ALTERED ELIMINATION- MULTI SYSTEM From glomerulus -> Bowman’s capsule ->

PROBLEM proximal convoluted tubule -> loop of henly ->

distal convoluted tubules -> collecting duct
FLUID
Renal System:

Anatomy and Physiology:

Kidneys – two small, but mighty bean-shaped

organs that remove excess fluid and waste
products from the body. (R-kidney is lower
than L-kidney because of liver)

Layers:

Filtration -> reabsorption -> secretion ->

excretion
Inner to outer:
REABSORPTION
Renal medulla, renal cortex, renal capsule,
adipose capsule (perirenal fat), renal fascia, PCT – Na, Cl, K, glucose, amino acids, urea,
pararenal fat bicarbonate. H2O
Renal protection: LOH – (descending: h2o; ascending: Na, Cl, K)
Capsule – tough fibrous connective tissue layer DCT – Na, Cl, K, Mg, Ca, Bicarbonate
that covers the outside of each kidney.
(Composed primarily of collagen and elastin) CD – Na, Cl, Urea, H2o

Perirenal fat SECRETION

Fascia – wraps around the whole kidney to the
vena cava
NOTE: HOW MANY LITERS OF BLOOD DOES
KIDNEY FILTER EACH DAY: 142L OF BLOOD (but
only 2L becomes urine)
Urine Formation:
PCT – Creatinine, drugs, H
DCT – H, K
URINE – 95% h2o, nitrogenous waste, ions,
metabolites, wbc and rbc (low levels)
RENAL ASSESSMENT:
“Kidneys filter and remove” Hyponatremia (<130) – usually asymptomatic

Obvious signs – gross hematuria (blood in Treatment: increase by 0.5 mEq/hr (if seizures
urine), complaints of flank pain is present = increase by 2.4 mEq/hr)

Signs require more assessment – edema, CHEM-8 (Potassium [K+]) – 3.5-5 mEq/L
Hypertension, Signs and symptoms or uremia
Special role for: muscle contraction, fluid
Silent (asymptomatic) signs – Elevated serum balance, nerve transmission
creatinine, abnormal urinalysis results
Check: https://youtu.be/LJai9zjFnTs for chem-8
(Read more on acute kidney injury (AKI) or
acute renal failure (ARF) or chronic renal
➢ CMP – Comprehensive Metabolic Panel
disease)
- Test for liver function
Early identification = Safety - Test for Alkaline Phosphate, AST, ALT,
Bilirubin, Total protein, albumin
- Monitoring and screening of pt’s kidney
function can identify problems earlier
and allow for intervention to slow the
progression of kidney disease
- When disease or damage is discovered,
additional testing is a priority to
determine the degree of damage
and/or progression

DIAGNOSTIC EXAMS

Metabolic Panels – assess electrolytes, kidney

function, and liver function

2 Types:

➢ BMP – Basic Metabolic Panel

- Test for electrolytes and kidney
function
(chem 8)

CHEM-8 (Sodium [Na+]) – 135-145 mEq/L

- Maintain serum osmolality

- H2o/ion shifts
- Higher concentration in blood vs. cells

Hypernatremia (>145-150)

Treatment: correct water balance = lower by

0.5-1 mEq/L
URINALYSIS
- Is a commonly ordered panel of test on
a urine sample
- Gross inspection = color and turbidity
- Dipstick = specific gravity, pH, glucose,
Heme, Protein, Leukocyte esterase,
Nitrites, Ketones, Bilirubin
- Microscopy = WBCs, RBCs, bacteria,
crystals, casts
Gross Inspection
Color – can be influenced by medical
conditions, medications, and ingested food.
RED – medical conditions: bleeding
Orange – Hyperbilirubinemia (Liver disease);
rifampin
Brown/Black – If severe = red/orange urine is
concentrated enough
Green – UTIs, methylene blue, ingestion of blue
dyes
Purple – infected urinary catheters
White – Hypercalciuria, chyluria
Turbidity – how cloudy a urine is
- May indicate the presence of UTI; do
not base the turbidity for the presence
or absence of UTI
DIPSTICK
- Assessment of contents of urine
Specific gravity (n= 1.001-1.035)
- density of urine/density of water
Usually around 1.010
SG closer to 1.001 = urine more dilute than
normal (excessive hydration, diabetes insipidus)
SG closes to 1.035 = dehydration (SIADH,
impaired perfusion or CHF)
SG fixed at 1.010 regardless of dehydration or
excessive hydration
➢ advanced kidney failure
urine pH – 4.5-8.0
when kidneys are functioning normally:
excrete more H+ in acidemia (lower pH <5)
excrete less H+ in alkalemia (higher pH 7-8)
➢ helpful in diagnosing tubular acidosis
➢ monitoring urine alkalinization
➢ differentiation of different types of
kidney stones
Glucose
- glucose in urine is called glucosuria (if
severe, can lead to osmotic diuresis and
dehydration)
Heme
- dipstick highly sensitive for hemoglobin
- also detects myoglobin
Detectable Heme
- Hematuria
Protein
- Most sensitive for albumin
Detectable protein
- Glomerular disease
- Overflow proteinuria
- Post-renal proteinuria
Leukocyte Esterase and Nitrites
- Used to aid in diagnosis of UTIs
- Leukocyte esterase = qualitative
measure of WBC in urine
- Nitrites detect enterobacteriacae
Ketones
Detectable Ketones
- Ketoacidosis (diabetic, alcoholic,
starvation)
- Ketogenic diet
BLOOD TESTS
Creatinine – chemical waste of muscle
metabolism
- Assess renal (kidney) function
- Impaired kidney = inc. creatinine
- Inversely proportional to GFR
GFR (glomerular filtration rate) – a more
specific measure of CKD (chronic kidney
disease)
eGFR (estimated GFR)
GFR > 60 = normal
GFR < 60 = may indicate kidney disease
GFR < 15 = medically defined as kidney failure
Note: In calculation of CFR:
- Creatinine level must be stable
- Not as accurate in AKI or dialysis
- Not valid for pts <18 yrs old
IVU (Intravenous Urography)
- Radiological investigation of the urinary
tract following injection of water-
soluble contrast media (contrast media
administered in the vein of the arm)
Indication:
➢ Hematuria, suspected renal calculi,
suspected transitional cell carcinoma,
suspected ureteric obstruction, flank
pain
Contraindication: depends of renal function
➢ Renal failure (cannot excrete contrast
media)
➢ Multiple myeloma
➢ Elevated creatinine levels (>200)
➢ Risk of severe contrast media reaction
➢ Pregnancy
Contrast Media:
➢ Water-soluble Non-ionic LOCM (350-
370mgl/ml). Average volume of 50mL
Preparation:
➢ Bowel preparation (use laxatives 2 days
before exam)
➢ Fluid restriction (avoid fluids 2-3 hrs
before exam)
➢ Empty bladder
Technique:
➢ Patient is placed supine
➢ Contrast media injected in MEDIAN
CUBITAL VEIN
When not to use compression
➢ Suspected renal calculi
➢ Suspected abdominal aorta aneurysm
➢ Pain
➢ Recent surgery
➢ Trauma
Alternatives for compression
➢ High dose contrast media
➢ Trendelenburg position
Aftercare:
➢ Cannula is removed and pressure
applied to prevent bleeding
➢ Pt. is advised to drink sufficient water
Complications:
➢ Contrast media reactions
➢ Burning sensation in arm
Special Considerations:
➢ Emergency IVU – no bowel preparation
and fluid restriction; inc. contrast media
amt. to compensate
ACUTE KIDNEY INJURY (AKI)
➢ Abrupt loss of kidney function
➢ Retention of urea
➢ Dysregulation of extracellular volume
Oliguria - <500mL urine output in 24h
Anuria <100mL urine output in 24h (essentially
not producing urine)
➢ High mortality rates
Causes:
PRERENAL – dec. pressure and/or blood to
kidneys / any problems in perfusion
- Dec. cardiac output: Cardiac problems
- Shock
- Dehydration/diuresis/diarrhea/
hemorrhage
- 3rd spacing: cirrhosis ->splanchnic
vasodilation
- Artery obstruction
- Drugs: ACEi/ARB; NSAIDs
INTRARENAL – Direct damage to kidneys
- Glomerular
- Tubular
- Tubulointerstitial: drugs
- Vascular
POSTRENAL – obstruction of urine flow
- Calculi
- Malignancy
- BPH
- Urethral strictures
PRERENAL vs INTRARENAL/RENAL
MANAGEMENTS FOR AKI: DURING (Cont.)

➢ Labs: Creatinine, BUN, eGFR ➢ Give supplemental vitamins (but usually

AFTER) – the problem if given during,
Goals:
vitamins can still be eliminated.
1. Treat the cause
Peritoneal Dialysis – patient is usually stable;
2. Manage the effects (symptoms)
almost never given to AKI (because it is usually
➢ Patient is having retention (fluids and
SLOW)
metabolic waste products) – Renal
replacement
RENAL REPLACEMENT TYPES:
AKI Medications:
- Hemodialysis (1) most common
- Peritoneal Dialysis – associated w/ CKD ➢ Diuretics – offer symptomatic relief
- CRRT – for critically ill patients - Furosemide – manages the symptoms
but no effect on the disease itself
Hemodialysis:
➢ Inotropic Agents – both dopamine and
BEFORE: dobutamine if given together, inc.
contraction of heart and inc. renal
➢ Check BP – due to removal of fluids, BP
function (INC. BP)
is usually low (a normal or higher than
- Dopamine (1st choice)
normal is acceptable)
- Dobutamine (2nd choice)
➢ Monitor Labs (BUN)
➢ Weight – how big is the fluid loss NOTE: Titrated (Order: “Start dobutamine
➢ Dialysis site – check for bleeding (if premixed 500mcg/250mL @15cc/hr with
soaked ang pads); check for bruits and the following titrations: titrate at
thrills (if absent, vessels not patent or increments/decrements of 5cc/hr for BP
presence of clots) above or below 120mmHg every 15 mins)
➢ Hold Medications:
- If BP is less than 120, inc. the dose
- Anti-hypertensives and diuretics (lowers
- If BP is higher than 120, dec. the dose
BP)
- Antibiotics, Water-soluble vitamins
(eliminated during dialysis, usik)

DURING:

➢ Disequilibrium syndrome – Patient may

experience headache; rapid removal of
fluids in the body causes shifting in the
brain. NOTE: patients may experience
SEIZURES
➢ Hypertension/Hypotension – due to
rapid removal of fluid
mngt:
Hypotension - lay pt. flat in bed, reverse
trendelenberg
Hypertension – raise head of the pt
 Recent 2 medications that shows positive
effects for AKI:
➢ ANP (hormone) – improve kidney
function; stimulate excretion of Na and
H2O
➢ Norepinephrine (vasoconstriction) –
though it causes vasoconstriction, it
improves kidney function
EMERGENCY DIALYSIS: Possible reasons for pts
w/ AKI
➢ Hyperkalemia – due to cardiac effects
(may cause death of the pt)
➢ Pulmonary edema
➢ Profound acidosis
➢ Severe uremia – BUN-Creatinine ratio
inc. (n=10:1), if 30,40,50:1, it is now a
problem
NOTE: Watch out for dehydration (during
diuretic phase)
CHRONIC KIDNEY DISEASE
Kidney damage
➢ pathological abnormalities
➢ Clinical Markers of kidney damage:
o Proteinuria
- >150 mg of proteinuria per day
- >30 mg of albuminuria per day
o Glomerular hematuria
- Dysmorphic RBCs or RBC casts
o Imaging
- Polycystic kidneys
- Hydronephrosis
- Small kidneys with thinned cortices
ESRD: Common Causes
➢ DM nephropathy
➢ Hypertension
➢ AKI
SHOCK
COMMON INTERVENTIONS
➢ 1st = O2 (Airway)
- intubate due to possible acidosis, dec.
LOC (impending respiratory failure)
- check ABG before intubation
- If patient is conscious = sedate the pt.
before intubation (cardio safe =
ketamine)
➢ FLUIDS (may be contraindicated for
other types of shock)
- Immediately give fluids during
hypovolemic shock
NOTE: DO NOT GIVE FLUIDS FOR PT
UNDERGOING CARDIOGENIC SHOCK; For any
type of shock (anaphylactic or septic), fluids
may be given
- Safest is ISOTONIC (Plain NSS, lactated
ringers)
- IV – large bore needles (to prepare for
the possibility of blood transfusion,
many side drips in a single line)
NOTE: If suspected cardiogenic but there is no
problem in L ventricles – FLUID CHALLENGE –
give 250mL/min to check for status
➢ Medications
- Vasopressors – to increase the BP
- Inotropes – for cardiogenic shock (check
video)
- Anaphylactic Shock – Epinephrine,
corticosteroids, and
immunosuppressants (cyclosporine)
- Septic Shock – Empiric antibiotics
(broad spectrum); can also use narrow
spectrum (depends on common
microbes in a specific area that caused
the septic shock)
➢ IDENTIFY AND TREAT THE CAUSE