*Review electrolytes, assessment of imbalances, normal values for Na+, K+, BUN,
Creatinine
When does this Water loss OR sodium gain Water excess OR sodium loss
happen
*primary protection is thirst from *can lead to hypoosmolality
hypothalamus leading to cellular swelling and
explosion
o Clinical states (Diabetes
insipidus) Sodium depletion from:
o Hyperosmolality as a result of:
o Hyperosmolar tube feedings o Diuretics
o Osmotic diuretics (mannitol) o Diarrhea
o Sensible losses (fever) o Fistula drainage
o Excessive sweating o NG suction
o Sodium gain o Abnormal losses via diaphoresis
o Hyperglycemia (glucose-
induced diuresis)
o Adrenal insufficency
Water intoxication:
-SIADH
-CHF/Cirrhosis/nephrotic syndrome
4.5-5.5 (ionized)
1.5-2.5 mEq/L
Foods high in
o Potassium-
o fruits and vegetables
Banana
Oranges
Avocado
Sweet potato
o salt substitutes
o Calcium
o cheese
o yogurt
o fortified juices
o milk
o spinach
o salmon
o Phosphates
o Processed meats and dairy
o Soda
o In many additives and fortified grains
o Pumpkin seeds, almonds, peanuts in plant form are known as phytate
o Magnesium
o Beans and nuts
o Whole grains
o Green leafy vegetables
o Dark chocolate
Fluid and movement between extracellular and intracellular fluid will cause deficits
and excess.
Water Regulation
***Water regulation is managed by pituitary, adrenal cortex, kidney, hypothalamus,
cardiac and GI tract.
o Pituitary:
Under control of hypothalamus, posterior pituitary releases ADH, which
regulates water retention by the kidneys.
o Adrenal Cortex:
Adrenal cortex releases hormones to regulate both water and
electrolytes
1. Glucocorticoids
2. Mineralocorticoids
a. Aldosterone is a mineralocorticoid with potent sodium-
retaining and potassium excreting capability.
o Kidneys:
Kidneys are primary organs for regulating fluid and electrolyte balance.
Selective reabsorption and excretion of eater and electrolytes
Renal tubules are sites of action of ADH and aldosterone
Impaired renal function =
- Edema
- K+ and PO4- retention
- Acidosis
- Electrolyte imbalances
o Cardiac:
Atrial natriuretic factor (ANF) is released by the cardiac atria in
response to increased atrial pressure.
B-type natriuretic peptide (BNP) is released by the cardiac ventricles in
response to decompensated heart failure.
ANF & BNP causes vasodilation and increased urinary excretion of
sodium and water.
o GI:
Gastrointestinal tract accounts for most of water intake.
Small amounts of water are eliminated by GI tract in feces.
Fluid Volume Excess Fluid Volume Deficit
(hypervolemia) (hypovolemia)
Hematology: 7
The picture above shows the maturation process of blood cells. We always
start with the stem cell. Remember that blasts are indicative of the cell
being immature and cyte is the mature cell.
o Blood Cells
4-6million
About 45% of the blood is composed of formed elements, or
blood cells. The three types of blood cells are erythrocytes
(RBCs), leukocytes (WBCs), and thrombocytes (platelets).
o Erythrocytes (RBCs)
Primary function of erythrocytes is oxygen and carbon dioxide
transportation and assistance in maintaining acid-base balance.
Erythrocytes are primarily composed of a large molecule called
hemoglobin. Hemoglobin is a complex protein-iron compound
composed of heme (iron compound) and globin (simple protein),
binds with oxygen and carbon dioxide.
RBCs carry oxygen linked to hemoglobin from the lungs to the
tissue capillaries
Erythropoiesis (the process of RBC production) is regulated by
cellular oxygen requirements and general metabolic activity.
Erythropoiesis is stimulated by hypoxia and controlled by
erythropoietin, a glycoprotein growth factor synthesized and
released primarily by the kidney!
Erythropoietin stimulates the bone marrow to increase
erythrocyte production.
Several distinct cell types evolve during erythrocyte maturation.
Three alterations in erythropoiesis that decrease RBC production
Decreased hemoglobin synthesis
Defective DNA synthesis in RBCs
Diminished availability of erythrocyte precursors
The reticulocyte is an immature erythrocyte. The reticulocyte
count measures the rate at which new RBCs appear in the
circulation.
o Leukocytes (WBCs)
Normal Range 5,000-10,000
Leukocytes originate from stem cells within the bone marrow
There are different types of leukocytes, each with a different
function.
Granulocytes- include three types
- Neutrophils: Bands (immature neutrophil) & Segs
(mature neutrophil)
- Eosinophils
- Basophils
The primary function of granulocytes is
phagocytosis, a process in which WBCs ingest or
engulf any unwanted organism and then digest and
kill it.
Agranulocytes- Leukocytes that do not have granules
within the cytoplasm.
Lymphocytes cellular & humoral immune response
Monocytes - Also strong phagocytic activity. Monocytes
are only present in the blood for a short time before
they migrate into the tissue and become
macrophages.
Kupffer cells liver, osteoclasts bone, alveolar
macrophages lungs.
o Thrombocytes (platelets)
Normal: 200,000-400,000/l
*Know your terms and nursing care for anemia(s), thrombocytopenia, neutropenia,
leukocytosis, polycythemia
Renal: 7
o Prerenal Etiology
Hypovolemia, hemorrhage, burns, severe hyponatremia & H20
loss, hypotension or hypoperfeusion, sepsis, CV failure, PE, renal
artery stenosis, severe dehydration
o Intrarenal Etiology
Acute tubular necrosis (ATN), post ischemic or nephrotoxic
glomerulopathies, malignant HTN, SLE, thrombotic disorders,
aminoglycosides, radiocontrast media, sepsis, hypotension
o Post Renal Etiology
Obstructive uropathies (bilateral), ureteral destruction, bladder
neck obstruction (prostate disease).
Complications
o infections, neurologic changes, peripheral neuropathy, CKD-mineral
and bone disease, pruritus, infertility, personality and behavioral
changes, lethargy, and depression.
Goal of care in CKD
o reducing the risk of cardiovascular disease and premature death.
Secondary goals of CKD therapy are to deter the progression of kidney
dysfunction, recognize and treat the associated complications, and provide
for the patients comfort.
Medical management is started in an effort to postpone the need for
maintenance dialysis.
In certain situations, CKD progression can be delayed by using
drug therapy to reduce the damaging effects of proteinuria
and hypertension.
Erythropoietin and iron replacement are used for the
treatment of anemia.
Statins (HMG-CoA reductase inhibitors) are the most effective drugs for
lowering low-density lipoprotein (LDL) cholesterol levels.
Prior to dialysis, dietary protein may be restricted to slow the
progression of kidney dysfunction. Once the patient starts dialysis,
protein intake is usually increased.
Fluid intake depends on the daily urine output
DIALYSIS
Dialysis is a therapeutic intervention in which substances move from the
blood through a semipermeable membrane and into a dialysis solution
(dialysate). Dialysis solutions have an electrolyte composition similar to that
of plasma.
The two methods of dialysis are peritoneal dialysis (PD) and hemodialysis
(HD).
PERITONEAL DIALYSIS
Two types of PD are automated peritoneal dialysis (APD) and continuous
ambulatory peritoneal dialysis (CAPD).
PD is indicated (as a patient preference) when there are vascular access
problems or when a patient is intolerant of HD.
The three phases of the PD cycle (called an exchange)
o inflow (fill), dwell (equilibration), and drain (outflow).
The patient dialyzing at home will be given a daily prescription of exchanges
that is specific for the individual patient.
complications
o infection of the peritoneal catheter exit site, peritonitis, and pain.
Additional complications include hernias, lower back pain, protein loss,
bleeding, atelectasis, pneumonia, and bronchitis.
HEMODIALYSIS
The types of vascular access include arteriovenous fistulas (AVFs),
arteriovenous grafts (AVGs), and temporary catheters.
AVFs are created most commonly in the forearm with an anastomosis
between an artery (usually radial or ulnar) and a vein (usually
cephalic). Native fistulas have the best overall patency rates and least
number of complications.
AVGs are made of synthetic materials and form a bridge between the
arterial and venous blood supplies. Grafts are placed under the skin
and are surgically anastomosed between an artery (usually brachial)
and a vein (usually antecubital).
The majority of HD patients are treated in community-based dialysis facilities
and routinely dialyze for 3 to 4 hours 3 days each week.
o nurses complete an assessment that includes evaluation of a
patients fluid status (weight, BP, peripheral edema, lung and
heart sounds), condition of vascular access, and temperature.
Complications
o hypotension, muscle cramps, and blood loss.
The primary nursing goals
o help the patient regain or maintain a positive self-image and
achieve the highest degree of independent functional capacity
possible.
Chronic Pyelonephritis
Pyelonephritis is an inflammation of the renal parenchyma and collecting
system, including the renal pelvis.
o The most common cause is bacterial infection that begins in the lower
urinary tract. Recurring infection can result in chronic
pyelonephritis.
Clinical manifestations
o Acute
mild fatigue to the sudden onset of chills, fever, vomiting,
malaise, flank pain, and the lower UTI characteristics.
o Chronic
HTN, inability to conserve Na, Hyperkalmia and acidosis, decrease
ability to concentrate urine
Diagnostics
o UA (pyuria: pus in urine, bacteriauria, hematuria)
o CBC
o Blood Cultures
o Ultrasound
o IVP (intravenous pyelogram), CT Scan
Collaborative Care
o Antibiotic therapy
o Adequate hydration is necessary
o Interventions include teaching about the disease process with emphasis
on the need to continue drugs as prescribed, the need for a follow-up
urine culture to ensure proper management, and identification of risk for
recurrence or relapse.
o Avoid catheterization, IVP and contrast CT Scan
Nursing Diagnosis
o Impaired urinary elimination, readiness for enhanced self-health mgmt
Renal Calculi
Risk Factors
o Warm climates, high protein diet, dehydration, family history,
immobility
o pH
o Infection: urince becomes alkaline and stones form
Types of Calculi
o Calcium oxalate (most common)
o Uric acid
o Struvite
o Cysteine
Clinical Manifestations
o Abdominal pain or flank pain
o Hematuria
o Renal colic (pain that occurs as peristaltic action of ureters is
increased)
o Coll, moist skin
o N/V
o As stone moves through the urinary tract, may feel pain in testicles,
labia, groin, and/or rectum
Diagnostic Studies
o U/A
Assess for hematuria; ph.; pyuria crystals; casts
o Stone analysis
o BUN & Cr: assess renal function
o 24-hour urine collection: determine GFR; assess for increased uric acid,
calcium, [phosphate oxalate, cysteine
Collaborative Care
o MANAGE PAIN!
o Encourage fluids, but do not force-may increase renal colic
o Expulsion therapy-corticosteroids & nifedipine
o Relaxation
o I/O
Strain urine
o Ambulation
o Restrict sodium intake
o Control of infections (struvite stones)
o Antibiotics: if infection is present
o Evaluate cause of stone formation
o Stone removal
Lithotripsy: extracorpeal shock-wave lithotripsy
Complications: hemorrhage, retained fragments, infection,
damage to surrounding tissues.
Endourologic procedures: endoscope inserted through
urethra: stones can be pulverized with sound waves, ultrasonic
waves, laser or can be removed with basket.