RENAL AND HEALTH

PROBLEMS
Renal and Urinary Systems
 The urinary system—the structures of which
precisely maintain the internal chemical
environment of the body—perform various
excretory, regulatory, and secretory functions
Functions
 to maintain the body’s state of homeostasis
by regulating fluid and electrolytes, removing
wastes, and providing hormones involved in
red blood cell production, bone metabolism,
and control of blood pressure
Renal Anatomy
THE KIDNEYS
 The kidneys are a pair of brownish-red
structures located retroperitoneally on the
posteriorwall of the abdomen from the 12th
thoracic vertebra to the 3rd lumbar vertebra in
the adult. An adult kidney weighs 120 to 170
g (about 4.5 oz) and is 12 cm (about 4.5
inches) long, 6 cm wide, and 2.5 cm thick.
THE NORMAL KIDNEY
THE NEPHRON
 The Nephron Is the Basic Unit of Renal Structure and Function
 Each human kidney contains about one million nephrons each of
which consists of a renal corpuscle and a renal tubule. The renal
corpuscle consists of a tuft of capillaries, the glomerulus,
surrounded by Bowman's capsule. The renal tubule is divided into
several segments. The part of the tubule nearest the glomerulus is the
proximal tubule. This is subdivided into a proximal convoluted
tubule and proximal straight tubule. The straight portion heads
toward the medulla, away from the surface of the kidney. The loop of
Henle includes the proximal straight tubule, thin limb, and thick
ascending limb. Connecting tubules connect the next segment, the
short distal convoluted tubule, to the collecting duct system. Several
nephrons drain into a cortical collecting duct, which passes into an
outer medullary collecting duct. In the inner medulla, inner medullary
collecting ducts unite to form large papillary ducts.
Functions of the Kidneys
 Urine formation through filtration, reabsorption, and excretion.
 Excretion of waste products
 Regulation of electrolytes
 Regulation of acid-base balance
 Control of blood pressure
 Renal Clearance
 Regulation of red blood cell production
 Synthesis of vitamin D to active form
 Secretion of prostaglandins
 Regulates calcium and phosphorus balance
 Activates growth hormone
THE URETER
 Are long fibromascular tubes that connect each kidney to the
bladder
 It originates at the lower portion of the renal pelvis and
terminated in the trigone of the bladder wall.
 It’s lining is made up of urothelium that prevents reabsoption of
urine
 It has 3 narrowed areas of the ureters: the uretheropelvic
junction, the urethral segment near the sacroiliac junction and
the ureterovesical junction
 These 3 areas of the ureters have propensity for obstruction by
calculi or stricture
THE URINARY BLADDER
 Urinary Bladder
 It is muscular hallow sac located just behind the
pubic bone
 The capacity of adult bladder is about 300 to 500 ml.
 The bladder is characterized by its hallow area called
vesicle which has 2 inlets (the uretra) and one outlets
the (the urethra)
 The bladder neck is called urethrovesical junction is
responsible for efflux of urine
 It has internal sphincter.it helps to maintain
incontinence.
THE URETHRA
 It arises from the vase of the bladder
 In the male, it passes the penis, the prostate
gland which lies below the bladder neck,
surrounds the urethra posteriorly and laterally
 In the female, it opens just anterior to the
vagina
 --------------------------------------
 Clinical manifestation of Urinary
Dysfunction
Clinical manifestation of Urinary
Dysfunction
Hematuria (red blood cells in the urine)

1.Hematuria is considered a serious sign that

requires evaluation
2.Color of bloody urine dependent on pH of
urine and amount of blood present.
 Acid urine is dark and smoky color
 Alkaline urine is red in color
HEMATURIA
3.Hematuria may due to systemic cause such as blood dyscrasias,
anticoagulant theraphy, neoplasm, trauma, extreme exercise
4.Painless hematuria may indicate neoplasm in the urinary tract
5. Hematuria from renal colic ( stone in the kidney)
6. Bloody spotting reveals bleeding from the urethra, bladder
neoplasm.
7. Hematuria also seen in renal tuberculosis, polycystic disease of
the kidney Acute pyelonephritis, Trombosis and involving renal
artery and vein
Protenuria (Albuminuria)

 Normal urine does not contain significant quantities

 Protenuria is characteristically seen in all form of acute and chronic
renal disease (more of glumerulonephritis than pyelonephritis

 The protein is mainly albumin but globulin is also present

 Albumin and globulin escape through damage glomerular capillaries

in a grater amount than can be reabsorbed by the tubules, or
damage tubules fails to reabsorbed amount filtered

- anoxia, as in cardiac decompensation , diabetic glomerulosclerosis.

 Mild protienuria may occur from other sources- Urethritis, prostatitis,

Dysuria
(painful or difficult voiding)-
 Seen in wide variety of pathologic condition
FREQUENCY
 voiding occurs more often than usual, when
compared with the patient usual pattern (or
with a generally accepted norm of once
every 3-6 hours)
 Determine if habits governing fluid intake
have been altered
 Increase in frequency can result in variety of
conditions such as infection and disease of
urinary tract, metabolic disease, medication
(diuretics)
 Urgency (strong desire to urinate- due to
inflammatory lesion in the bladder,
 prostate, or urethra, acute bacterial infection
and chronic urethrotrigonitis in women
 Burning upon urination- seen in urethral
irritation or bladder infection
OTHER CHANGES
1.Strangury (slow and painful urination) only small amounts of
urine is
 Voided; blood staining may be noted- seen in severe cystitis
2. Hesitancy (undue delay and difficulty in initiating voiding)
may indicate
3. Compression of urethra, outlet obstruction, nuerogenic
bladder.
Nocturia (excessive urination at night)- it suggest decreasing
renal concentrating ability or heart failure, diabetes
mellitus, poor bladder emptying.
4. Urinary incontinence (involuntary loss of urine) may be due
to injury to external urinary sphincter acquired nuerogenic
disease, nuerogenic disease
OTHER CHANGES
5..Stress incontinence (intermittent leakage of urine due
to sudden strain) due weakness of sphincteric
mechanism
6. Polyuria (large volume of urine voided in a given time)-
demonstrated in Diabetes mellitus, diabetes
insipidus, chronic renal disease, diuretics.
7. Oliguria (small volume of urine; output between 100 to
500ml./24 hours)- may result from acute renal failure,
shock, dehydration, fluid-ion
OTHER CHANGES
9.Anuria ( absence of urine in the bladder ; output less
than 50 ml./ in 24 hours indicates severe renal
dysfunction requiring immediate medical intervention.
10.Enuresis (involuntary voiding during sleep) may be
physiologic at age of 3 years; thereafter may be
functional or symptomatic of obstructive
disease( usually the urinary tract)
11. Pnuematuria (passage of gas during voiding) Cause
by fistulos connection between the bladder and
bowel, rectosigmoid cancer, regional ileitis, sigmoid
deverticulitis, and gas forming urinary tract infection
URINARY TRACT PAIN
1. Genitourinary pain is not always present in renal
disease, but generally seen in more acute
conditions
2. Pain of renal disease is cause by sudden distension
of the renal capsule; severity is
3. Related to how quickly the distension developed
4. Kidney pain- may be felt as a dull ache in
costovertebral angle ; may spread to umbilicus.
5.Urethral pain – felt in the back and radiates to the
abdomen, upper thighs, or labia
URINARY TRACT PAIN
6.Flank pain (side area between the ribs and iluim )-
radiates to lower abdomen or ipigastrium and is
often associated with nausea , vomiting, and
paralytic ilues; most commonly secondary to a
renal lesion.
7.Bladder pain (low abdominal pain or suprapubic area)
may be due bladder infection or over distended
bladder.
8.Urethral pain from irritation of bladder neck , from
foreign body in the canal , or from urethritis due to
infection or trauma.
URINARY TRACT PAIN
9.Pain in scrotal area from inflammatory swelling of
epipidymis or testicle, or torsion of the testicle.
10.Testicular pain due to injury, mumps orchitis, torsion
of spermatic cord.
11.Perineal or rectal discomfort from acute prostitis,
prostatic abscess.
12Back leg pain from cancer of prostate with
metastases of pelvic bone
13Pain in glands penis is usually from prostatitis; penile
shaft pain is from urethral problems.
Related Gastrointestinal Symptoms
1.Gastrointestinal symptoms related to urologic
conditions include nausea, vomitingabdominal
discomfort, paralytic ileus, and gastrointestinal
hemorrhage with uremia.
2.Occur with urologic conditions because the
gastrointestinal and urinary tracts have common
autonomic and sensory innervations and because
of renointestinal reflexes.
Assessment of Urologic Function
History and physical Assessment
 What is the patient chief concern? Why is
he seeking help?
 What is (are) the Patient’s present and past
occupation(s)?(look for occupational hazard
related to the urinary tract- contact with
chemicals, plastics, pitch, tar, rubber.
 What is the patient history?
 What is the past history, especially in the
relation to urinary problems?
 Is there any family history of renal disease
Health History
 What childhood diseases did the patient
have
 Is there history of urinary infection
 Did enuresis continue beyond age (past 3
years old
 Are there any voiding disorder?
 Is there pain present?
HEALTH HISTORY
 Has patient has fever? Chills? passage of
stone?
 Any history of genital lesion or history of
STD.
 Does the patient have diabetes mellitus?
Hypertension? Allergies?
 Does the patient is receiving any
prescription or OTC ?
Diagnostic Test
Radiological Techniques
 Plain film- of the abdomen or KUB (Kidneys,
ureters, bladders)
 Delineates size, shape of the kidneys
 Reveals any deviation, Such as stone,
Hydronephrosis, cysts, tumors.
 Computed Tomography- provides a cross-
sectional view of kidney and urinary tract to detect
presence and extent of urologic disease.
 Magnetic Resonance Imaging ( MRI)
 Relies on magnets and computers to produce
images.
 In urology, provides excellent images of soft tissue.
Diagnostic Test
Radiological Techniques
H. Renal Angiography-visualization of renal arterial
supply
1. A special needle is used to pierce the femoral artery
(or axillary artery) and a Catheter is threadend
through the femoral and iliac arteries into the aorta or
Renal artery.
Contrast medium is injected to opacity the renal
arterial supply
4. Angiography evaluates blood flow dynamics,
demonstrate abnormal Vasculature , and
differentiates renal cysts from renal tumors.
Radionuclide Imaging

1.Radiopharmaceutical ( 99 Tc- labeled compound or

(131 I-hippurate) areInjected intravenously.
2.Studies obtained with a scintillation camera placed
posterior to the kidney with The patient in supine
position , prone or sitting position.
3. The resultant image (Scan) indicates the distribution
of pharmaceutical with in the kidneys.
4.The Tc scan provides information provides
information about the kidney Perfusion and is useful
when renal function is poor.
5. The hippurate scan provides information about the
kidney function
ULTRASOUND
Ultrasound ( ultrasonic scan) uses sound
waves that passed into the body.
 In the urinary system create ultrasonic
images.
 Abnormalities such as masses, malformations
or obstruction can be identified
 ENDOUROLOGY
UROLOGIC ENDOSCOPIC
EXMINATION
 Cystoscopic Examination is a method of direct visualization
of the urethra , prostatic urethra , and bladder by means of a
cystoscope that is inserted through the urethra into the
bladder. It has optical lens that provides view of the bladder
 Renal and urethral brush biopsy- after cystocopy,
introduction of catheter dollowed by a biopsy brush, which is
passed to the catheter, suspected lesion is brush back and to
obtain cells and surface tissue for histologic diagnosis.
 Renal Endoscopy, Nephroscopy Intoduction of fibroptic
scope into the renal pelvis during renal operation (pyelotomy)
or percutaneous to view interior of the renal pelvis, removed
calculi, biopsy of small lesion, and diagnose renal hematuria
and selected renal tumors.
NEEDLE BIOPSY OF THE
KIDNEY
 It is performed by percutaneous needle biopsy
through renal tissue or by open biopsy through
a small flank incision.
 It is useful in evaluating renal disease and
securing specimen for electron and
immunoflorescent microscopy.
URINE EXAMINATION
 Amount
 1200-1500ml/24 HRS. ; Less than 500ml is
considered oliguria
 Day volume 2-3 times more than night
volume
Appearance

 Normal is clear.
 Turbid (cloudy) urine is not always pathologic.
Normal urine may developed turbidity on
refrigeration or by standing room
temperature; bacteria ferment quickly at room
temerature
 Abnormally cloudy urine- due to pus, blood,
epithelial cells, bacteria, fat, colloidal partical,
phosphate and urates.
ODOR

 Normal –Faint aromatic odor

 Characteristic odors produced by ingestion of
asparagus or thymol.
 Cloudy urine with ammonia in odor- urea
splitting bacteria such as proteus, causing
urinary tract infection
 Offensive odor- bacterial action in presence
of pus
REACTION (PH)

 Reflects the ability of kidney to maintain normal hydrogen ion

concentration in plasma and extracellular fluid; indicates the
acidity or ackalinity of urine.
 The pH should be measured in fresh urine, since the breakdown
of urine to ammonia causes urine to become alkaline.
 Normal pH is around 6(acid); may normally vary from 4.6 to 7.5
 Urine acidity or alkalinity has relatively little clinical significance
unless the patient is on special diet or therapeutic program or is
being treated for renal calculus disease.
 Alkaline urine is often cloudy because of phosphate crystals.
SPECIFIC GRAVITY

 Reflects the kidney’s ability to concentrate or

dilute urine; may reflect degree of hydration
or dehydration
 Normal specific gravity ranges from 1.005-
1025
 Specific gravity is fixed at 1.010 in chronic
renal failure.
 In a person eating normal diet , inability to
concentrate or dilute urine indicates disease.
OSMOLALITY

 Osmolality is an indication of the amount of

osmotically active particles in
urine( specifically, it is the number of particles
per volume of water).
 The unit of osmotic mesure is the osmole
 Average Values:
 Females: 300- 1090 mOsm./Kg
 Males:390-1090 mOsm./kg
RENAL FUNCTION TEST

 1. Renal concentration test-the ability to concentrate

solutes in the urine.
 2. Creatinine clearance provides a reasonable
approximation of rate of glomerular filtration.
 3. Serum creatinin-Balance between production and
filtration by renal glomerulus.
 Most sensitive test of renal function.
 4. Serum urea nitrogen Serves as index of renal
excretory capacity.
 urea is the nitrogenous end-product of protein
metabolism.
5. Microalbumin-Test for development of
proteinuria; >30 mcg/mg creatinine predicts
early
nephropathy.
6. Urine casts-Mucoproteins and other
substances present in renal inflammation.
7.Red cell casts present in glomerulonephritis.
8.Fatty casts in nephrotic syndrome.
9.White cell casts in pyelonephritis
CONCEPTS OF FLUID AND
ELECTROLTE BALANCE
 ELECTROLYTES
1. Description: A substance that is dissolved in
a solution and some of its molecule
dissociates into an electrically charge atoms
or ions
Movement of body Fluids
1. Description:
A. Cell membrane separate fluids from interstitial to intravascular
fluid
B. Fluids and electrolytes must be kept balance for health: when
they remain out of balance death can occur.
2. Intracellular compartment- fluid in the cell
3. Extracellular compartment- fluid outside the cell
4.Intravascular Compartment- fluids with in the blood vessels
5. Intravascular compartment- fluid with in the blood vessels
6.Interstitial compartment- fluids between the cells and blood
vessels
Movement of body fluids

Third Spacing: is the accumulation and

sequestration of trapped extracellular fluid in
an potential or actual body space result of
disease or injury
 Trapped fluid represent fluid loss and is
unavailable for normal physiological process
 Edema is an excess accumulation in the
interstitial space.( Anascara)
Body fluid transport
 1. Diffusion- movement of particles and
solvent by all direction through solution.
 2. Osmosis- draws water from less
concentrated solution through semipermeable
membrane to higher concentration
 3. Filtration- movement of solutes and solvent
by hydrostatic perssure
 4. Hydrostatic pressure- is the force excerted
by a solution
TYPES OF SOLUTION
1. Isotonic Solution
 When the solution on both sides of a selectively
permeable membrane have established equilibrium
or equal concentration is said to be isotonic
 Example: is 0.9% Sodium Chloride, 5% Dextrose in
water, and Lactated Ringer solution
 Nursing Implication : assess for hypervolemia such
as bounding pulse and shortness of breath
Types of Solution
 Hypotonic Solution: When a solution contains
lower concentration of salt or solute than
other solution (less salt and more water)
 Example 0.45 NaCl for water replacement,
use for cellular dehydration and established
renal function.
 Nursing implication: Do not use in increase
INC or third fluid shift
Types of solution
 Hypertonic solution it has high concentration
of solutes than another solution
 Example: 5% in normal saline (D5NS)- Fluid
replacement for sodium and calories.
 5% in 0.45% NaCL- for maintenance of body
fluid and nutrition
 5% dexstrose In lactated Ringer’s solution- it
mimics electrolyes concentration of blood
 Nursing implication it expand vascular volume
 Donot give with heart and kidney disease
Body Fluid Replacement
 Skin by diffusion 400 ml
 Skin by perspiration 100 ml
 Lungs 350 ml ( water is lost through expired
air)
 Feces 150 ml (secreted to GIT)
 Kidney 1500 ml (play major role in regulating
fluid and electolyte
BODY REPLACEMENT
1. Water enters the body throught 3 routes
(2500 ml)
 A. oral ingested food
 B. orally ingested fluids
 C. and water formed by oxidation(10 ml per
100 calories of fats, CHO, protien metabolism
2. Electrolytes are present in foods and liquids
in normal diet an excess of electrolyte are
excreted.
Maintaining Fluids and Electrolytes
 A. Hemeostasis (relative stability of the
internal environment)
 B. Concentration and composition of body
fluis must be nearly constant
 C. When fluids and elecrolytes is deficient it
must be replaced
 D. When excess it should be iliminated
Maintaining Fluids and Electrolytes
 The kidney plays the major role in controlling
all types of balance in Fluids and Electrolytes
 The adrenal glands, Through secretion of
aldosterone regulate Na and water
reabsorption.
 ADH sectreted by pituitary glands regulates
water reabsorbed by the kidney
Fluid Volume Deficit

 Description
 A. Dehydration
 B the goal is to restore fluid volume and
replace electrolyte as needed, and eliminate
the cause of fluid volume deficit
Types of fluid volume Deficit
 1. Isotonic Dehydration-
 water and electrolyte are lost in equal
proportions
 Hypovolimia
 Leads to decrease circulating blood volume
and tissue perfusion
 Causing: Inadequate intake of fluids and
solutes, Fluid shift from
compartment,Excessive loss from isotonic
body levels.
Types of fluid volume Deficit
2. Hypertonic dehydration
 Water loss exceeds electrolyte loss
 It will result from alterations in specific plasma
concentration
 Fluids from the intracellular moves into the plasma
and interstitial space causing cellular dehydration and
shrinkage
 Causes Excessive perspiration, Hyperventilation, KA,
prolonged fever,diarrhea, early stage renal failure and
DI
Types of fluid volume Deficit
 Hypotonic Dehydration
 Electrolytes loss exceeds water loss
 Cuasing decrease plasma volume
(hypovolimia)
 Fluids moves from the plasma and interstital
space into the cells causing the cell to swell
 Causes: Chronic Illness, Excessive fluid
replacement,Renal Failure,Chronic
malnutrition.
Assessment for fluid volume deficit
 Cardiovascular: Thredy,increase pulse,
Decrease BP, flat and neck veins, Diminish
peripheral pulse.
 Respiratory: Increase in rate and depth of
respiration
 Nueromascular: Decrease CNS activity from
Lethargy to coma
 Renal: Decrease urine output increase in
specific Graviry.
Assessment for fluid volume deficit
 Integumentary: Dry skin, poor turgor,dry
mouth
 GI: Decrease motility and Diminished bowel
sound, constipation, Thirst
 Hypotonic tonic Dehydration: skeletal muscle
weaknes
 Hypertonic dehydration: Deep tendon reflex
(hyperactive) Pitting edema
INTERVENTION Of FLUID AND
ELECTROLYTE IMBALANCE
 PHSICAL ASSESSMENT
 PREVENT Further FLUID LOSS
 Provide oral and intravenous therapy
 Administer medications to correct cause any
symptoms
 Administer Oxygen
Monitor electrolyte values to treat imbalance
FLUID VOLUME in Excess
A. Description
1. Fluid intake or fluid retention exceed the
fluid needs of the body
2. Fluid volume in excess also called
overhydration or fluid overload
3. The goal of treatment is to restore fluid
correct electrolyte imbalances if present and
eliminate or control the underlying over load
TYPES OF FLUID VOLUME
EXCESS
1. Isotonic overhydration (Hypervolemia)
 Only extra cellular compartment is expanded
 Fluid does not shift between the extracellular and
intracellular compartment
 It cause circulatory overload and interstitial edema.
 If severe if patient have poor cardiac function may
lead to CHF and pulmonary edema
 Causes:Uncontrolled IV therapy,renal failure
 Long term used of corticosteroid therapy
HYPERTONIC OVERHYDRATION
 It is rare because it is cause by excessive
sodium intake
 Fluid is drawn from the intracellular
compartment; the extracellular fluid expand
and the intracellular fluid volume contracts
 Causes: Excessive sodium ingestion, rapid
infusion of hypertonic saline, Excessive
soduim bicarbonate therapy
Hypotonic Overhydration a type of
fluid volume excess
 Also known as water intoxication
 The excessive fluid moves into the
intracelluar space and all body compartment
 Electrolyte imbalance occur as a result of
dilution.
 Cuases: early renal failure, CHF, SIADH,
Replacement of isotonic fluid loss with
hypotonic fluids
ASSESSMENT
1. Cardiovascular:
a. bounding; increase pulse rate
b. Elevated blood pressure
c. Distended neck veins and hand veins
d. Elevated CVP
2. Respiratory:
a. Increase RR
b. Dyspnea ( moist crackles)
ASSESSMENT for Fluid Volume in
excess
3. Nueromascular
a. Altered LOC
b. Headache
c. Visual Disturbances
d. Skeletal muscle weakness
e. paresthesias
Assessment for fluid volume Excess
4. Integumentary
a. Pitting edema
b. Skin pale and cool to touch
5. Increase motility of GIT
Assessment for fluid volume Excess
6. For isotonic overhydration
a. Liver enlargement
b. Ascites
7. Hypotonic overhydration : polyuria, diarrhea,
non pitting edema, dysrhymias, projectile
vomiting
INTERVENTION FOR FLUID
VOLUME EXCESS
1. Monitor for cardiovascular, respiratory,
nueromascular renal, integumentary and
gastrointestinal status.
2. Prevent further fluid overload, and restore
fluid balance.
3. Administer diuretics
4. Restrict fluid and soduim intake
5. Monitor I and O
6. Monitor electrolyte values and prepare
medication for fluid imbalance
HYPONATREMIA
A. Description: Na 135-145 mEQ/ L
1. Hyponatremia is serum level is less than
135 mEq/L
2. Sodium imbalance is usually associated with
fluid imbalances.
SODIUM
 FUNCTIONS
 1. participates in the Na-K pump
 2. assists in maintaining blood volume
 3. assists in nerve transmission and muscle
contraction
 Aldosterone increases sodium retention
 ANF increases sodium excretion
 Dominant extracellular ion.
 About 90 to 95% of the osmotic pressure of the
extracellular fluid results from sodium ions and the
negative ions associated with them.
 Recommended dietary intake is less than 2.5 grams
per day.
Sodium (Function)
 Kidneys provide the major route by which the excess
sodium ions are excreted.
 In the presence of aldosterone, the reabsorption of
sodium ions in the loop of Henle is very efficient.
When aldosterone is absent, the reabsorption of
sodium in the nephron is greatly reduced and the
amount of sodium lost in the urine increases.
 Also excreted from the body through the sweat
mechanism.
 Primary mechanisms that regulate the sodium ion
concentration in the extracellular fluid:
 Changes in the blood pressure
 Changes in the osmolality of the extracellular fluid
CAUSES OF HYPONATREMIA
1.Increase soduim excretion
a. Excessive diaphoresis
b. Diuretics
c. Wound drenaige, especially GI
d. Renal Disease
2. Inadequate sodium intake
a. NPO
b. Low salt diet
CAUSES OF HYPONATREMIA
3. Dilution of serum intake
a. Excessive ingestion of hypotonic fluids or
irrigation with hypotonic fluids
b. Renal failure
c. Fresh water drowning
d. Syndrome of inappropriate antidiuretic
hormone
e. Hyperglycemia
f. CHF
Assessment for Hyponatremia
1. Cardovascular
a. Symtoms vary with changes in vascular
volume
b. Normovolimic: rapid pulse rate, normal BP
c. Hypovolemic: thready, weak, rapid rate,
hypotension, flat neck veins, normal or low
CVP
2. Respiratory: shallow, ineffective respiratory
movement related to muscle weakness
Assessment for Hyponatremia
3. Nueromascular:
a. Generalized muscle weakness
b. Diminish deep tendon reflexes
4. Cerebral function
 Headache
 Nausea,abdominal cramping, diarrhea
5. Renal:
a. decrease specific gravity
b. Increase I and O
INTERVENTION for Hyponatremia
1. Monitor cardovascular,nueromascular,
respiratory, cerebral, renal, and GI status
2. If hyponatremia is accompanied by fluid
deficit, IV saline infussion is administer to
restore sodium content and fluid volume
3. If Hyponatremia is accompanied by fluid
excess Osmotic diuretic are administered to
promote excretion of water rather than
sodium
INTERVENTION for Hyponatremia
4. If in case of excessive or inappropriate
secretion of antidiuretic hormone, medication
that antagonize antidiuretic hormone is given
like lithuim and democycline
5. Increase sodium intake in the diet
6. If client is taking lithium, monitor because
hyponatremia can cause decrease lithuim
excretion resulting to toxicity
HYPERNATREMIA

A. Description: Soduim normal value 135-145

mEq/L
Hypernatremia is a serum soduim level that
exceeds 145 mEQ/L
Causes of Hypernatremia
1.Decrease Na excretion
a. Corticosteroid (can cause Na and Fluid
retention)
b. Cushing syndrome
c. Renal failure
d. Hyperaldosteronism
2. Increase Na intake ( food or IV)
3. Decrease water intake: Nothing by mouth
4. Increase water loss
Assessment for Hypernatremia

1. Cardiovascular: heart rate and blood pressure that

respond to vascular volume
2. Respiratory: pulmonary edema if hypervolemia is
present
3. Nueromascular: Early muscle twiches,irregular
muscle contraction
4. CNS: altered cerebral function is the most common
manifestation of hypernatremia
5. Renal: Increase specific gravity, Decrease urine
output
6. Presence or absence of edema may be present.
INTERVENTION FOR
HYPERNATREMIA
1. Monitor for cardiovascular, respiratory,
cerebral, renal and integumentary status
2. Target the cause
a. If the cause is fluid loos replace throug IV
infusion
b. If the cause is inadequate renal excretion
prepare diuretics that promote sodium loss
c. Restrict sodium and fluid intake as prescribe
HYPOKALEMIA
Normal value: 3.5 -5.1 mEq/ L
1. Description
a. Serum potassium is less than 3.5 mEq/ L
b. Potassium deficit is potentially dangerous
because every body system is affected
POTASSIUM
 FUNCTIONS
 1. maintains ICF Osmolality
 2. nerve conduction and muscle contraction
 3. metabolism of carbohydrates, fats and proteins
 Aldosterone promotes renal excretion of K+
 Acidosis promotes exchange of K+ for H+ in the cell
 Electrically excitable tissue such as muscle and
nerves are highly sensitive to slight changes in
extracellular potassium concentration.
 The ECF concentration of potassium must be
maintained within a narrow range for tissues to
function normally.
FUNCTIONS OF POTASSIUM
 Aldosterone also plays a major role in
regulating the concentration of potassium
ions in the ECF.
 Circulatory system shock resulting from
plasma loss, dehydration, and tissue damage
causes extracellular potassium ions to
become more concentrated than normal. In
response, aldosterone secretion increases
and causes potassium secretion to increase.
Causes of Hypokalemia
1. Actual total body potassium loss
a. Excessive use of medication such as
diuretics and corticosteroids
b. Increase secretion of aldosterone
c. Vomiting;diarrhea
d. Wound drainage, particularly GI
e. Prolonged nasogastic suctioning
f. Renal disease impairing reabsorption of K
Causes of Hypokalemia
2. Inadequate Potassium intake: nothing by
mouth
3. Movement of potassium from extracellular to
the intracellular
a. Alkalosis
b. Hyperinulinism
4. Dilution of potassium
a. Water intoxication
b. Intravenous theraphy with potassium poor
solutions
Assessment for Hypokalemia
1.Cardiovascular:
a.Thready , weak, irregular pulse
b.Peripheral pulse is weak
c.Orthostatic hypotension
d. Electrocardiogram Changes
 ST depression ( ventricle still depolarized)
 Flat or inverted T wave (Ventricular
repolarization)
 Prominent U wave
Assessment for Hypokalemia
2. Respiratory
a. Shallow, ineffective respiration due to
propound weaknes skeletal muscle of
respiration
b. Diminish breath sound
3. Nueromascular: Skeletal muscle weakness:
eventual flaccid paralysis
4. Renal: Decrease specific gravity and
increase urinary output
INTERVENTION FOR HYPO K

1. Monitor physical Status and place patient in

cardiac monitor
2. Monitor Electrolytes
3. Administer K supplement orally or
Intravenously as prescribe
4. Oral K may cause Nausea and vomiting
 Should be taken with food
 Liquid potassium chloride has unpleasant
taste should be taken with juice
Precaution for Intravenous Potassium
1. Potassium is never given by IV push or by
intramascular or subcutaneous injection
2. Dilution of no more than 1 mEq/10 ml of solution is
recommended
3. After adding potassium in an IV, shake the bag and
invertit to ensure that the potassium is distributed
evenly throughout the IV solution
4. The maximum recommended infusion rate is 5 to 10
mEq/hr, never exceed 20 mEq/hr under any
circumstances
5. Patient receiving more than 10 mEq/hr should be
placed in cardiac monitor and the infusion should be
controlled in an infusion pump
Precaution for Intravenous Potassium
6. Potassium infusion can cause phlebitis
7. Nurse should assess for client renal function test
before administering potassium and monitor intake
and output during administration
8. Institute safety measure for muscle weakness
9. If the patient is taking potassium- losing diuretic; it
may be discontinued; a potassium sparing diuretic
may be prescribe
10 Instruct Client food high in Potassium
Hyperkalemia
 Many are spurious or associated with
acidosis
 Common practice of repeatedly clenching and
unclenching the fist during venipuncture may
raise the potassium concentration by 1-2
meq/L by causing local release of potassium
from forearm muscles.
CAUSES OF HYPERKALEMIA
 1.SPURIOUS
 Leakage from erythrocytes if separation of
serum from clot is delayed.
 Thrombocytosis
 Marked leukocytosis
 Repeated fist clenching during phlebotomy
 Specimen drawn from arm with infusion
CAUSES OF HYPERKALEMIA
 2.DECREASED EXCRETION
 Renal failure, acute and chronic
 Severe oliguria
 Renal secretory defects
 Adrenocortical insufficiency
 Hyporeninemic hypoaldosteronism
 Spironolactone, Triamterene, ACE-I,
Trimethoprim, NSAIDs
CAUSES OF HYPERKALEMIA
 3.SHIFT FROM TISSUES
 Burns, rhabdomyolysis, hemolysis
 Metabolic acidosis
 Hyperosmolality
 Insulin deficiency
 Hyperkalemic periodic paralysis
 Succinylcholine, arginine, digitalis toxicity, beta-
adrenergic blockers
 4.EXCESSIVE INTAKE
 Over treatment, orally or parenterally
CLINICAL FINDINGS
 CLINICAL FINDINGS
 Weakness and flaccid paralysis
 Abdominal distention and diarrhea
 ECG is not a sensitive method, but if abnormalities
are present, the most common findings are:
 Peaked T waves
 ST segment elevation
 Tachyarrhythmia / supraventricular tachycardia
 Ventricular tachycardia
 Ventricular fibrillation
 Cardiac arrest
TREATMENT for HYPERKALEMIA
 TREATMENT
 Confirm that the elevated level of serum potassium is
genuine.
 Measure plasma potassium.
 Withholding of potassium.
 Giving cation exchange resins by mouth or enema:
polystyrene sulfate, 40-80 g/day in divided doses.
 Emergent treatment is indicated if cardiac toxicity or
muscular paralysis is present, or if hyperkalemia is
severe (> 6.5-7 meq/L) even in the absence of ECG
changes
Treatment for hyperkalemia
 Insulin plus 10-50% glucose may be
employed to deposit potassium with glycogen
in the liver.
 Calcium may be given intravenously as an
antagonist ion.
 Stimulate transcellular shifts by giving beta-
adrenergic agonist drugs.
 Sodium bicarbonate as an emergency
measure.
 Hemodialysis or peritoneal dialysis.
FLUID ELECTROLYTE
MANAGEMENT
CALCIUM
 Constitute 2% of body weight, but only 1% of the total
body calcium is in solution in body fluid.
 In plasma, calcium is present as a non-diffusible
complex with protein (33%); as a diffusible but
undissociated complex with anions like citrate,
bicarbonate, and phosphate (12%); and as ionized
calcium (55%).
 Normal total plasma (or serum) calcium concentration
is 8.5 to 10.5 mg/dL.
 It is the ionized calcium that is necessary for muscle
contraction and nerve function (normal: 4.7 to 5.3
mg/dL).
CALCUIM
 CALCIUM
 Majority of calcium is in the bones and teeth
 Normal serum range 8.5-10 mg/dL
Functions of calcuim
 FUNCTIONS
 1. formation and mineralization of bones/teeth
 2. muscular contraction and relaxation
 3. cardiac function
 4. blood clotting
 5. enzyme activation
Regulation of Calcuim
 Regulation:
 GIT absorbs Ca+ in the intestine with the help of Vit. D
 Kidney Ca+ is filtered in the glomerulus and reabsorbed
 in the tubules
 PTH increases Ca+ by bone resorption, Ca+ retention
 and activation of Vitamin D
 Calcitonin released when Ca+ is high, it decreases Ca+
 by excretion in the kidney
 Extracellular concentration of calcium ions is maintained
Parathyroid hormone (PTH) secreted by the parathyroid glands
increases extracellular calcium levels.
 Calcitonin is secreted by the thyroid gland.
 It reduces blood levels of calcium when they are too high.
Hypocalcemia
 Seen commonly in critically ill patients due to
acquired defects in parathyroid-vitamin D
axis.
 Results occasionally in hypotension which
responds to calcium replacement therapy.
CAUSES OF HYOCALCEMIA
 .DECREASED INTAKE OR ABSORPTION
 Malabsorption
 Small bowel bypass, short bowel
 Vitamin D deficit
 2.INCREASED IONS
 Alcoholism
 Chronic renal insufficiency
 Diuretic therapy (furosemide or bumetanide)
CAUSES OF HYOCALCEMIA
 3.ENDOCRINE DISEASES
 True and pseudohypoparathyroidism
 Calcitonin hypersecretion
 4.PHYSIOLOGIC CAUSES
 Alkalosis and decreased response to vit. D
 Decreased serum albumin
 Hyperphosphatemia
 Aminoglycosides, loop diuretics, foscarnet
CLINICAL FINDINGS
Symptoms and Signs
Hypocalcemia
 Extensive spasm of skeletal muscle causing
cramps and tetany
 Laryngospasm with stridor
 Convulsions with paresthesias of the lips and
extremities
 Abdominal pain
 Chvostek’s sign
 Trousseau’s sign
Laboratory Findings for
hypocalcemia
 Low serum calcium
 Elevated serum phosphorus
 Low serum magnesium
 Prolonged QT interval on the ECG
MANAGEMENT for hypocalcemia
 TREATMENT
 Severe symptomatic hypocalcemia:
 In the presence of tetany, arrhythmias or seizures,
calcium gluconate 10% is administered intravenously
for 10-15 minutes or via calcium infusion.
 10-15 mg of calcium per kilogram body weight, or 6-8
10-ml vials of 10% calcium gluconate (558-744 mg of
calcium) is added to 1 liter of D5W and infused over 4
to 6 hours.
Management For hypocalcemia
 Asymptomatic hypocalcemia:
 Oral calcium and vitamin D preparations
 Calcium carbonate is well tolerated and
inexpensive.
Hypercalcemia
CAUSES OF HYPERCALCEMIA
 INCREASED INTAKE OR ABSORPTION
 Milk-alkali syndrome
 Vitamin D or vitamin A excess
 2. ENDOCRINE DISORDERS
 Primary and secondary hyperparathyroidism
 Acromegaly
 Adrenal insufficiency
Hypercalcemia
CAUSES OF HYPERCALCEMIA
 NEOPLASTIC DISEASES
 Tumors producing PTH-related proteins
 Metastases to bone
 Lymphoproliferative disease
 Secretion of prostaglandins and osteolytic factors
 4. MISCELLANEOUS CAUSES
 Thiazide diuretics and renal transplant complications
 Sarcoidosis and Paget’s disease of the bone
 Hypophosphatasia, immobilization, iatrogenic
Clinical Findings
Symptoms and Signs:
 Polyuria and constipation
 Stupor, coma and azotemia
 Ventricular extrasystoles and idioventricular
rhythm
LABORATORY FINDINGS
 Significant elevation of serum calcium
 Serum phosphorus may or may not be
elevated
 Shortened QT interval on the ECG
MANAGEMENT
 TREATMENT
 Renal excretion of calcium is promoted by
giving saline with furosemide.
 Treatment of underlying condition
MANAGEMENT
 TREATMENT
 Renal excretion of calcium is promoted by
giving saline with furosemide.
 Treatment of underlying condition
MAGNESIUM
 MAGNESIUM
 Second to K+ in the ICF
 Normal range is 1.3-2.1 mEq/L
 FUNCTIONS
 1. intracellular production and utilization of
ATP
 2. protein and DNA synthesis
 3. neuromuscular irritability
HYPOMAGNESIA
 Hypomagnesemia
 Nearly half of hospitalized patients have
unrecognized hypomagnesemia.
 In critically ill patients, arrhythmias and
sudden death may be complications.
CAUSES OF HYOMAGNESEMIA
 . DIMINISHED ABSORPTION OR INTAKE
 Malabsorption, chronic diarrhea, laxative abuse
 Prolonged gastrointestinal suction
 Small bowel bypass, malnutrition
 Alcoholism, parenteral alimentation
 2. INCREASED LOSS
 DKA, diuretic therapy, diarrhea
 Hyperaldosteronism, Bartter’s syndrome
 Hypercalciuria
 Renal magnesium wasting
 3. UNEXPLAINED
 Hyperparathyroidism
 Postparathyroidectomy
 Vitamin D therapy
 Aminoglycoside antibiotics, cisplatin, amphotericin B
CLINICAL FINDINGS
Symptoms and Signs:
 Weakness
 Muscle cramps
 CNS hyperexcitability with tremors
 Athetoid movements
 Jerking, nystagmus
 Positive Babinski response
 Hypertension, tachycardia and ventricular
arrhythmias
 Confusion and disorientation
 LABORATORY FINDINGS
 Decreased serum magnesium levels
 Hypocalcemia and hypokalemia
 Prolonged QT interval on the ECG
 Lengthening of the ST segment on the ECG
TREATMENT AND
MANAGEMENT
 Use of IVF containing magnesium as chloride
or sulfate, 240-1200 mg/day (10-50
mmol/day) during the period of severe deficit,
followed by 120 mg/day (5 mmol/day) for
maintenance.
 MgSO4 may also be given intramuscularly in
a dosage of 200-800 mg/day (8-33 mmol/day)
in four divided doses.
 Serum levels must be monitored.
Hypermagnesemia
 Almost always the result of renal insufficiency
and the inability to excrete what has been
taken in from food or drugs, especially
antacids and laxatives.
 Potentially life-threatening as it impairs both
central nervous system and muscular
function.
CLINICAL FINDINGS
Symptoms and Signs: Hypermagnesia
 Muscle weakness
 Mental obtundation and confusion
 Hypotension
 Respiratory muscle paralysis or cardiac arrest
 Elevated serum magnesium, BUN, creatinine,
K
 Decreased serum calcium
 Increased PR interval on the ECG
 Broadened QRS complex with elevated T
waves
Treatment for hypermagnesia
 TREATMENT
 Alleviating renal insufficiency
 Administration of calcium
 Hemodialysis or peritoneal dialysis
FLUID AND ELECTROLYTE
MANAGEMENT
ACID BASE DISTURBANCES
 Arterial Blood Gases
 Regulation of pH is accomplished by:
 Kidneys
 Lungs
 Buffer systems
 Information obtained from the arterial blood gas
measurements:
 pH
 Partial pressure of carbon dioxide (pCO2)
 Partial pressure of oxygen (pO2)
 HCO3 level
 Oxygen saturation (O2Sat)
BICARBONATES

 BICARBONATES
 Present both in ICF and ECF
 Normal range- 22-26 mEq/L
 FUNCTION
 1. regulates acid-base balance
 2. component of the bicarbonate-carbonic
acid
 buffer system
ABG
 NORMAL VALUES
 pH = 7.35 – 7.45
 pCO2 = 35 – 45 mmHg
 pO2 = 80 – 100 mmHg
 HCO3 = 22 – 26 meqs/L
 O2Sat > 95%
Steps in obtaining an ABG specimen:
Check the bleeding parameters of
the patient.
 Prepare the following:
 Glass syringe
 Heparin (1,000 units/mL)
 Alcohol
 Cotton balls (soaked with alcohol AND dry)
 Container with ice water
PROCEDURE
 Aspirate 1 mL of heparin using a glass syringe
 Coat the inner surface of the syringe with
heparin, taking care to pull and push the plunger
to make sure heparin evenly coats the syringe.
 Expel the excess heparin from the syringe.
 Palpate for the radial pulse.
 With the needle directed at a slight angle from the
vertical, and pointed cephalad, gradually
puncture the site and wait for arterial blood to
rush in.
PROCEDURE FOR ABG
 After obtaining the specimen, secure the
needle and place the syringe with the
specimen in ice water.
 Apply direct pressure on the puncture site
for at least one minute, or until bleeding
stops using a dry sterile cotton ball.
 Send the specimen directly to the
laboratory.
 A sample is allowed to stand for a
maximum of two hours only.
HELPFUL HINTS
 Carbon dioxide is considered to be ACID
because of its relationship with carbonic acid
 pH measures the degree of acidity and
alkalinity. It is inversely related to Hydrogen.
Normal ph 7.35-7.45
 Decreased pH- ACIDIC-increased Hydrogen
—pH below 7.35
 Increased pH- ALKALOSIS-decreased
hydrogen—pH above 7.45
DON’T FORGET
 REMEMBER
 a high hydrogen acidic pH is low
 a low hydrogen alkalosis pH is high
 a high CO2may mean acidic
 a low CO2 may mean alkalosis
DYNAMICS OF ACIDS AND
BASES
 Acids and bases are constantly produced in
the body.
 They must be constantly regulated.
 CO2 and HCO3 are crucial in the balance.
 A ratio of 20:1 is maintained (HCO3:H2CO3)
 Respiratory and renal system are active in
regulation
WAYS TO BALANCE ACID AND
BASES
 Excretion
 Acid can be excreted, and Hydrogen can be excreted in
ACIDOTIC condition.
 Bicarbonate can be excreted in ALKALOTIC condition.
 Production
 Bicarbonate can be produced in ACIDOTIC condition.
 Hydrogen can be produced in ALKALOTIC condition.
 The respiratory system compensates for metabolic
problems
 CO2 (acid) can be exhaled from the body
 to normalize the pH in ACIDOSIS.
 CO2 (acid) can be retained in the body to
 normalize the pH in ALKALOSIS.
WAYS TO BALANCE ACID AND
BASES
 The kidney can compensate for problems in therespiratory
system
 The Kidney reabsorbs and generates Bicarbonate
 (alkaline) in ACIDOSIS.
 The Kidney can excrete H+ excess (Acidosis) to
 normalize the pH in ACIDOSIS.
 The kidney can excrete bicarbonate (alkali) in
 conditions of ALKALOSIS.
 The kidney can retain H+ (acid) in conditions of ALKALOSIS.
 Chemical buffers can also participate in the balance of
acid-base
 1. Carbonic acid- bicarbonate buffer
 2. Phosphate buffer
 3. protein buffer- ICF and hemoglobin
 The action is immediate but very limited
MARAMING SALAMAT PO
I HOPE YOU LEARN FROM ME
SIR LITO R.N., M.A.N