Fluid and

Electrolytes
kidneys
• Are bean-shaped organs outside the
peritoneal cavity
• Right lower than the left
• N e p h r o n s - functional unit of the kidney
• Contains the g l o m e r u l u s
• Regulate the concentration of water and
soluble substances like sodium salts by
filtering the blood, reabsorbing what is
needed and excreting the rest as urine
• Eliminates wastes from the body
• Regulates blood volume and pressure
• Controls levels of electrolytes and
metabolites
• Regulates blood pH
Tests for renal function
Urinalysis
General
Characteristics
Color: Yellow - amber
Turbidity: clear to slightly
hazy
SG: 1.010 – 1.025
pH: 4.6 – 6.8 (average 6.0)
Chemical
Determinations
Urobilirogen: 0.1 – 1
NEGATIVE for glucose,
ketones, CHON and bilirubin
N E G A T I V E for nitrate for
bacteria and leukocyte esterase

Microscopy
N E G A T I V E for casts,
RBCs, crystals, WBCs and
few epithelial cells
Tests for renal function
Glomerular filtration rate Blood urea nitrogen
- Gauge for renal function
2.9-7.1mmol/L
- Used clearance for creatinine
- Normal creatinine clearance: - 2/3 of renal function must be
115-125mL/min lost before significant rise in
serum BUN
Blood tests: - Less sufficient to determine
S e r u m c r e a t i n i n e 50- renal sufficiency
100mmol/L
-Reflect GFR
-Higher GFR, lower percentage of
renal function
Tests for renal function
• Cystoscopy
• Ultrasonography
• Radiologic/and
imaging studies
Disorders of fluid and electrolytes balance
Factors influencing amount of body fluid

1. Age younger > older

2. Sex men > women
3. Body fat obese > thin
 Compartmental distribution of body fluids
Intracellular fluid (ICF)
• 2/3 of total body fluid
• Primarily in the skeletal muscle
mass

Extracellular fluid (ICF)

1. Intravascular (eg. Plasma)
2. Interstitial (eg. Lymph)
3. Transcellular (eg. CSF, pericardial
fluid, synovial, intraocular fluid)
 SOLUTES – Dissolved Particles

• Electrolytes – charged particles BALANCE:

 Cations – positively charged ions
 Na+, K+, Ca++, H+ Hydrostatic Pressure
 Anions – negatively charged VS. Osmotic Pressure
 Cl-, HC03-, P043-
• Non-electrolytes – uncharged
 Proteins, urea, glucose, O2,
CO2
 Developmental and Biological
Considerations
• Infants younger than 6 weeks do not produce tears
• In an infant, a sunken fontanel may indicate
dehydration
• Infants are dependant on others to meet their fluid
needs
• Infants have limited ability to dilute and concentrate
urine
 F and E Assessment
Physical Exam
• Assess skin, edema, skin dryness, mucous
membrane, conjunctiva
• VS – respiratory rate in response to hypoxia
• Altered mental status – confusion, lethargic etc
• Neuromuscular assessment of muscle tone and
strength, movement, coordination and tremors
• Cardiovascular – orthostatic hypotension
• Renal – weight loss, I&O
 F and E Assessment
Laboratory & Diagnostics
• Hemoconcentration
– Elevated haemoglobin
– Hematocrit
– Glucose
– Protein
– Blood urea
 F and E Assessment
• Mental Status – change in mental status,
confusion, poor memory, anxious, restless,
disoriented etc. More obvious with hypertonic and
hypotonic dehydration because of ICF shifts in brain
cells, shrinkage or swelling of cells
• Assess other systems – cardiac,
dysrhythmias, GI – increase peristalsis
• Fluid loss – results in decrease blood volume
results in decrease oxygen level (hypoxia) and
increased respiratory rate to increase oxygen delivery
F and E Assessment
Fluid volume disturbances
Fluid Volume Deficit
(Hypovolemia)
• Water and electrolyte loss
• Dehydration – water loss ONLY with Na+ elevation
Etiology:
• Decrease fluid intake
• Abnormal losses
– Vomiting
– Diarrhea
– GI suctioning
Fluid Deficits
3 types of Dehydration
• Isotonic – fluid and electrolyte loss equally;
decline in circulating blood volume
• Hypertonic – fluid loss exceeds loss of
electrolytes
• Hypotonic – electrolytes loss exceeds loss of
water
Fluid Volume Deficit
(Hypovolemia)
Clinical Manifestations:
• Acute weight loss • Cool, clammy skin
• Poor skin turgor • Thirst, anorexia
• Oliguria • Lassitude
• Urine Concentration
• Muscle weakness
• Postural hypotension
• Cramps
• Weak, rapid pulse
• Flattened neck veins
• Elevation of T waves
Fluid volume disturbances
Fluid Volume Excess
(Hypervolemia)
• Isotonic expansion of the ECF
Etiology:
• Abnormal water and sodium retention
• Increase in total body sodium content causing
increase in water content
• Serum sodium levels remain normal
Fluid Excess
3 types of Overhydration
• Isotonic – Only ECF is expanded
• Hypertonic – excessive Na+ intake; fluid shifts
from ICF to ECF
• Hypotonic – water intoxication; life
threatening; fluid moves in ICF and all
compartment expands
ELECTROLYTE
IMBALANCES
Acid base
imbalances
Disorders of Renal Function

Infection (UTI)
Obstructive Disorders
Glomerular Dysfunction
Tubulointerstitial Disorders
CONGENITAL DISORDERS OF THE KIDNEY
• Agenesis and hypoplasia
Agenesis is the complete failure of organ to develop.
Total agenesis of both kidneys is incompatible with
extrauterine life
Hypoplasia the kidneys do not develop to normal size

• Alterations in kidney position and form. Ex.

Horseshoe kidney
Urinary Tract Infection (UTI)
• Infection of the genitourinary tract is one of the most
common conditions of childhood
• Occur in 1-3% of girls and 1% of boys.
• In girls, the first UTI usually occurs by the age of 5 yr,
with peaks during infancy and toilet training.
• In boys, most UTIs occur during the 1st yr of life; UTIs
are much more common in uncircumcised boys,
especially in the 1st year of life.
ANATOMIC AND PHYSICAL FACTORS
• The structure of the lower urinary tract is believed to
account for the increased incidence of bacteriuria in
females
• The short urethra, which measures about 2 cm (0.75
inch) in young girls and 4 cm (1.6 inches) in mature
women, provides a ready pathway for invasion of
organisms. In addition, the closure of the urethra at the
end of micturition may return contaminated bacteria to
the bladder.
• The longer male urethra (as long as 20 cm [8 inches] in
an adult) and the antibacterial properties of prostatic
secretions inhibit the entry and growth of pathogens
The 3 basic forms of UTI are:

• Pyelonephritis
• Cystitis
• Asymptomatic
bacteriuria
Pyelonephritis
• Pyelonephritis is characterized by any or all of
the following:
• abdominal, back, or flank pain; fever; malaise;
nausea; vomiting; and, occasionally, diarrhea.
Fever may be the only manifestation.
• Newborns can show nonspecific symptoms
such as poor feeding, irritability, jaundice, and
weight loss.
• Pyelonephritis is the most common serious bacterial
infection in infants <24 mos of age who have fever
without an obvious focus.
• These symptoms are an indication that there is
bacterial involvement of the upper urinary tract.
• Involvement of the renal parenchyma is termed
acute pyelonephritis, whereas if there is no
parenchymal involvement, the condition may be
termed pyelitis.
• Acute pyelonephritis can result in renal injury,
termed pyelonephritic scarring.
Cystitis
• Cystitis indicates that there is bladder
involvement; symptoms include dysuria,
urgency, frequency, suprapubic pain,
incontinence, and malodorous urine.
• Cystitis does not cause fever and does not
result in renal injury.
Factors Predisposing to Development
• Short female urethra close
to vagina and anus
• Incomplete emptying
(reflux) and overdistention
of bladder
• Concentrated urine
• Constipation
Diagnostic Evaluation
• Clean-catch technique
• Suprapubic aspiration
• Catheterization
CLINICAL MANIFESTATIONS
Neonatal Period (Birth–1 Month)
• Poor feeding
• Vomiting
• Failure to gain weight
• Rapid respiration (acidosis)
• Respiratory distress
• Spontaneous pneumothorax or
pneumomediastinum
• Frequent urination
• Screaming on urination
• Poor urine stream
• Jaundice
• Seizures
• Dehydration
• Other anomalies or stigmata
• Enlarged kidneys or bladder
Infancy (1–24 Months)
• Poor feeding
• Vomiting
• Failure to gain weight
• Excessive thirst
• Frequent urination
• Straining or screaming on
urination
• Foul-smelling urine
• Pallor
• Fever
• Persistent diaper rash
• Seizures (with or without fever)
• Dehydration
• Enlarged kidneys or bladder
CLINICAL MANIFESTATIONS
Childhood (2–14 • Swelling of face
Years) • Seizures
• Poor appetite • Pallor
• Vomiting • Fatigue
• Growth failure • Blood in urine
• Excessive thirst • Abdominal or
• Enuresis, back pain
incontinence, • Edema
frequent • Hypertension
urination
• Tetany
• Painful urination
THERAPEUTIC MANAGEMENT
The objectives of treatment of children with UTI are to:
(1) eliminate current infection
(2) identify contributing factors to reduce the risk of
recurrence
(3) prevent systemic spread of the infection, and
(4) preserve renal function

• Antibiotic therapy should be initiated on the basis of

identification of the pathogen, the child’s history of
antibiotic use, and the location of the infection
Health Teachings
• Practice perineal hygiene: wipe from front to back.
• Avoid tight clothing or diapers; wear cotton panties rather
than nylon.
• Check for vaginitis or pinworms, especially if child scratches
between legs.
• Avoid “holding” urine; encourage child to void frequently,
especially before long trips or other circumstances in which
toilet facilities are not available.
• Empty bladder completely with each void. Have the child
“double void” (void, wait a few minutes, and void again).
Severe cases may require clean, intermittent catheterization
or biofeedback instruction.
• Avoid straining during defecation and avoid constipation.
• Encourage generous fluid intake.
 Obstruction Disorders
• Structural or functional abnormalities of the
urinary system that obstruct the normal flow of
urine can produce renal disorders. When there is
interference with urine flow, the backup of urine
above the obstruction causes hydronephrosis
(dilation of the renal pelvis from distention) with
eventual pressure destruction of renal
parenchyma, although the dilating ureters form a
reservoir that reduces the effect on the kidneys for
a long time
MECHANISMS OF RENAL DAMAGE
1. Degree of Damage
• Complete vs. Incomplete
• Unilateral vs. Bilateral

2. Duration of Obstruction
Damaging Effects:
1. Urinary Stasis
• High risk for infection
2. Backpressure
Development
• Interferes with renal
blood flow and destroys
kidney tissue
MANIFESTATIONS
1. Pain
• Secondary to bladder, renal capsule or collecting
system distention
• SITE: flank area (obstruction of renal pelvis or
ureter), testes/labia (obstruction is lower)
• Hypertension
2. S/Sx of UTI
3. Renal dysfunction (inability to concentrate urine)
 Glomerular Injury
NEPHROTIC SYNDROME
• a clinical state that includes massive proteinuria,
hypoalbuminemia, hyperlipidemia, and
edema
• characterized by increased glomerular permeability
to plasma protein, which results in massive urinary
protein loss
The disorder can occur as:
(1) a primary disease known as idiopathic nephrosis,
childhood nephrosis, or minimal-change nephrotic
syndrome (MCNS);
(2) A secondary disorder that occurs as a clinical
manifestation after or in association with
glomerular damage that has a known or presumed
cause; or
(3) a congenital form inherited as an autosomal
recessive disorder.
Causes of nephrotic syndrome include:
• lipid nephrosis
• glomerulonephritis
• metabolic diseases such as diabetes mellitus
• collagen-vascular disorders such as SLE
• circulatory diseases, such as heart failure, sickle cell
anemia, and renal vein thrombosis
• nephrotoxins, such as mercury, gold, and bismuth
• allergic reactions
DIAGNOSTIC EVALUATION
• massive proteinuria (higher than 2+ on urine
dipstick)
• Hyaline casts, oval fat bodies, and a few red blood
cells (RBCs) can be found in the urine
• GFR is usually normal or high
• Total serum protein concentration is low
• serum albumin significantly reduced
• plasma lipids elevated
CLINICAL MANIFESTATIONS
• Weight gain -Poor intestinal absorption
• Puffiness of face (facial edema): • Ankle or leg swelling
-Especially around the eyes • Irritability
-Apparent on arising in the • Easily fatigued
morning • Lethargic
-Subsides during the day • Blood pressure normal or
• Abdominal swelling (ascites) slightly decreased
• Pleural effusion • Susceptibility to infection
• Labial or scrotal swelling • Urine alterations:
• Edema of intestinal mucosal, -Decreased volume
possibly causing: -Frothy
-Diarrhea
-Anorexia
THERAPEUTIC MANAGEMENT
• Objectives of therapeutic management include (1)
reducing excretion of urinary protein, (2) reducing fluid
retention in the tissues, (3) preventing infection, and (4)
minimizing complications related to therapies. Dietary
restrictions include a low-salt diet and, in more severe
cases, fluid restriction. If complications of edema
develop, diuretic therapy may be initiated to provide
temporary relief from edema. Sometimes infusions of
25% albumin are used. Acute infections are treated with
appropriate antibiotics.
• Corticosteroids are the first line of therapy for MCNS
Nursing Interventions:
• Maintain fluid balance and monitor for signs of fluid volume
excess, such as edema, ascites, weight gain, decreased and
concentrated urine, and pulmonary congestion.
• Assess for signs of electrolyte imbalance—cardiovascular,
neurologic, GI, and skin changes—and work with the health
care providers to correct imbalances that may exist
• Assess general nutritional status and work to improve it by
providing a diet the child will eat (with sufficient protein and
other nutrients and without excess sodium). Parents can help
with this, too, by bringing in food from home that the child
likes, as long as it fits within the child’s dietary restrictions.
• Assess for adverse effects of medications, and report them to
the health care provider as soon as possible
 Glomurelar Injury
CATEGORIES:
• The NEPHRITIC SYNDROMES evokes an inflammatory
response in the glomeruli
CHARACTERISTICS:
1. Hematuria with red cell casts
2. Diminished GFR
3. Oliguria
4. Hypertension
5. Azotemia (presence of nitrogenous wastes on
blood)
 Glomurelar Injury

EXAMPLES:
1. Acute Glumerulonephritis
2. Chronic Glumerulonephritis
3. IgA Nephropathy
 Tubulointerstitial Disorders
• Diseases affecting the renal tubular structures;
including the proximal and distal convoluted tubules
• Also affects the interstitial tissues that surround the
tubules
EXAMPLES
1. Acute tubular necrosis
2. Renal tubular acidosis
3. Pyelonephritis
4. Effects of drugs and acute hypersensitivity
 Tubulointerstitial Disorders
ACUTE
• Sudden onset
• Interstitial edema
• Examples: pyelonephritis, acute hypersensitivity to drugs
CHRONIC
• Produces interstitial fibrosis, atrophy, mononuclear
infiltrates
• Commonly manifests as electrolyte imbalances reflecting
subtle changes in tubular function (inability to
concentrate urine, metabolic acidosis, diminished
reabsorption of Na and other substances)