renal and genitourinary conditions

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

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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 tract5. 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 developed4. 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 FunctionHistory 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 TestRadiological 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 TestRadiological 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 cell3. Extracellular compartment- fluid outside the cell4.Intravascular Compartment- fluids with in the blood vessels 5. Intravascular compartment- fluid with in the blood vessels6.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.


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


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 EXCESS1. 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 EXCESS1. Monitor for cardiovascular, respiratory,

nueromascular renal, integumentary and gastrointestinal status.

2. Prevent further fluid overload, and restore fluid balance.

3. Administer diuretics4. Restrict fluid and soduim intake 5. Monitor I and O6. 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 weaknessb. Diminish deep tendon reflexes4. Cerebral function Headache Nausea,abdominal cramping, diarrhea5. Renal:a. decrease specific gravityb. 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 excretiona. Corticosteroid (can cause Na and Fluid

retention)b. Cushing syndromec. Renal failured. Hyperaldosteronism2. Increase Na intake ( food or IV)3. Decrease water intake: Nothing by mouth4. 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. Alkalosisb. Hyperinulinism4. Dilution of potassiuma. Water intoxicationb. Intravenous theraphy with potassium poor

solutions

Assessment for Hypokalemia

1. Cardiovascular:a. Thready , weak, irregular pulseb. Peripheral pulse is weakc. Orthostatic hypotensiond. 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


2.DECREASED EXCRETION Renal failure, acute and chronic Severe oliguria Renal secretory defects Adrenocortical insufficiency Hyporeninemic hypoaldosteronism Spironolactone, Triamterene, ACE-I,

Trimethoprim, NSAIDs


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 MANAGEMENTCALCIUM 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 FINDINGSSymptoms 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.

HypercalcemiaCAUSES 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

HypercalcemiaCAUSES 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 FindingsSymptoms 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

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 FINDINGSSymptoms 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 FINDINGSSymptoms 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 MANAGEMENTACID 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 CO2may 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