potassium NEPHROTIC SYNDROME
◦ Serum calcium
◦ Lipid panel •A renal failure manifested by massiveproteinuria,
◦ Blood glucose hypoalbuminemia, highserum cholesterol and
◦ Urinalysis hyperlipidemia
◦ Urinary albumin-to-creatinine ratio • any condition that damages the capillarymembrane
MEDICAL MANAGEMENT and results in increasedglomerular permeability to
•ACE inhibitors plasma protein
• treat underlying cause CLINICAL MANIFESTATIONS
• presence of edema (soft and pitting)
ACUTE NEPHRITIC SYNDROME • irritability
• glomerular inflammation • headache
• causing passage of protein in urine (2 to 3 g per day) • malaise
• a combination of protein range proteinuria ASSESSMENT AND DIAGNOSTIC FINDINGS
CLINICAL MANIFESTATIONS • proteinuria (3.5 g/day)
• azotemia • presence ofWBC in urine
• microscopic hematuria • epithelial casts in urine
• edema • renal biopsy
• proteinuria MEDICAL MANAGEMENT
• cola-colored urine • treat underlying conditions
• Severe cases • prevention of CKD
•Headache • prescribing diuretics
• malaise •ACE inhibitors
• flank pain • antilipidemic agents
 CLINICAL MANIFESTATIONS
• lethargic and appear critically ill
• dry mucous membranes
• headache, drowsiness
• muscle twitching and seizures
ASSESSMENT AND DIAGNOSTIC FINDINGS

•Scanty to normal volume

POLYCYSTIC KIDNEY DISEASE • urine specific gravity is low
• Inability to concentrate urine is the earliest sign of
• presence of cysts in the kidney kidney damage
• may be inherited • anatomic changes in kidney in CT scan or MRI
•Autosomal dominant /recessive PKD •Progressive metabolic acidosis Prevention
CLINICAL MANIFESTATIONS • provide adequate hydration
• increasing size of kidneys • prevent and treat shock promptly
•Hematuria • treat hypotension promptly
• polyuria • assess renal function continuously
• hypertension • treat infections promptly
• renal calculi • treat sepsis
• fullness and flank pain •Prevent toxic drug effecs
ACUTE RENAL FAILURE MEDICAL MANAGEMENT
• hemodialysis / peritoneal dialysis / CRRT
• acute renal failure (ARF) • treatment of hyperkalemia (usage of Kayexalate)
• rapid loss of renal function due to damage • proper ventilation
• potentially life-threatening • phosphate-binding agents
• increase in serum creatinine of 50% • may have •Nutritional therapy
oliguria, nonoliguria, or anuria
ACUTE RENAL FAILURE NURSING MANAGEMENT
• CATEGORIES • monitoring fluid and electrolyte imbalance
• Prerenal • reducing metabolic rate
• Intrarenal • promoting pulmonary function
• Postrenal • preventing infection
• providing skin care
• provide psychosocial support
INFECTIONS OF THE URINARY TRACT

URINARY TRACT INFECTIONS

• caused by pathogenic microorganisms
• classified either lower UTI and upper UTI
• second most common infection in the body
• cases common in women (1 out of 5)
• urinary tract is the most common site for nosocomial
infections UTIs
•Lower UTI
• cystitis
• prostatitis
• bacterial urethritis
• Upper UTI
• pyelonephritis
 • Suprapubic or pelvic pain
•Complicated UTI
• Sepsis or shock
ASSESSMENT AND DIAGNOSTIC FINDINGS
• Urine cultures
• Groups of patients to have urine culture when
bacteriuria is present
• all children all men DM patients
• recent instrumentation and hospitalized
• pregnant women postmenopausal women
• sexually active or with new sexual partners
•3 or more recent UTI in a year
ASSESSMENT AND DIAGNOSTIC FINDINGS
• pyuria (WBC 4 /hpf) • CT scan for abscesses
• ultrasound for obstruction
•Cystourethroscopy
MEDICAL MANAGEMENT

LOWER UTI: PATHOPHYSIOLOGY

• Bacterial invasion of the urinary tract
• Deactivation of glycosaminoglycan (GAG)
• absence of normal bacterial flora of the vagina and
urethra
• absence if immunoglobulin A (IgA)
• Reflux
• urethrovesical reflux
• ureterovesical reflux

NURSING MANAGEMENT
• relieving pain
• increase fluid intake
• remove urinary tract irritants
• bacteriuria • encourage frequent voiding
• more than 105 colonies of bacteria per ml of • Monitoring potential complications
urine • use strict aseptic technique when inserting catheters
• Routes of infections • securing catheters
• transurethral route • maintaining a closed system
• bloodstream • perineal care
• fistula • teaching self-care
CLINICAL MANIFESTATIONS UPPER UTI
• 50% with bateriuria do not manifest symptoms • Pyelonephritis
• s/s of uncomplicated lower UTI • acutely ill with fever and chills
• burning on urination • leukocystosis
• increased frequency • flank pain
• incontinence • nausea and vomiting
• nocturia
 PYELONEPHRITIS: ASSESSMENT
•CT scan
• IV pyelogram
• radionuclide imaging
• urine culture and sensitivity testst
PYELONEPHRITIS: MEDICAL MANAGEMENT
• medications for UTI (table)
• hydration with oral or parenteral fluids
PYELONEPHRITIS: NURSING MANAGEMENT
• increase OFI
• VS q4
• medications as ordered
• emptying bladder frequently
• proper perineal hygiene
•Adherence to treatment regimen
MANAGEMENT OF PATIENTS WITH URINARY
DISTURBANCES
URINARY INCONTINENCE
• involuntary loss of urine from the bladder
Types of Urinary Incontinence
 Stress incontinence
 Urge incontinence
 Functional incontinence
 Iatrogenic incontinence
 Mixed urinary incontinence

1. Stress incontinence
 involuntary loss of urine through an intact
urethra as a result of sneezing, coughing, or
changing position
 predominantly affects women who have had
vaginal
 deliveries
 In men, is often experienced after a radical
prostatectomy ASSESSMENT AND DIAGNOSTIC FINDINGS
2. Urge incontinence • History
 involuntary loss of urine associated with a • Urodynamic tests
strong urge to void that cannot be suppressed. • Urinalysis
 The patient is aware of the need to void but is • Urine culture
unable to reach a toilet in time MEDICAL MANAGEMENT
 Precipitating factor: uninhibited detrusor Behavioral Therapy
contraction • FLUID MANAGEMENT
 can occur in a patient with neurologic  daily fluid intake of approximately 50 to 60
dysfunction that impairs inhibition of bladder ounces (1500 to 1600 mL), taken as
contraction small increments between breakfast and
3. Functional incontinence the evening meal
 instances in which lower urinary tract function  Fluids containing caffeine, carbonation, alcohol,
is intact but other factors, such as severe or artificial sweetener should be avoided
cognitive impairment (eg, Alzheimer’s • STANDARDIZED VOIDING FREQUENCY
dementia), make it difficult for the patient to • Timed voiding
identify the need to void or physical  involves establishing a set voiding frequency
impairments make it difficult or impossible for (such as every 2 hours if incontinent episodes
the patient to reach the toilet in time for voiding tend to occur 2 or more hours after
4. Iatrogenic incontinence voiding).
 refers to the involuntary loss of urine due to  The individual chooses to “void by the clock” at
extrinsic medical factors, predominantly the given interval while awake, rather than
medications. wait until a voiding urge occurs.
 Example: alpha-adrenergic agents • Prompted voiding
5. Mixed urinary incontinence  timed voiding that is carried out by staff or
 encompasses several types of urinary family members when the individual has
incontinence cognitive difficulties
 involuntary leakage associated with urgency • Habit retraining
and also with exertion, effort, sneezing, or
coughing
  timed voiding at an interval that is more
frequent than the individual would
usually choose.
 helps to restore the sensation of the need to
void in individuals who are
experiencing diminished sensation of
bladder filling due to various medical
conditions
• Bladder retraining
 Incorporates a timed voiding schedule and
urinary urge inhibition exercises to
inhibit voiding, or leaking urine
 When the first timing interval is easily reached
on a consistent basis without urinary urgency
or incontinence, a new voiding interval,
usually 10 to 15 minutes beyond the last, is
established
• PELVIC MUSCLE EXERCISE (PME)
 Also known as Kegel exercises
 aims to strengthen the voluntary muscles that
assist in bladder and bowel continence in both
men and women
 Biofeedback-assisted PME uses either
electromyography or manometry to help the
individual identify the pelvic muscles as he or
she attempts to learn which muscle group is
involved when performing PME
 PME involves gently tightening the same
muscles used to stop flatus or the stream of
urine for 5- to 10-second increments, followed
by 10-second resting phases.
• VAGINAL CONE RETENTION EXERCISES
 an adjunct to the Kegel exercises
 Vaginal cones of varying weight are inserted
 intravaginally twice a day
 The patient tries to retain the cone for 15
minutes by contracting the pelvic muscles.
•TRANSVAGINAL OR TRANSRECTAL ELECTRICAL
STIMULATION
 electrical stimulation is known to elicit a
passive contraction of the pelvic floor
musculature, thus re-educating these muscles
to provide enhanced levels of continence
 often used with biofeedback-assisted pelvic
muscle exercise training and voiding
schedules.
NEUROMODULATION
 Neuromodulation via transvaginal or
transrectalnerve stimulation of the pelvic floor
inhibits detrusor overactivity and hypersensory
 bladder signals and strengthens weak
sphincter muscles
• Pharmacologic Therapy
• Anticholinergic agents
 Inhibit bladder contraction
 first-line medication for urge incontinence
• tricyclic antidepressants
 (eg, amitriptyline [Endep], amoxapine
[Asendin])
 can also decrease bladder contractions as
well as increasebladder neck
resistance
• Pseudoephedrine sulfate (Sudafed)
 acts on alpha-adrenergic receptors,
causing urinary retention
 may be used to treat stress incontinence;
 needs to be used with caution in men with
prostatic hyperplasia.
• Hormone therapy
 (eg, estrogen)
SURGICAL MANAGEMENT
• Anterior vaginal repair, retropubic suspension, or
needle suspension to reposition the urethra
• Women with stress incontinence may undergo.
• Periurethral bulking
 is a semipermanent procedure in which small
amounts of artificial collage are placed within
the walls of the urethra to enhance the closing
pressure of the urethra
• Artificial urinary sphincter
 can be used to close the urethra and promote
continence
• Transurethral resection of the prostate
 For men with overflow and stress incontinence
NURSING MANAGEMENT
• For behavioral therapy to be effective, the nurse must
provide support and encouragement
• Teach patient to develop and use a log or diary to
record timing of pelvic floor muscle exercises, frequency
of voiding, any changes in bladder function, and any
episodes of incontinence
• Maintain skin integrity
• Promote measures to maintain fluid and electrolyte
imbalance
• Ensure adequate nutrition
• Provide an environment that promotes easy access to
bathroom, urinal, or bedpan
• Promote client and family coping
NEUROGENIC BLADDER
 a dysfunction that results from a lesion of the
nervous system and leads to urinary
incontinence.
 It may be caused by spinal cord injury, spinal
tumor, herniated vertebral disk, multiple
sclerosis, congenital disorders (spina bifida or
myelomeningocele), infection, or complications
of diabetes mellitus
 PATHOPHYSIOLOGY
• The two types of neurogenic bladder:
• spastic (or reflex) bladder
 Empties on reflex, with minimal or no
controlling influence to regulate its activity.
 Caused by a lower motor neuron lesion,
commonly resulting from trauma
• flaccid bladder
 Caused by any spinal cord lesion above
the voiding reflex arc (upper motor neuron
lesion)
 The result is a loss of conscious sensation
and cerebral motor control.

ASSESSMENT AND DIAGNOSTIC FINDINGS
• Clinical Manifestations:
 Residual urine detected on bladder
catheterization
 Some degree of incontinence
 Bladder distention
 Restlessness
• Labs
 Cystography – detects vesicoureteral
reflex
 Urethrography-detects urethral
complications
 BUN, s. crea, creatinine clearance
elevated
 Postvoid catheterization – reveals residual
urine more than 50 ml

COMPLICATIONS
 UTI
 urolithiasis
 vesicoureteral reflux
 Hydronephrosis

MEDICAL MANAGEMENT
• Continuous, intermittent or self-catheterization
• Diet low in calcium(to prevent calculi)
• Mobility and ambulation
• Liberal fluid intake
• Bladder retraining
• Parasympathomimetic medications
• Bethanechol (Urecholine) - increase the contraction of
the detrusor muscle.
• Surgery to correct bladder neck contractures

NURSING MANAGEMENT
• Perform intermittent catheterization usually every 4-6
hours
• Instruct client and family on self-catheterization
• Instruct the client on the proper way to apply and use
an external collecting device (Eg. Condom cath) •
Provide bladder training
• Prevent calculi
 BASE BALANCE FLUIDS &
ELECTROLYTES
ACID-BASE BALANCE
• Governed by the regulation of hydrgen ion
(H+) concentration in the body
• pH = negative logarithm of the H+
concentration
• Acids - proton donors & give up H+
• Bases - H+ acceptors
• Acidic - inc. in concentration of H+
• Basic - dec. in concentration of H+
COMPENSATORY MECHANISMS
• Normal acid-base ration is 1:20 - 1 part
carbonicacid to 20 parts base
• Chemical buffers
• Respiratory Compensation
• Renal Compensation
CHEMICAL BUFFERS
• First line of defense against acid-base
balance
• Consists of weak base or weak acid and its
conjugate salts
4 major buffers:
• Carbonic acid-bicarbonate buffer system
- Most important buffer system
• Hemoglobin-oxyhemoglobin buffer system
- Works within red blood cells
• Other protein buffers
- Work intracellularly and extracellularly
• Phosphate buffer system
- Works primarily in intracellular fluid
RESPIRATORY COMPENSATION
• Second line of defense against acid-base
imbalance
• Changes in CO2 level is detected by the
chemoreceptors in medulla which regulate
depth and rate of ventilation
• PaCO2 reflects carbon dioxide levels
• Higher PaCO2 results in a higher respiratory
rateand depth promoting elimination of CO2
• Lower PaCO2 results in a lower respiratory
rate and depth promoting retention of CO2
RENAL COMPENSATION
• Kidneys regulate the bicarbonate ion
concentration on ECF and excrete acid by
products of metabolism that the respiratory
system cannot eliminate
• Takes hours to days to correct an imbalance
• Acidemia results in renal elimination of
excess hydrogen ions which may combine with
phosphate or ammonia to form titrable acids
• Alkalemia results in renal elimination of
excessbicarbonate ions usually with sodium
ions.
MEASUREMENTS
• Arterial Blood Gas
• pH
RESPIRATORY ALKALOSIS
• Carbonic Acid Deficit
• Characterized by ↓CO2 due to
Hyperventilation
• pH : >7.45
• CO2 : <35mmHg
CAUSES OF RESPIRATORY ALKALOSIS
• Anxiety (hyperventilation)
• Salicylate intoxication (Aspirin overdose) -
stimulatethe respiratory center potentially
leading toHyperventilation.
• Mechanical Ventilation---Rate of tidal Volume
ofvent is excessive
• Hypoxia
• ↑Temperature

NURSING DIAGNOSES: RESPI ALKA
• Anxiety related to cause of respiratory
alkalosis.
• Impaired gas exchange related to alveolar
hyperventilation.
• Ineffective breathing pattern related to deep,
rapidbreathing.
MEDICAL MANAGEMENT
& NURSING INTERVENTIONS
• Institute safety measures for the patient with
vertigo or the unconsciouspatient.
• Encourage the anxious patient to verbalize
fears
• Administer sedation as ordered to relax the
patient
• Keep the patient warm and dry
• Encourage the patient to take deep, slow
breaths or breathe into abrown paper bag
(inspire CO2).
• Monitor vital signs
• Monitor ABGs, primarily PaCO2; a value less
than 35 mmHg indicates toolittle CO2
(carbonic acid)
RESPIRATORY ACIDOSIS
• Carbonic Acid Excess
• pH : <7.35
• CO2 : >42 mmHg
CAUSES OF RESPIRATORY ACIDOSIS
• Depression of Respiratory center
• Lung disease
• Airway obstruction
• Disorders of the chest wall and respiratory
muscles
• Breathing air with high CO2 content
• Chronic Metabolic Alkalosis
• Neuromuscular diseases
CLINICAL MANIFESTATIONS
Sudden hypercapnia (elevated PaCO2):
◦ increased pulse and respiratory rate,
◦ increased blood pressure,
◦ mental cloudiness or confusion, and a
feeling of fullness in the head, or a
decrease in the level of consciousness
An elevated PaCO2:
◦ causes cerebrovascular vasodilation
and increased cerebral blood flow.
◦ Ventricular fibrillation may be the first
sign of respiratory acidosis in
anesthetized patients.
SEVERE respiratory acidosis:
◦ intracranial pressure may increase,
resulting in papilledema and dilated
conjunctival blood vessels.
◦ Hyperkalemia- hydrogen concentration
overwhelms the compensatory
mechanisms and H+ moves into cells,
causing a shift of potassium out of the
cell
NURSING DIAGNOSES:
• Fear related to threat of death.
• Impaired gas exchange related to alveolar
hypoventilation.
• Ineffective breathing pattern related to rapid
shallow respirations.
MEDICAL MANAGEMENT
& NURSINGINTERVENTIONS:
• Institute safety measures
• Assist with positioning
• Monitor I&O and administer fluids as ordered
• Administer oxygen and medications for order;
monitor hourly vital signs and respiratory status
(may require mechanical ventilation)
• Monitor arterial blood gases (ABGs); pH,
PaCO2,HCO3
 METABOLIC ALKALOSIS MEDICAL/ NURSING MGT: META ALKA
• Mild Metabolic Alkalosis may require NO
treatment.
• Base Carbonate Excess • Severe Metabolic Alkalosis includes
• pH : >7.35 administrationof IV Ammonium Chloride
• HCO3 : >26 mEq/L • Potassium chloride and normal saline
solutions(replace gastric losses)
CAUSES: METABOLIC ALKALOSIS • Oral or IV Acetazolamide (enhances renal
• Vomiting bicarbonate excretion)
• Gastric Suctioning • When administering IV solutions containing
• Hypokalemia potassium salts, dilute potassium with
• Drug Induce [ingesting antacids that contain theprescribed IV solution and use an IV
HCO3or administration of HCO3 to treat infusion pump.
metabolicacidosis. • Infuse ammonium chloride 0.9% IV no faster
than 1Lover 4 hours; Faster administration
may cause RBChemolysis. Don’t give
ammonium chloride topatients with hepatic/
renal disease.
• Observe seizure precautions, and provide a
safe environment for the patient with altered
thought process. Orient the patient as needed.
• Irrigate the patient’s NG tube with normal
salinesolution instead of plain water to prevent
loss of gastric electrolytes.

METABOLIC ACIDOSIS
• Base Carbonate Deficit
• pH : <7.35
• HCO3 : <22 mEq/L
CAUSES OF METABOLIC ACIDOSIS
• Diabetes (Diabetic Ketoacidosis-incomplete
oxidation of fatty acids)
• Renal Insufficiency
• Diarrhea, vomiting [loss K+, Na+],
• Lower intestinal fistulas - loss of base

NURSING DIAGNOSES: META ALKA

• Disturbed thought processes related to
neurologic dysfunction.
• Decreased cardiac output related to AV
arrhythmias.
• Risk for injury related to tetany.
 NURSING DIAGNOSES: META ACID
• Disturbed thought processes related to
neurologicdysfunction.
• Decreased cardiac output related to
arrhythmias.
• Ineffective breathing pattern related to
pulmonarydysfunction.

MEDICAL/NURSING MGT
• Acute Metabolic Acidosis, treatment may
include IV administration of Sodium
Bicarbonate.
• Chronic Metabolic Acidosis, treatment may
includeoral bicarbonate.
• Provide care to eliminate the underlying
cause of metabolic acidosis.
• Position the patient to promote chest
expansionand turn him every 2 hours.
• Orient the patient frequently.
 Mgt of Pts with ◦ Ecchymosis- dark purple spot forms on
your skin when blood leaks out of your
Renal & Urinary Disturbances blood vessels into the top layer of your
skin. (larger extravasations of blood.)
CHRONIC RENAL FAILURE ◦ Purpura- purple-colored spots and
◦ When a patient has sustained enough patches that occur on the skin
kidney damage to require renal (haemorrhagefrom small blood vessels)
replacement therapy on a permanent ◦ Thin, brittle nails
basis, the patient has moved into the ◦ Coarse, thinning hair
fifth or final stage of CKD, also referred CARDIOVASCULAR
to as chronic renal failure (CRF) or ◦ Hypertension
ESRD. ◦ Pitting edema (feet, hands, sacrum)
PATHOPHYSIOLOGY ◦ Periorbital edema
◦ End products of protein metabolism ◦ Pericardial friction rub
accumulate in the blood ◦ Engorged neck veins
◦ Uremia develops and adversely affects ◦ Pericarditis
every system in the body ◦ Pericardial effusion
◦ The rate of decline in renal function ◦ Pericardial tamponade
and progression of ESRD is related to ◦ Hyperkalemia
the underlying disorder, the urinary ◦ Hyperlipidemia
excretion of protein, and the presence PULMONARY
of hypertension ◦ Crackles
◦ Thick, tenacious sputum
◦ Depressed cough reflex
◦ Pleuritic pain
◦ Shortness of breath
◦ Tachypnea
◦ Kussmaul-type respirations
◦ Uremic pneumonitis
GASTROINTESTINAL
◦ Ammonia odor to breath (“uremic fetor”)
◦ Metallic taste
◦ Mouth ulcerations and bleeding
◦ Anorexia, nausea, and vomiting
◦ Hiccups
◦ Constipation or diarrhea
◦ Bleeding from gastrointestinal tract
HEMATOLOGIC
◦ Anemia
CLINICAL MANIFESTATIONS ◦ Thrombocytopenia
NEUROLOGIC REPRODUCTIVE
◦ Weakness and fatigue ◦ Amenorrhea
◦ Confusion ◦ Testicular atrophy
◦ Inability to concentrate ◦ Infertility
◦ Disorientation ◦ Decreased libido
◦ Tremors MUSCULOSKELETAL
◦ Seizures ◦ Muscle cramps
◦ Asterixis ◦ Loss of muscle strength
◦ Restlessness of legs ◦ Renal osteodystrophy
◦ Burning of soles of feet ◦ Bone pain
◦ Behavior changes ◦ Bone fractures
INTEGUMENTARY ◦ Foot drop
◦ Gray-bronze skin color
◦ Dry, flaky skin
◦ Pruritus
 ASSESSMENT AND DX FINDINGS
Glomerular Filtration Rate
◦ As the GFR decreases the creatinine
clearance decreases, while the serum
creatinine and BUN levels increase
Sodium and Water Retention
◦ Some patients retain sodium and water,
increasing the risk for edema, heart
failure, and hypertension.
◦ Hypertension may also result from
activation of the renin–angiotensin–
aldosterone axis and the concomitant
increased aldosterone secretion
◦ Other patients have a tendency to lose
sodium
Acidosis
◦ Metabolic acidosis occurs because the
kidneys are unable to excrete
increased loads of acid
◦ Decreased acid secretion results from
the inability of the kidney tubules to
excrete ammonia (NH3-) and to
reabsorb sodium bicarbonate(HCO3–)
Anemia
◦ Anemia develops as a result of
inadequate erythropoietin production,
the shortened lifespan of RBCs,
nutritional deficiencies, and the
patient’s tendency to bleed.
Calcium and Phosphorus Imbalance
◦ With a decrease in filtration through the
glomerulus of the kidney, there is an
increase in the serum phosphate level
and a reciprocal or corresponding
decrease in the serum calcium level.
COMPLICATIONS
◦ Hyperkalemia due to decreased
excretion, metabolic acidosis,
catabolism, and excessive intake (diet,
medications, fluids)
◦ Pericarditis, pericardial effusion, and
pericardial tamponade due to retention
of uremic waste products and
inadequate dialysis
◦ Hypertension due to sodium and water
retention and malfunction of the renin–
angiotensin–aldosterone system
◦ Anemia due to decreased
erythropoietin production, decreased
RBC lifespan, bleeding in the GI tract
from irritating toxins and ulcer
formation, and blood loss during
hemodialysis
◦ Bone disease and metastatic and
vascular calcifications due to retention
of phosphorus, low serum calcium
levels, abnormal vitamin D metabolism,
and elevated aluminum level
MEDICAL MANAGEMENT
◦ Goal: to maintain kidney function and
homeostasis for as long as possible
MEDICAL MANAGEMENT
Pharmacologic Therapy
Calcium and Phosphorus Binders
◦ calcium carbonate or calcium acetate
◦ sevelamer hydrochloride (Renage)
◦Magnesium-based antacids are
avoided to prevent magnesium toxicity
Antihypertensive and Cardiovascular
Agents
◦ Antihypertensive agents
◦ digoxin (Lanoxin) or dobutamine
(Dobutrex)
Antiseizure Agents
◦ IV diazepam (Valium) or phenytoin
(Dilantin)
Erythropoietin
◦ Recombinant human erythropoietin
(Epogen)
◦ administered intravenously or
subcutaneously
◦ ◦ Iron supplements
Nutritional Therapy
◦ Protein is restricted because urea, uric
acid, and organic acids accumulate
rapidly in the blood
 allowed protein must be of high
biologic value (dairy products,
eggs, meats)
◦ Usually, the fluid allowance per day is
500 mL to 600 mL more than the
previous day’s 24-hour urine output
◦ Calories are supplied by carbohydrates
and fat to prevent wasting.
◦ Vitamin Supplementation
Dialysis
◦ usually initiated when the patient
cannot maintain a reasonable lifestyle
with conservative treatment.
NURSING DIAGNOSIS: Excess fluid volume
related to decreased urine output, dietary
excesses, and retention of sodium and water
NURSING INTERVENTIONS
 Assess fluid status:
◦ Daily weight
◦ Intake and output balance
◦ Skin turgor and presence of edema
◦ Distention of neck veins
◦ Blood pressure, pulse rate, and rhythm
◦ Respiratory rate and effort
 Limit fluid intake to prescribed volume.
 Identify potential sources of fluid:
◦ Medications and fluids used to take or
administer medications: oral and
intravenous
◦ Foods
 Explain to patient and family rationale for
fluid restriction.
 Assist patient to cope with the discomforts
resulting from fluid restriction.
 Provide or encourage frequent oral
hygiene.
NURSING MANAGEMENT
NURSING DIAGNOSIS: Imbalanced nutrition:
less than body requirements related to
anorexia, nausea, vomiting, dietary restrictions,
and altered oral mucous membranes
Nursing Interventions
 Assess nutritional status:
◦ Weight changes
◦ Laboratory values (serum electrolyte,
BUN, creatinine, protein, transferrin, and
iron levels)
 Assess patient’s nutritional dietary patterns:
◦ Diet history
◦ Food preferences
◦ Calorie counts
 Assess for factors contributing to altered
nutritional intake:
◦ Anorexia, nausea, or vomiting
◦ Diet unpalatable to patient
◦ Depression
◦ Lack of understanding of dietary
restrictions
◦ Stomatitis
 Provide patient’s food preferences within
dietary restrictions.
 Promote intake of high-biologic-value
protein foods: eggs, dairy products, meats.
 Encourage high-calorie, low-protein, low-
sodium, and low-potassium snacks
between meals.
 Alter schedule of medications so that they
are not given immediately before meals.
 Explain rationale for dietary restrictions
and relationship to kidney disease and
increased urea and creatinine levels.
 Provide written lists of foods allowed and
suggestions for improving their taste
without use of sodium or potassium.
 Provide pleasant surroundings at meal-
times.
 Weigh patient daily.
 Assess for evidence of inadequate protein
intake:
◦ Edema formation
◦ Delayed wound healing
◦ Decreased serum albumin levels
NURSING DIAGNOSIS: Deficient knowledge
regarding condition and treatment
NURSING INTERVENTIONS
 Assess understanding of cause of renal
failure, consequences of renal failure, and
its treatment:
◦ Cause of patient’s renal failure
◦ Meaning of renal failure
◦ Understanding of renal function
◦ Relationship of fluid and dietary
restrictions to renal failure
◦ Rationale for treatment (hemodialysis,
peritoneal dialysis, transplantation)
 Provide explanation of renal function and
consequences of renal failure at patient’s
level of understanding and guided by
patient’s readiness to learn.
 Assist patient to identify ways to
incorporate changes related to illness and
its treatment into lifestyle.
 Provide oral and written information as
appropriate about:
◦ Renal function and failure
◦ Fluid and dietary restrictions
◦ Medications
◦ Reportable problems, signs, and
symptoms
◦ Follow-up schedule
◦ Community resources
◦ Treatment options
NURSING DIAGNOSIS: Activity intolerance
related to fatigue, anemia, retention of waste
products, and dialysis procedure
NURSING INTERVENTIONS
 Assess factors contributing to activity
intolerance:
◦ Fatigue
◦ Anemia
◦ Fluid and electrolyte imbalances
◦ Retention of waste products
◦ Depression
 Promote independence in self-care
activities as tolerated; assist if fatigued.
 Encourage alternating activity with rest.
 Encourage patient to rest after dialysis
treatments.
NURSING DIAGNOSIS: Risk for situational
low self-esteem related to dependency, role
changes, change in body image, and change
in sexual function
NURSING INTERVENTIONS
 Assess patient’s and family’s responses
and reactions to illness and treatment.
 Assess relationship of patient and
significant family members.
 Assess usual coping patterns of patient
and family members.
 Encourage open discussion of concerns
about changes produced by disease and
treatment:
◦ Role changes
◦ Changes in lifestyle
◦ Changes in occupation
◦ Sexual changes
◦ Dependence on health care team
 Explore alternate ways of sexual
expression other than sexual intercourse.
 Discuss role of giving and receiving love,
warmth, and affection.
NURSING MANAGEMENT
1. Hyperkalemia
◦ Monitor serum potassium levels. Notify
physician if level greater than 5.5 mEq/L,
and prepare to treat hyperkalemia.
◦ Assess patient for muscle weakness,
diarrhea, ECG changes (tall tented T
waves and widened QRS)
2. Pericarditis, Pericardial Effusion, and
Pericardial Tamponade
 Assess patient for fever, chest pain, and a
pericardial friction rub (signs of pericarditis)
and, if present, notify physician.
 If patient has pericarditis, assess for the
following every 4 hours:
◦ Paradoxical pulse _10 mm Hg
◦ Extreme hypotension
◦ Weak or absent peripheral pulses
◦ Altered level of consciousness
◦ Bulging neck veins
 Prepare patient for cardiac ultrasound to
aid in diagnosis of pericardial effusion and
cardiac tamponade.
 If cardiac tamponade develops, prepare
patient for emergency pericardiocentesis.
3. Hypertension
 Monitor and record blood pressure as
indicated.
 Administer antihypertensive medications
as prescribed.
 Encourage compliance with dietary and
fluid restriction therapy.
 Teach patient to report signs of fluid
overload, vision changes, headaches,
edema, or seizures.
4. Anemia
 Monitor RBC count, hemoglobin, and
hematocrit levels as indicated.
 Administer medications as prescribed,
including iron and folic acid supplements,
Epogen, and multivitamins.
 Avoid drawing unnecessary blood
specimens.
 Teach patient to prevent bleeding: avoid
vigorous nose blowing and contact sports,
and use a soft toothbrush.
 Administer blood component therapy as
indicated
5. Bone Disease and Metastatic Objectives:
Calcifications ◦ to extract toxic nitrogenous
◦ Administer the following medications as substances from the blood
prescribed: phosphate binders, calcium ◦ to remove excess water
supplements, vitamin D supplements.  Dialyzer serves as a synthetic
◦ Monitor serum lab values as indicated semipermeable membrane, replacing the
(calcium, phosphorus, aluminum levels) renal glomeruli and tubules as the filter for
and report abnormal findings to physician. the impaired kidneys
◦ Assist patient with an exercise program  Principles on which hemodialysis is based:
◦ Diffusion
RENAL REPLACEMENT THERAPIES ◦ Osmosis
◦ Ultrafiltration
 DIALYSIS  The body’s buffer system is maintained
Types: using a dialysate bath made up of
◦ Hemodialysis bicarbonate (most common) or acetate,
◦ CRRT which is metabolized to form bicarbonate.
◦ PD  The anticoagulant heparin is administered
to keep blood from clotting in the dialysis
1. DIALYSIS circuit.
 Acute dialysis is indicated when there Vascular Access Devices
Is High level of serum potassium  Immediate access to the patient’s
◦ fluid overload, or impending pulmonary circulation for acute hemodialysis is
edema achieved by inserting a double-lumen,
◦ increasing acidosis noncuffed, large-bore catheter into the
◦ Pericarditis ◦ Subclavian
◦ severe confusion ◦ Internal
◦ may also be used to remove medications ◦ Jugular
or toxins from the blood ◦ femoral vein
◦ edema that does not respond to other
treatment
◦ hepatic coma
◦ Hyperkalemia
◦ Hypercalcemia
◦ Hypertension
◦ uremia
 Chronic or maintenance dialysis is
indicated in advanced CKD and ESRD
in the following instances:
◦ presence of uremic signs and symptoms
affecting all body systems
◦ Hyperkalemia
◦ fluid overload
◦ not responsive to diuretics and fluid
restriction
◦ general lack of well-being

2. HEMODIALYSIS
◦ Used for patients who are acutely ill and
require short-term dialysis (days to weeks)
and for patients with advanced CKD and
ESRD who require long-term or permanent
renal replacement therapy.
◦ Does not compensate for the loss of
endocrine or metabolic activities of the
kidneys.
Arteriovenous Fistula (AVF) COMPLICATIONS
 preferred method of permanent access  Cardiovascular complications
 created surgically (usually in the forearm) ◦ Heart failure, coronary heart disease,
by anastomosing an artery to a vein, either angina, stroke, and peripheral vascular
side to side or end to side insufficiency
 2 to 3 months to “mature” before it can be  Anemia
used  Gastric ulcers
 Patient is encouraged to perform hand  Bone pain and fracture
exercises to increase the size of the  Sleep problems
vessels (ie, squeezing a rubber ball for  Other complications of dialysis treatment
forearm fistulas) to accommodate the may include:
large-bore needles. ◦ Episodes of shortness of breath
◦ Hypotension
◦Nausea and vomiting, diaphoresis,
tachycardia, and dizziness
◦ Painful muscle cramping
◦ Exsanguination
◦ Dysrhythmias
◦ Air embolism (rare)
◦ Chest pain
◦ Dialysis disequilibrium - results from
cerebral fluid shifts.

Arteriovenous Graft
 can be created by subcutaneously
interposing a biologic, semibiologic, or
synthetic graft material between an artery
and vein
 a graft is created when the patient’s
vessels are not suitable for creation of an
AV fistula
 Common complications: NURSING MANAGEMENT
◦ Stenosis Promoting Pharmacologic Therapy
◦ Infection ◦ Monitor patients with ongoing medications
◦ thrombosis to ensure that blood and tissue levels of
these medications are maintained without
toxic accumulation.
◦ Educate patient as to when and when not
to take their meds (especially
antihypertensives)
Promoting Nutritional and Fluid Therapy
◦ Restrict dietary protein (1.2 to 1.3 g/kg
ideal body weight per day)
◦ Restrict fluids (amount equal to the daily
urine output plus 500 mL/day)
◦ Restrict sodium ( 2 to 3 g/day)
◦ Potassium restriction (depends on the
amount of residual renal function and the
frequency of dialysis)
Meeting Psychosocial Needs
◦ Give the patient and family the opportunity
to express feelings of anger and concern
about the limitations that the disease and
treatment impose, possible financial
problems, and job insecurity
◦ Counseling and psychotherapy
◦ Administer antidepressants as indicated
◦ Refer patient to a mental health provider
◦ Patients and their families should be
encouraged to discuss end-of-life options
and have developed advanced directives
or living wills.
CONTINUOUS RENAL REPLACEMENT
THERAPIES
 may be indicated for patients with acute or
chronic renal failure who are too clinically
unstable for traditional hemodialysis,
◦ for patients with fluid overload
secondary to oliguric renal failure
◦ for patients whose kidneys cannot
handle their acutely high metabolic or
nutritional needs.
 does not require dialysis machines or
dialysis personnel to carry out the
procedures, and can be initiated quickly
 A hemofilter (an extremely porous blood
filter containing a semipermeable
membrane) is used in all types.

3. PERITONEAL DIALYSIS
Goals of PD:
◦ to remove toxic substances and
metabolic wastes
◦ To reestablish normal fluid and
electrolyte balance
 may be the treatment of choice for patients
with renal failure who are unable or
unwilling to undergo hemodialysis or renal
transplantation.
 Peritoneal membrane that covers the
abdominal organs and lines the abdominal
wall serves as the semipermeable
membrane
 Sterile dialysate fluid is introduced into the
peritoneal cavity through an abdominal
catheter at intervals
 Usually takes 36 to 48 hours to achieve
what hemodialysis accomplishes in 6 to 8
hours.
 NURSING MANAGEMENT OF Caring for the Catheter Site
THE HOSPITALIZED PATIENTON DIALYSIS  Instruct pt on proper care of catheter site

Administering Medications
Protecting Vascular Access
 Monitor all drugs taken by pt during
 Assess the vascular access for patency
dialysis
 Take precaution to ensure that the
extremity with the vascular access is not
Providing Psychological Support
used for measuring blood pressure or for
 Provide opportunities for patients to
obtaining blood specimens
express their feelings and reactions and to
 Assess for bruit over the venous access
 explore options; refer to psychologists,
site every 8 hours
counselors, spiritual advisors as needed.
 Observe for signs and symptoms of
infection in the access site
UROLITHIASIS AND NEPHROLITHIASIS
 Assess the integrity of the dressing and
 UROLITHIASIS AND NEPHROLITHIASIS
change it as needed
 refer to stones (calculi) in the urinary tract
and kidney
Taking Precautions During Intravenous
 occurrence of urinary stones occurs
Therapy
predominantly in the third to fifth decades
 Regulate IV fluids (usually slow)
of life and affects men more than women
 Monitor Intake and Output
 About half of patients with a single renal
stone have another episode within 5 years
Monitoring Symptoms of Uremia
 Monitor patients whose metabolic rate
accelerates accumulate waste products
more quickly

Detecting Cardiac and Respiratory

Complications
 Assess for signs of pulmonary edema
 Assess for signs of pericarditis

Controlling Electrolyte Levels and Diet

 Check serum electrolyte levels
 Monitor dietary intake

Managing Discomfort and Pain

 Administer antihistamine and analgesics
as ordered
 Keep pt’s skin clean and well moisturized
 Teach the patient to keep the nails
trimmed to avoid scratching and
excoriation
PATHOPHYSIOLOGY
Monitoring Blood Pressure  Stones are formed in the urinary tract
 Monitor BP when urinary concentrations of substances
 Teach patient about antihypertensive meds such as calcium oxalate, calcium
 Antihypertensive agents must be withheld phosphate, and uric acid increase
before dialysis to avoid hypotension  Stone formation not clearly understood,
theories about their causes:
Preventing Infection  deficiency of substances that normally
 Prevent infection prevent crystallization in the urine, such as
citrate, magnesium, nephrocalcin
 fluid volume status of the patient
 Certain factors favor the formation of MEDICAL MANAGEMENT
stones:  Fluids
◦ Infection  Antimicrobial agents
◦ urinary stasis  Opioid analgesics
◦ periods of immobility  Diuretics
 Calcium stones (75%)- Increased calcium  Low-calcium diet
concentrations in the bld and urine  Oxalate-binding cholestyramine (Questran)
 Uric acid stones (5% to10%) -in patients  Parathyroidectomy
with gout or myeloproliferative disorders  Allopurinol (Zyloprim)
 Struvite stones (15%) -persistently  Daily small doses of ascorbic acid
alkaline, ammonia rich urine caused by the  Percutaneous Ultrasonic lithotripsy
presence of urease-splitting bacteria such  Extracorporeal shockwave lithotripsy
as Proteus, Pseudomonas, Klebsiella, (ESWL)
Staphylococcus, or Mycoplasma
 Cystine stones (1% to 2% ) -exclusively
in pts with a rare inherited defect in renal
absorption of cysteine
 Several conditions as well as certain
metabolic risk factors
◦ Anatomic derangements
◦ inflammatory bowel disease and in
those with an ileostomy or bowel
resection because these patients
absorb more oxalate.
 Medications known to cause stones:
◦ Antacids
◦ Acetazolamide (Diamox)
◦ vitamin D
◦ laxatives
◦ high doses of aspirin
CLINICAL MANIFESTATIONS
 Mild to severe flank pain
 Nausea
 Vomiting
 Fever and Chills
 Hematuria
 Abdominal distension
 Urinary frequency
 Urinary hesitancy
 Dysuria
 Anuria
ASSESSMENT AND DIAGNOSTIC
FINDINGS
◦ X-ray of KUB
◦ UTZ of KUB
◦ IV urography
◦ Retrograde pyelography
◦ 24-hour urine test for measurement of
calcium, uric acid, creatinine, sodium, pH,
and total volume
◦ Dietary and medication histories
◦ family history of renal stones
◦ Stone analysis
 NURSING MANAGEMENT
 Monitor intake and output
 Strain urine through gauze or a tea strainer
and save for analysis
 Encourage pt to walk and promote intake
of fluids to maintain a urine output of 2-4
L/day
 Offer fruit juices (cranberry)to acidify urine
 Stress importance of proper diet and
compliance of drug therapy
 Prepare pt for surgery
 Check dressings regularly
 Watch for signs of infection