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Care of Clients with Problems In Oxygenation, Fluids and Electrolytes, Metabolism and Endocrine (NCM103) Patients With Fluids

and Electrolytes (Renal) Alteration I


Anatomy and Physiology Of the Renal System

Topics Discussed Here Are: 1. Anatomy and Physiology of the Renal System 2. Functions of the Kidney 3. Assessment of the Renal System 4. Diagnostic Procedures

Anatomy and Physiology of the Renal System

1. Kidneys Located at the 12th Thoracic Vertebrae and 2nd Lumbar Vertebrae Also known as the COSTOVERTEBRAL ANGLE (CVA) Color & Shape: Reddish-brownish in color; BEAN SHAPED People have 2 kidneys, but we can survive with just 1 kidney as long as it is normal WE CANT LIVE WITHOUT A KIDNEY The RIGHT is slightly LOWER due to the liver which is located at the right upper quadrant On TOP of each kidney are the ADRENAL GLANDS The blood supply of the kidneys are supplied by the RENAL ARTERIES 20 25% of the CARDIAC OUTPUT goes to the KIDNEY! (Highly Vascular) Nephrons If in the Event There are 1 million nephrons There is damage to the Also known as: The UNIT of functioning of the KIDNEYS! kidneys Nephrons are made up of: And 20% are left a. Glomerulus FILTERING ELEMENT *We should consider RENAL Encapsulated by the Bowmans Capsule REPLACEMENT/TRANSPLANT b. Tubular Components Bowmans Capsule Proximal Tubule Loop of Henle o Descending and Ascending Loop of Henle Distal Tubule Ureters Gets out through the Transport of urine from the kidneys to the urinary bladder is by PERISTALSIS! Right URETER is SHORTER than the LEFT due to the location Ureters is roughly about 24 40 cm LONG Once the urine is transported, it is stored in the URINARY BLADDER URINARY BLADDER Storage / Reservoir of urine Can hold 300 ml 400 ml of urine!!
If in the Event The person cannot void due to some factors The URINARY BLADDER CAN HOLD UPTO 1 LITER of URINE! But Can BRING DAMAGE to the muscles of the bladder To PREVENT DAMAGE: o Instruct to VOID every 3 HOURS Number of urination is 8 times per day





Urethra If in the Event Function: For the passageway of urine to the outside Female Urethras are more shorter, a. Male: (Size and Function) then they are more at risk for UTI / Ascending infections 1. Excretion of urine 2. Reproduction (Passage of semen) b. Female: (Size differs from male) 1. Excretion of urine ONLY Nursing Consideration Correct technique of perineal care (UP DOWN) Urethritis Males have a much larger emotional IMPACT

Functions of the Kidney

1. Urine Formation Glomerular Filtration Tubular Reabsorption Tubular Excretion Excretion of waste products UREA is the most important waste product to be removed!! Assessment of Kidney Function BUN (Blood Test) Urea (24 Hour urine collection!~) Creatinine If in the Event Sulfate There is an abnormal LIVER, then the ammonia cant be Phosphate converted into urea, there would be an ACCUMULATION URIC ACID Waste product of of WASTE PRODUCTS Purine metabolism (At risk for HEPATIC ENCEPHALOPATHY) NO UREA if NO PROTEIN~ Waste products of drugs!~
Intake of PROTEIN is , then amount of UREA is also


Situation Start End Saturday 7:00 AM Sunday 7:00 AM

Saturday woke up at 8:30 AM, DISCARD and not part of the 24 Hour urine collection But when urinated at 9:00 AM, already a part of the collection


Regulation of Electrolytes Sodium (Na) [135 145 mEq/L) If in the Event Most ABUNDANT electrolyte in the ECF! There is more INTAKE of Na Normal Intake: 6 8 grams Then there would be OVERHYDRATION! Function: Where Na goes, H2O goes Potassium (K) [3.5 5.5 mEq/L] Most ABUNDANT electrolyte in the ICF Normal Intake: 6 8 grams o The amount of Na and K passed out is affected by Aldosterone o Dietary Intake: K Diet = Hyperkalemia K Diet = Hypokalemia GREATEST PROBLEM IS WHEN K CANNOT BE EXCRETED ( Contraction of HEART)



Regulates Acid-Base Balance Two Functions of the kidneys for regulating acid-base balance i. REABSORPTION of BICARBONATE Tubular Reabsorption Brings back the HCO3 to the circulation ii. EXCRETION of URIC ACID Tubular Excretion Control of H2O Balance Controlled through URINE OUTPUT Amount of fluid intake should be equal to the output
If in the Event Fluid intake (DILUTED URINE) Fluid intake (CONCENTRATED URINE)



Control of Blood Pressure Vasa Recta Special type of blood vessel Responsible for recognizing pressure on the blood vessel Renal Clearance Ability of the kidney to CLEAR solutes from the plasma To perform: Use the 24 Hour Urine Collection Production of erythropoietin or regulation of RBC production Erythropoietin Bone Marrow Erythropoiesis




Synthesis of Vitamin D to its active FORM Functions of Vitamin D o To maintain the normal balance of Ca in the body o Sun is a good source for Vitamin D (Infants are exposed under the sun for 10 15 minutes) o 1,25 dihydroxycholecalciferol

10. Production of PROSTAGLANDIN Produces VASODILATION To maintain the normal renal blood flow~ Functions of the Kidney~ (Gsto ko lang isa-isahin ulit ) Urine Formation 6. Control of Blood Pressure Excretion of waste products 7. Renal Clearance Regulation of Electrolytes 8. Production of erythropoietin or regulation of Regulates Acid-Base Balance RBC production Control of H2O Balance 9. Synthesis of Vitamin D to its active FORM 10. Production of PROSTAGLANDIN

1. 2. 3. 4. 5.


Assessment of Patients with Renal and Urinary Tract Disorders

A. Risk Factors Health History Age Gender Recurrent attacks of URTI (Tonsillitis) Glomerulonephritis Renal Failure! Ask if ever been catheterized (At risk for UTI) HTN / DM? Renal Failure Prolonged immobilization (At risk for STONE FORMATION) Ask if has history of exposure to chemical agents (Plastic, Tar, Rubber) [At risk for renal failure!] B. Clinical Manifestations 1. Anemia Due to production of erythropoietin 2. Pain Serves as a WARNING SIGNAL! CVA to Umbilical are = KIDNEY PAIN CVA to Lower Abdomen Area / Testes / Groin = URETER PAIN Pain at Hypogastric Area = URINARY BLADDER IS DISTENDED Limited in the Perineal Area, Penis / Urethra = URETHRAL PAIN Scrotal, radiate to Rectal Area = PROSTATE GLAND IS AFFECTED 3. Change in micturation Certain problems: The process is painless Frequency Number of times the client voids and effortless Supposed to void 8 times Urgency Strong desire to VOID within 24 hours (Every 3 Hesitance Difficulty of imitation of voiding hours) Nocturia Voiding of more than once in the night Average amount of Urine a. Pathological Urination more than 2 3 times Output is 1200 1500 mL/24 hrs b. Physiological Normal (Pregnant women) Amount varies by certain Dysuria Painful urination / Difficulty of urination factors: Incontinence Involuntary loss of urine o Amount of May / may not feel the urge to void fluid intake o Temperature Cannot control process of voiding of the Enuresis Involuntary voiding during sleep environment Anuria UO < 50ml/day o Accompanying condition Oliguria UO > 50ml/day but < 400 ml/day (Diarrhea, (50 400 ml/day) vomiting) Polyuria UO > 1500 ml/day 4. GIT Manifestations Urological The main reason why there is GIT manifestations is because: Both the GIT and GUT share the SAME common autonomic and (sympathetic) sensory stimulation / enervation GUT and GIT disorders are affected by each other Example: N/V Diarrhea Abdominal discomfort / abdominal distention


Physical Assessment
1. 2. 3. 4. Inspection Palpation Auscultation Percussion

Only modality USED o Is there presence of edema? o Bloating? o Periorbital edema? o Clubbed fingers? o Ascites? o Peripheral edema (Lower Extremities)

Can also be done: Patient is lying down Right hand / left hand under the patient depending upon the side Palpate and ask patient to inhale and exhale

Assess for presence of renal stenosis o Shock, CO Blood flow to the kidneys Narrowing of renal arteries o Bruit Sound Indication of difficulty of blood getting through a narrowed vessel (Renal Artery Stenosis)

Percussion of the Urinary Bladder is important! Percussion CANNOT BE DONE not until the urinary bladder is distended

Diagnostic Procedures
1. Urinalysis Supposed to get the 1st VOIDED urine (Mid-stream catch) Most basic urine test for kidneys and excretory Expect to See Color: o Normal (Amber) o Dehydration (Dark Yellow) Highly Concentrated o Overhydrated (Light Yellow) Highly Diluted o Bleeding (Tea-colored) o Drug Induced (Blue / Green Colored) Clarity o Transparent (Clear) o Turbid (Cloudy) INFECTION!! Positive (+) Pus / WBC o Supposed to be (NEGATIVE) [-] o If cloudy / turbid and (+) for pus/WBC then it is INFECTION Look for level of RBC, should be (-) o Tea colored and (+) RBC o BLEEDING due to STONE FORMATION
After collection of urine, it should be brought to the lab within 30 mins! If in the event that it cannot be brought to the lab immediately, it should be refrigerated! NOT SUPPOSED TO ALLOW IT TO STAY! o Because if it remains in room temperature, it may come in contact with microorganisms within the environment and it can become CONTAMINATED !


Urine Culture and Sensitivity Test a. Can be taken anytime of the day b. Supposed to be sterile urine specimen c. Ideally speaking, client should be catheterized d. Client must clean perineal area and mid-stream catch e. Should not have taken any antibiotics for 2 3 days CULTURE Identification of microorganism SENSITIVITY What drug the microorganism responds to 2. Renal Function Test Used to determine the ability of the kidney to excrete waste products of metabolism Creatinine Urea BUN Determines the Urine Specific Gravity (N: 1.000 1.03) Urine Specific Gravity means the ability of the kidney to CONCENTRATE solutes within the urine Determines the Urine Osmolality (N: 300 900 mOsm/kg/24 hours) Urine Osmolality is the ability of the kidney to DILUTE / CONCENTRATE the urine Creatinine: 1. Urine (24 hour urine collection) 2. Assess the level of Serum Creatinine (Through the BLOOD) Imaging Procedures a. KUB (Kidney Ureter Bladder) Is the X-RAY of the abdomen to visualize the KIDNEY, URETER and BLADDER It can determine: IMPORTANT in CARE of Gen. Utz 1. Number of functioning kidneys FULL BLADDER before performing 2. Size (Small, large, abnormal) procedure 3. Ureters (Patency, strictures, mass) Cannot proceed if bladder is EMPTY!! b. General Ultrasonography (Utz) General Abdominal Ultrasonography It differs from KUB because General Utz uses the principle of SOUND with a transducer b. c. CAT Scan d. MRI e. Intravenous Urography It is visualization of the Kidney, Ureters and Bladder, but uses a CONTRAST MEDIA per IV IMPORTANT: Assess clients history of allergic reaction to SEA FOODS!! Do SKIN TESTING f. Retrograde Pyelography Visualization of Kidney, Bladder and Ureters BUT! Contrast media is NOT GIVEN per IV, but directly to the URETHRA up to the URINARY BLADDER, URETERS and KIDNEYS Uses a CYSTOSCOPE to insert a catheter to introduce a radiopaque dye followed by a series of X-rays g. Cystography SPECIFIC FOR THE URAINARY BLADDER ONLY! Used to assess if the bladder is traumatized (Due to accidents such as; falls, vehicular accidents, stab wounds) Uses contrast media



h. Renal Angiography Visualization of RENAL ARTERIES by use of a radiopaque dye To assess if blood flow to the kidney is enough or patent IMPORTANT: Get CONSENT NPO (6 8 hours prior to procedure) Produce a CLEAR COLON To have a BETTER visualization of renal arteries 1. Laxatives 2. Enemas ENDOSCOPIC EXAMINATION Cystoscopy (Visualization of the urinary bladder) 4. Biopsy To get a piece of tissue, not merely brushing! a. Urethral Brushing Kind of like a Pap Smear Uses a brush to wipe mass and into a slide b. Renal Biopsy Through the use of a LAPAROSCOPE, a lighted instrument Makes an incision on flank area Pinch like a stapler and get a piece of TISSUE And put on a slide to check if its malignant or not Important Nursing Care in BIOPSY Before: o Doctor should first KNOW the CLOTTING TIME OF THE CLIENT! o Place the patient on NPO After: (Situation) o Biopsy: Right kidney had just gone biopsy o Position: Place the client on a PRONE position Place a pillow on the right side to promote PRESSURE and prevent possibility of BLEEDING Assess if patient is BLEEDING! WOF: Urine OUTPUT!

8:00 AM

12:00 PM

3:00 PM

Reddish If more red, BLEEDING is progressive

Lighter in color

Lighter in color