NCM112 LECTURE

MEDICAL-SURGICAL NURSING

FLUID DISTRUBANCES, ELECTROLYTE IMBALANCES, RENAL AND KIDNEY DISORDERS

TOPIC OUTLINE:  which describes the loss of sodium
from the extracellular space (i.e.,
ALCON, MARY GRACE intravascular and interstitial fluid) that
AQUINO, JVY MARIE occurs during gastrointestinal
AZUTEN, ZYZA-ZHOLEY hemorrhage, vomiting, diarrhea, and
BALLESTA, ERIKA diuresis;
BORJA, RIVERT JAMES  Dehydration
CARTUJANO, DAZLYNE
CASTERAL, EILEITHIA CHYAVANNA  which refers to the loss of
CORPUZ, MARK ANTHONY intracellular water (and
DERY, JOHN BRYAN total body water) that
TACCAD, HANNAH ultimately causes cellular
TALOSIG, KEZIAH desiccation and elevates
SOMERA, KARLA MAE the plasma sodium
concentration and
I. FLUID VOLUME DISTURBANCES osmolality.
(Hypovolemia, Hypervolemia)
II. ELECTROLYTE IMBALANCES (Sodium, ALTERATIONS IN HEALTH (DIAGNOSIS)
Potassium, Calcium, Magnesium Imbalance,
Phosphorus, Chloride)  Fluid volume deficit
III. ACID–BASE DISTURBANCES (Metabolic
Acidosis, Metabolic Alkalosis, Respiratory CAUSES
Acidosis, Respiratory Alkalosis , Mixed
Acid–Base Disorders)  Commonly caused by dysfunction of various organs,
IV. PARENTERAL FLUID THERAPY (Purpose, such as Congestive Heart Failure or Kidney
Types of Intravenous Solutions, Nursing Failure.
Management of the Patient Receiving
 Rarely, neurological disorders, particularly those
Intravenous Therapy
V. KIDNEY DISORDERS (Chronic Kidney affecting the hormones that regulate kidney
Disease, Nephrotic Syndrome , Acute functioning can also cause hypovolemia.
Kidney Injury, End-Stage Kidney Disease or  Dehydration, which may result from excessive water
Chronic Kidney Disease) evaporating from the skin in extreme heat or when
VI. RENAL REPLACEMENT THERAPIES experiencing a fever. Dehydration can also result
(Dialysis, Hemodialysis Dialyzers, from continuous vomiting or diarrhea without
Continuous Renal Replacement Therapies, sufficient fluid intake, usually associated with
Peritoneal Dialysis) infections that cause gastroenteritis.
VII. INFECTIONS OF THE URINARY TRACT  It may also result from excessive accumulation of
(Lower Urinary Tract Infections) fluids within the interstitial space, between cells.
VIII. ADULT VOIDING DYSFUNCTION (Urinary
For instance, when an infection becomes severe,
Incontinence, Urinary Retention, Neurogenic
Bladder) sepsis can occur, which is a life-threatening condition
in which the individual's response to the infection
leads to organ dysfunction and systemic
FLUID VOLUME DISTURBANCES inflammation.
 Other conditions that can cause fluids to exit blood
vessels include pancreatitis, pericarditis, burns,
and nutritional hypoalbuminemia.
HYPOVOLEMIA
 Sudden blood loss due to a trauma, like a motor
 FVD, or hypovolemia, occurs when loss of ECF vehicle accident or a fall from a height. External or
(extracellular fluid) volume exceeds the intake of internal bleeding may occur and, if not identified
fluid. It occurs when water and electrolytes are lost in quickly, can be life-threatening.
the same proportion as they exist in normal body
fluids, thus the ratio of serum electrolytes to water SIGNS & SYMPTOMS
remains the same. FVD should not be confused with
Severity:
dehydration, which refers to loss of water alone, with
increased serum sodium levels. FVD may occur  Dizziness when standing.
alone or in combination with other imbalances.  Dry skin and dry mouth.
Unless other imbalances are present concurrently,
 Feeling tired (fatigue) or weak.
serum electrolyte concentrations remain essentially
 Muscle cramps.
unchanged.
 Unable to pee (urinate) or the color of your urine is
o Two distinct disorders:
darker than normal.
 Volume Depletion

BSN 3A | PBL GROUP 1 1

BSN 3A | PBL GROUP 1

NCM112 LECTURE
MEDICAL-SURGICAL NURSING

FLUID DISTRUBANCES, ELECTROLYTE IMBALANCES, RENAL AND KIDNEY DISORDERS

Severe: your symptoms, especially if you get
dizzy when you’re upright, which is a
 Confusion. sign of hypovolemia.
 Difficulty breathing or fast breathing.
 Excessive sweating. CLINICAL MANIFESTATION
 Losing consciousness.
 Low blood pressure.
 Low body temperature.
 Pale skin tone or a blue tone to the skin and lips
(cyanosis).

COMPLICATIONS

 Hypoxia
 Hypovolemic Shock
 Dysrhythmias
 Acute Kidney Failure

PATHOPHYSIOLOGY

 FVD results from loss of body fluids and occurs more

rapidly when coupled with decreased fluid intake.
FVD can also develop with a prolonged period of
inadequate intake. Causes of FVD include abnormal
fluid losses, such as those resulting from vomiting,
diarrhea, GI suctioning, and sweating; decreased
intake, as in nausea or lack of access to fluids; and
third-space fluid shifts, or the movement of fluid from
the vascular system to other body spaces (e.g., with
edema formation in burns, ascites with liver
dysfunction). Additional causes include diabetes
insipidus (a decreased ability to concentrate urine
owing to a defect in the kidney tubules that interferes
with water reabsorption), adrenal insufficiency,
osmotic diuresis, hemorrhage, and coma.

ASSESSMENT AND DIAGNOSTIC FINDINGS

 LABORATORY TESTS
o Elevated Potassium and BUN
o Urine Specific Gravity
o Urine Sodium Concentration
o Creatinine
o Blood Test:
 CBC
 Chemistry Panels
o UTZ or Echocardiogram
 DIAGNOSTIC PROCEDURES
o Skin and Mucous Membrane
 During a physical exam, your provider
will examine your skin and the mucous
membranes in your mouth, tongue, and
nose for dryness, which is a sign of the
condition.
o Pulse, body temperature and blood pressure:
 Your provider will test your vitals while MEDICAL MANAGEMENT
you’re sitting and while you’re
standing to monitor changes. During  Fluid Resuscitation
this process when you change your o to increase the amount of fluid volume in your
posture, your provider will examine body via fluid replacement (fluid resuscitation).

BSN 3A | PBL GROUP 1 2

BSN 3A | PBL GROUP 1

NCM112 LECTURE
MEDICAL-SURGICAL NURSING

FLUID DISTRUBANCES, ELECTROLYTE IMBALANCES, RENAL AND KIDNEY DISORDERS

During this procedure, an IV (intravenous) tube  Accurate and Frequent assessment of I&O, weight,
injects fluids into your vein vital signs, central venous pressure, level of
 Isotonic Electrolyte Solution (e.g. consciousness, breath sounds, and skin color
lactated Ringer’s solution, 0.9% o should be performed to determine when
sodium chloride) is frequently the first- therapy should be slowed to avoid volume
line choice to treat the hypotensive overload. The rate of fluid administration is
patient with FVD because they expand based on the severity of loss and the
plasma volume patient’s hemodynamic response to volume
 Hypotonic electrolyte solution (e.g., replacement
0.45% sodium chloride) is often used to  Fluid Challenge Test
provide both electrolytes and water for o When is not excreting enough urine and to
renal excretion of metabolic wastes. determine whether the depressed renal
o Function is caused by reduced renal blood
flow secondary to FVD (prerenal azotemia)
or, more seriously, by acute tubular
necrosis from prolonged FVD
o During a fluid challenge test, volumes of
fluid are administered at specific rates and
intervals while the patient’s hemodynamic
response to this treatment is monitored (i.e.,
vital signs, breath sounds, orientation
status, central venous pressure, urine
output).
o An example of a typical fluid challenge test
involves administering 100 to 200 mL of
normal saline solution over 15 minutes. The
goal is to provide fluids rapidly enough to
attain adequate tissue perfusion without
compromising the cardiovascular system.
The response by a patient with FVD but
normal renal function is increased urine
output and an increase in blood pressure
and central venous pressure.

Note:

Shock can occur when the volume of fluid lost exceeds 25%
of the intravascular volume or when fluid loss is rapid.

NURSING MANAGEMENT

 Monitors and measures fluid I&O at least every 8

hours, and sometimes hourly
o As FVD develops, body fluid losses exceed
fluid intake through excessive urination
(polyuria), diarrhea, vomiting, or other
mechanisms.
o Once FVD has developed, the kidneys
attempt to conserve body fluids, leading to
a urine output of less than 1 mL/kg/h in an
adult.
 Daily body weights monitored
o an acute loss of 0.5 kg (1 lb) represents a
fluid loss of approximately 500 mL (1L of
 Oxygen Therapy fluid weighs approximately 1 kg, or 2.2 lb)
o to alleviate the adverse effects of hypoxemia (Crawford & Harris, 2011c).
and tissue hypoxia  Vital Signs are closely monitored

BSN 3A | PBL GROUP 1 3

BSN 3A | PBL GROUP 1

NCM112 LECTURE
MEDICAL-SURGICAL NURSING

FLUID DISTRUBANCES, ELECTROLYTE IMBALANCES, RENAL AND KIDNEY DISORDERS

o The nurse observes for a weak, rapid pulse should be implemented to control diarrhea and
and orthostatic hypotension (i.e., a replacement fluids administered. This includes
decrease in systolic pressure exceeding 20 administering antidiarrheal medications and small
mm Hg when the patient moves from a lying volumes of oral fluids at frequent intervals.
to a sitting position) (Weber & Kelley, 2010).
o A decrease in body temperature often CORRECTING HYPOVOLEMIA
accompanies FVD, unless there is a
concurrent infection.  When possible, oral fluids are administered to help
 Skin and tongue turgor are monitored on a regular correct FVD, with consideration given to the patient’s
basis. likes and dislikes. The type of fluid the patient has
o In a healthy person, pinched skin lost is also considered, and fluids most likely to
immediately returns to its normal position replace the lost electrolytes are appropriate. If the
when released (Weber & Kelley, 2010). patient is reluctant to drink because of oral
o This elastic property, referred to as turgor, discomfort, the nurse assists with frequent mouth
is partially dependent on interstitial fluid care and provides nonirritating fluids. The patient
volume. In a person with FVD, the skin may be offered small volumes of oral rehydration
flattens more slowly after the pinch is solutions (e.g., Rehydralyte, Elete, Cytomax). These
released. solutions provide fluid, glucose, and electrolytes in
o In a person with severe FVD, the skin may concentrations that are easily absorbed. If nausea is
remain elevated for many seconds. present, an antiemetic may be needed before oral
o Tissue turgor is best measured by fluid replacement can be tolerated. If the deficit
pinching the skin over the sternum, inner cannot be corrected by oral fluids, therapy may need
aspects of the thighs, or forehead. Tongue to be initiated by an alternative route (enteral or
turgor is not affected by age (see previous parenteral) until adequate circulating blood volume
Gerontologic Considerations), and and renal perfusion are achieved. Isotonic fluids are
evaluating this may be more valid than prescribed to increase ECF volume (Crawford &
evaluating skin turgor. In a normal person, Harris, 2011c).
the tongue has one longitudinal furrow. HYPERVOLEMIA
o In the person with FVD, there are additional
longitudinal furrows and the tongue is  Hypervolemia is a medical condition when you have
smaller because of fluid loss. The degree of too much fluid in your body, also described as having
oral mucous membrane moisture is also excess water retention or fluid overload. Healthy
assessed; a dry mouth may indicate either people have a certain amount of fluid in their bodies.
FVD or mouth breathing. When you have too much excess fluid, it can cause
 Urine concentration is monitored by measuring the health complications such as swelling, high blood
urine specific gravity pressure, heart problems, and more.
o In a volume-depleted patient, the urine  Hypervolemia is common among people with chronic
specific gravity should be greater than kidney disease (CKD) and renal failure because their
1.020, indicating healthy renal conservation kidneys aren't working to remove excess fluid as
of fluid. healthy kidneys would. The good news is, once the
 Hemodynamic monitoring causes of your hypervolemia are understood, there
o Mental function is eventually affected, are treatments that can help control it.
resulting in delirium in severe FVD as a
result of decreasing cerebral perfusion. ALTERATIONS IN HEALTH (DIAGNOSIS)
Decreased peripheral perfusion can result
in cold extremities. In patients with relatively  Fluid Volume Excess
normal cardiopulmonary function, a low
central venous pressure is indicative of CAUSES
hypovolemia.
o Patients with acute cardiopulmonary  Kidney failure. Your kidneys are responsible for
decompensation require more extensive removing excess fluid from your body. When your
hemodynamic monitoring of pressures in kidneys aren’t working well, fluid can build up.
both sides of the heart to determine if  Congestive heart failure. When your heart is not
hypovolemia exists. pumping enough blood, your kidneys aren’t able to
work as well, leaving excess fluid in your body.
PREVENTION  Liver failure or cirrhosis. Your liver processes
nutrients and filters toxins. When your liver isn’t
 To prevent FVD, the nurse identifies patients at risk working as it should, fluid can build up in your
and takes measures to minimize fluid losses. For abdomen.
example, if the patient has diarrhea, measures

BSN 3A | PBL GROUP 1 4

BSN 3A | PBL GROUP 1

NCM112 LECTURE
MEDICAL-SURGICAL NURSING

FLUID DISTRUBANCES, ELECTROLYTE IMBALANCES, RENAL AND KIDNEY DISORDERS

 Hormonal changes. Women may experience mild factors can include heart failure, renal failure, and
fluid retention as a normal part of premenstrual cirrhosis of the liver. Another contributing factor is the
syndrome (PMS) or pregnancy. Excessive fluid consumption of excessive amounts of table or other
retention related to hormonal changes may be a sign sodium salts. Excessive administration of sodium-
of high blood pressure and should be checked out by containing fluids in a patient with impaired regulatory
a doctor. mechanisms may predispose him or her to a serious
 IV fluids. Receiving too much IV fluid, especially if FVE as well
there are other health conditions present, can lead to
fluid overload and swelling. ASSESSMENT AND DIAGNOSTIC FINDINGS
 Salt (Sodium). Too much salt (sodium) in your body
 Laboratory data useful in diagnosing FVE include
causes hypervolemia. Salt is an essential mineral in
BUN and hematocrit levels.
your body. Your body manages the amount of salt
you eat with water. If you eat food that contains too  In FVE, both of these values may be decreased
much sodium, your body will use water to balance it because of plasma dilution, low protein intake, and
back to a normal level. This is why you might feel anemia.
thirsty after eating a lot of salty foods.  In chronic renal failure, both serum osmolality and
the sodium level are decreased owing to excessive
Note: retention of water.
 The urine sodium level is increased if the kidneys are
If you’re living with CKD: you may be at risk for attempting to excrete excess volume.
hypervolemia—especially in later stages as kidney function  A chest x-ray may reveal pulmonary congestion.
declines. After a diagnosis of kidney failure, dialysis Hypervolemia occurs when aldosterone is
treatments replace some kidney function to help to remove chronically stimulated (i.e., cirrhosis, heart failure,
excess fluid from your body and get you as close to your “dry and nephrotic syndrome). Therefore, the urine
weight” as possible. Dry weight is your “ideal weight”—the sodium level does not increase in these conditions.
weight your care team determines you would be without the
excess fluid in your body. MEDICAL MANAGEMENT

If you’ve never been diagnosed with CKD: your doctor may  Pharmacological Therapy
perform several tests to help determine the cause of your fluid o Diuretics
overload. You’ll probably be given a test to determine the  are prescribed when dietary restriction
amount of sodium in your blood. You’ll likely also get a urine of sodium alone is insufficient to reduce
test to help the doctor determine whether your hypervolemia edema by inhibiting the reabsorption of
is being caused by a kidney issue. Further testing for kidney sodium and water by the kidneys.
function can help your doctor decide which steps to take next.  The choice of diuretic is based on the
severity of the hypervolemic state, the
SIGNS & SYMPTOMS
degree of impairment of renal function,
and the potency of the diuretic.
 Rapid weight gain
 Thiazide diuretics
 Noticeable swelling (edema) in your arms, legs, and
o block sodium
face
reabsorption in the distal
 Swelling in your abdomen
tubule, where only 5% to
 Cramping, headache, and stomach bloating 10% of filtered sodium is
 Shortness of breath reabsorbed.
 High blood pressure o Generally, thiazide
 Heart problems, including congestive heart failure diuretics, such as
hydrochlorothiazide
COMPLICATIONS (HydroDIURIL) or
chlorthalidone
 Pericarditis
(Thalitone), are
 HF prescribed for mild to
 Delayed wound healing moderate hypervolemia
 Tissue Breakdown and loop diuretics for
 Decreased bowl function severe hypervolemia
(Karch, 2012).
PATHOPHYSIOLOGY  Loop diuretics
o such as furosemide
 FVE may be related to simple fluid overload or
(Lasix), bumetanide
diminished function of the homeostatic mechanisms
(Bumex), or torsemide
responsible for regulating fluid balance. Contributing
(Demadex), can cause a

BSN 3A | PBL GROUP 1 5

BSN 3A | PBL GROUP 1

NCM112 LECTURE
MEDICAL-SURGICAL NURSING

FLUID DISTRUBANCES, ELECTROLYTE IMBALANCES, RENAL AND KIDNEY DISORDERS

greater loss of both decreasing sodium intake. Lemon
sodium and water juice, onions, and garlic are
because they block excellent substitute flavorings,
sodium reabsorption in although some patients prefer salt
the ascending limb of substitutes. Most salt substitutes
Henle’s loop, where 20% contain potassium and must
to 30% of filtered sodium therefore be used cautiously by
is normally reabsorbed. patients taking potassium-sparing
 Electrolyte imbalances may result from the effect of diuretics (e.g., spironolactone,
the diuretic. Hypokalemia can occur with all diuretics triamterene [Dyrenium], amiloride
except those that work in the last distal tubule of the [Midamor]). They should not be
nephrons. Potassium supplements can be used at all in conditions
prescribed to avoid this complication. associated with potassium
 Hyponatremia occurs with diuresis owing to retention, such as advanced renal
increased release of ADH secondary to a reduction disease. Salt substitutes
in circulating volume. Decreased magnesium levels containing ammonium chloride
occur with the administration of loop and thiazide can be harmful to patients with
diuretics due to decreased reabsorption and liver damage
increased excretion of magnesium by the kidney.  In some communities, drinking
 High uric acid levels (hyperuricemia) can also occur water may contain too much
from increased reabsorption and decreased sodium for a sodium-restricted
excretion of uric acid by the kidneys diet. Depending on its source,
 Dialysis water may contain as little as 1 mg
o If renal function is so severely impaired that or more than 1,500 mg of sodium
pharmacologic agents cannot act per quart. Patients may need to
efficiently, other modalities are considered use distilled water if the local water
to remove sodium and fluid from the body. supply is very high in sodium.
o Hemodialysis or peritoneal dialysis may be Bottled water can have a sodium
used to remove nitrogenous wastes and content that ranges from 0 to
control potassium and acid–base balance, 1,200 mg/L; therefore, if sodium is
and to remove sodium and fluid. restricted, the label must be
Continuous renal replacement therapy may carefully examined for sodium
also be required. content before purchasing and
 Nutritional Therapy drinking bottled water. Also,
o Restriction of sodium. patients on sodium-restricted diets
 An average daily diet not restricted should be cautioned to avoid
in sodium contains 6 to 15 g of water softeners that add sodium to
salt, whereas low-sodium diets water in exchange for other ions,
can range from a mild restriction to such as calcium. Protein intake
as little as 250 mg of sodium per may be increased in patients who
day, depending on the patient’s are malnourished or who have low
needs. serum protein levels in an effort to
 A mild sodium-restricted diet increase capillary oncotic
allows only light salting of food pressure and pull fluid out of the
(about half the usual amount) in tissues into vessels for excretion
cooking and at the table, and no by the kidneys.
addition of salt to commercially
NURSING MANAGEMENT
prepared foods that are already
seasoned
 Measures I&O at regular intervals to identify
 Foods high in sodium must be
excessive fluid retention
avoided. It is the sodium salt
 Monitored weight daily and rapid weight gain is noted
(sodium chloride) rather than
o The patient is weighed daily, and rapid
sodium itself that contributes to
weight gain is noted. An acute weight gain
edema. Therefore, patients are
of 1 kg (2.2 lb) is equivalent to a gain of
instructed to read food labels
approximately 1 L of fluid
carefully to determine salt content.
 Breath sounds are assessed at regular intervals in
 About half of ingested sodium is in
the form of seasoning, seasoning at-risk patients, particularly if parenteral fluids are
substitutes can play a major role in being administered
 monitors the degree of edema in

BSN 3A | PBL GROUP 1 6

BSN 3A | PBL GROUP 1

NCM112 LECTURE
MEDICAL-SURGICAL NURSING

FLUID DISTRUBANCES, ELECTROLYTE IMBALANCES, RENAL AND KIDNEY DISORDERS

 the most dependent parts of the body, such as the oncotic pressure, causing expansion of the interstitial
feet and ankles in ambulatory fluid compartment
 patients and the sacral region in patients confined to  Edema can be localized (e.g., in the ankle, as in
bed rheumatoid arthritis) or generalized (as in cardiac
o Pitting edema is assessed by pressing a and renal failure). Severe generalized edema is
finger into the affected part, creating a pit or called anasarca.
indentation that is evaluated on a scale of  Burns and infection are examples of conditions
1+ (minimal) to 4+ (severe). associated with increased interstitial fluid volume.
o Peripheral edema is monitored by  Obstruction to lymphatic outflow, a plasma albumin
measuring the circumference of the level less than 1.5 to 2 g/dL, or a decrease in plasma
extremity with a tape marked in millimeters oncotic pressure contributes to increased interstitial
(Weber & Kelley, 2010). fluid volume.
 The kidneys retain sodium and water when there is
PREVENTING HYPERVOLEMIA decreased ECF volume as a result of decreased
cardiac output from heart failure. A thorough
 require sodium-restricted diets in some form, and medication history is necessary to identify any
adherence to the prescribed diet is encouraged medications that could cause edema, such as
 instructed to avoid over-the-counter (OTC) nonsteroidal anti-inflammatory drugs (NSAIDs),
medications without first checking with a health care estrogens, corticosteroids, and antihypertensive
provider, because these substances may contain agents.
sodium. o Ascites is a type of edema in which fluid
 If fluid retention persists despite adherence to a accumulates in the peritoneal cavity; it
prescribed diet, hidden sources of sodium, such as results from nephrotic syndrome, cirrhosis,
the water supply or use of water softeners, should be and some malignant tumors. The patient
considered. commonly reports shortness of breath and
a sense of pressure because of pressure on
DETECTING AND CONTROLLING HYPERVOLEMIA the diaphragm.
 The goal of treatment is to preserve or restore the
 Promote rest, restrict sodium intake, monitor
circulating intravascular fluid volume. Thus, in
parenteral fluid therapy, and administer appropriate
addition to treating the cause of the edema, other
medications.
treatments may include diuretic therapy, restriction of
 Regular rest periods may be beneficial because bed
fluids and sodium, elevation of the extremities,
rest favors the diuresis of fluid.
application of anti-embolism stockings, paracentesis,
 Sodium and fluid restriction should be instituted as
dialysis, and continuous renal replacement therapy
indicated.
in cases of renal failure or life-threatening fluid
 Patients with FVE require diuretics, the patient’s volume overload
response to these agents is monitored.
 The rate of parenteral fluids and the patient’s ELECTROLYTE IMBALANCES
response to these fluids are also closely monitored
 If dyspnea or orthopnea is present, the patient is  An electrolyte imbalance occurs when certain
placed in a semi-Fowler’s position to promote lung mineral levels in your blood get too high or too low.
expansion. The patient is turned and repositioned at  This imbalance may be a sign of a problem
like kidney disease.
regular intervals because edematous tissue is more
 Electrolytes are minerals that give off an electrical
prone to skin breakdown than normal tissue.
charge when they dissolve in fluids like blood and
Note: urine. Our body makes electrolytes.
 Electrolytes in blood, tissue, urine and other body
 conditions predisposing to FVE are likely to be fluids play a critical role in balancing body fluids,
chronic, patients are taught to monitor their response regulating your heart rhythm and supporting nerve
and muscle function.
to therapy by documenting fluid I&O and body weight
 Our kidneys and liver, as well as other organs and
changes. The importance of adhering to the
tissue, continually move electrolytes in and out of
treatment regimen is emphasized. cells to adjust fluid levels within the compartments.
Certain health conditions can affect our body’s ability to
EDUCATING PX ABOUT EDEMA
move and balance electrolytes. When fluid compartments
have too many or too few electrolytes, it can develop to an
 gives special attention to edema when instructing the
electrolyte imbalance.
patient with FVE. Edema can occur as a result of
increased capillary fluid pressure, decreased
capillary oncotic pressure, or increased interstitial

BSN 3A | PBL GROUP 1 7

BSN 3A | PBL GROUP 1

NCM112 LECTURE
MEDICAL-SURGICAL NURSING

FLUID DISTRUBANCES, ELECTROLYTE IMBALANCES, RENAL AND KIDNEY DISORDERS

COMPONENTS OF ELECTROLYTES COMPLICATIONS
 Sodium controls fluid levels and aids nerve and A significant electrolyte imbalance (either too high or too low)
muscle function. can cause serious, life-threatening problems. These
 Potassium supports heart, nerve and muscle
complications include:
functions. It also moves nutrients into cells and
waste products out of them while supporting your  Coma.
metabolism.  Seizures.
 Calcium helps blood vessels contract and expand  Sudden cardiac death (sudden cardiac arrest).
to stabilize blood pressure. It also secretes
hormones and enzymes (proteins) that help the
nervous system send messages. CLINICAL MANIFESTATIONS
 Chloride helps maintain healthy blood levels, blood
pressure and body fluids. Symptoms of an electrolyte imbalance vary depending on the
 Magnesium aids nerve and muscle function. It also severity and electrolyte type. A slight electrolyte imbalance
promotes the growth of healthy bones and teeth.
may not cause noticeable changes. When problems occur,
 Phosphate supports the skeletal system, as well as
you may experience:
nerve and muscle function.
 Bicarbonate helps balance acids and basic alkaline  Confusion and irritability.
compounds (bases) in blood (pH balance).  Diarrhea or constipation.
Bicarbonate also helps move carbon dioxide (a  Fatigue.
waste product) through your bloodstream.  Headaches.
TYPES OF ELECTROLYTES  Irregular or fast heart rate (arrhythmia).
 Muscle cramps, muscle spasms or weakness.
High electrolyte imbalances include:
 Nausea and vomiting.
 Sodium: Hypernatremia.  Numbness or tingling in limbs, fingers and toes.
 Potassium: Hyperkalemia.
 Calcium: Hypercalcemia.
 Chloride: Hyperchloremia. DIAGNOSTIC TEST
 Magnesium: Hypermagnesemia.
 Phosphate: Hyperphosphatemia. An electrolyte panel is a blood test that measures electrolyte
 Bicarbonate: Alkalosis (low alkaline base). levels. Healthcare providers often order an electrolyte panel
if you:

Low electrolytes or electrolyte deficiencies include:  Need blood tests for a routine physical exam.
 Are in the hospital.
 Sodium: Hyponatremia.  Have certain health conditions.
 Potassium: Hypokalemia.  Experience disease symptoms.
 Calcium: Hypocalcemia.
 Chloride: Hypochloremia.
 Magnesium: Hypomagnesemia. MEDICAL MANAGEMENT
 Phosphate: Hypophosphatemia.
 Bicarbonate: Acidosis (high acid levels).  Treatment depends on the specific electrolyte
RISK FACTORS imbalance and cause. Some imbalances will correct
without treatment.
Certain conditions can also throw off your body’s electrolyte  To treat dehydration, your provider may recommend
levels. You may be more likely to develop an electrolyte rehydrating with electrolyte drinks or an oral
imbalance if you have: rehydration salt (ORS) solution. Medical provider
can tell the correct amount of sugar, salt and water
 Burns. to make this solution at home. Or can buy ORS
 Cancer. packets at a drugstore.
 Cardiovascular disease, heart failure or high blood  Medical treatments for electrolyte imbalances
pressure. include:
 Dehydration due to not drinking enough liquids or  IV fluids like sodium chloride to rehydrate our
from excessive vomiting, diarrhea, sweating body.
(hyperhidrosis) or fever.  IV medicines to restore a healthy electrolyte
 Overhydration or water intoxication (drinking too balance.
much water).  Medications or supplements to replace lost
 Eating disorders. electrolytes.
 Kidney disease.  Hemodialysis to correct electrolyte imbalances
 Liver disease like cirrhosis. caused by kidney failure or severe kidney
 Substance use disorder. damage.
 Proper hydration can help our body maintain a
healthy level of electrolytes. It’s especially

BSN 3A | PBL GROUP 1 8

BSN 3A | PBL GROUP 1

NCM112 LECTURE
MEDICAL-SURGICAL NURSING

FLUID DISTRUBANCES, ELECTROLYTE IMBALANCES, RENAL AND KIDNEY DISORDERS

important to drink enough fluids if experience CLINICAL MANIFESTATIONS
prolonged diarrhea, vomiting or sweating.
The clinical presentation depends on the underlying etiology.
Symptoms may include:
ACID–BASE DISTURBANCES
 Kussmaul respirations (slow, deep breathing)
 Diarrhea
 Ketoacidosis:
ACUTE AND CHRONIC METABOLIC ACIDOSIS  Polyuria
(BASE BICARBONATE DEFICIT)  Polydipsia
 Epigastric pain
 The renal system is responsible for eliminating the  Vomiting
daily load of non-volatile acids, which is
 Renal failure:
approximately 70 millimoles per day. This daily load
 Nocturia
comes primarily from anaerobic metabolism,
 Polyuria
absorption of acids, and excretion of bases from the
 Pruritis
GI system. Metabolic acidosis occurs when there is
 Methanol poisoning: visual symptoms (photophobia,
an increase in the levels of new non-volatile acids
scotomata, blindness)
(e.g., lactic acid), renal loss of HCO3-, or ingestion of
 Salicylate overdose:
toxic alcohols. Respiratory compensation occurs
 Tinnitus
very quickly (within minutes) and mitigates changes
 Blurred vision
in pH. In the acute period, metabolic disorders can
 Vertigo
cause severe symptoms. Management is aimed at
correcting the underlying etiology. ASSESSMENT AND DIAGNOSTIC FINDINGS
 Metabolic acidosis is the process that results in the
gain of hydrogen ions (H+) or the loss of HCO3-. In  ABG measurements are used in the diagnosis of
primary metabolic acidosis, arterial blood gas will acid–base imbalances such as metabolic acidosis.
show: Expected ABG changes include a low bicarbonate
 pH < 7.4 level (less than 22 mEq/L) and a low blood pH (less
 HCO3- < 24 mEq/L than 7.35). The cardinal feature of metabolic acidosis
 Partial pressure of arterial CO2 (PCO2) < 40 is a decrease in the serum bicarbonate level. In
mm Hg conditions of acidosis there is elevated H+ and the
sodium–potassium cellular pump brings H+ into the
PATHOPHYSIOLOGY cells in place of K+. Therefore, high K+ accumulates
in the bloodstream in metabolic acidosis as a result
 Normal anion gap metabolic acidosis results from the
of the shift of potassium out of the cells (Theodore,
direct loss of bicarbonate, as in diarrhea, lower
2019). Later, when the acidosis is corrected and pH
intestinal fistulas, ureterostomies, use of diuretics,
normalized, the cellular pump causes potassium to
early renal insufficiency, excessive administration of
move back into the cells and hypokalemia may
chloride, and the administration of parenteral
occur. Blood levels of potassium need to be closely
nutrition without bicarbonate or
monitored. ECG monitoring is recommended as
bicarbonateproducing solutes (e.g., lactate) (Emmett
changes of potassium in the bloodstream can cause
& Szerlip, 2018).
arrhythmias (Palmer & Clegg, 2016a).
 High anion gap metabolic acidosis occurs when
 In metabolic acidosis, the lungs compensate for the
there is an excessive accumulation of acids. High
high H+ through hyperventilation to decrease the
anion gap occurs in lactic acidosis, salicylate
CO2 level, which in turn reduces H+ (see carbonic
poisoning (acetylsalicylic acid), renal failure,
acid equation). Calculation of the anion gap is helpful
methanol, ethylene or propylene glycol toxicity, DKA,
in determining the cause of metabolic acidosis.
and ketoacidosis that occurs with starvation. The
There are certain conditions that cause high anion
high amount of hydrogen ions due to the acids
gap metabolic acidosis and others that cause normal
present are neutralized and buffered by HCO3−
anion gap metabolic acidosis
causing the bicarbonate concentration to fall and
become exhausted. Other anions in the bloodstream
are called upon to neutralize the high acid in the
blood. In all of these instances, abnormally high
levels of anions are used to neutralize the H+, which
increases the anion above normal limits (high anion
gap) (Emmett & Szerlip, 2019).

BSN 3A | PBL GROUP 1 9

BSN 3A | PBL GROUP 1

NCM112 LECTURE
MEDICAL-SURGICAL NURSING

FLUID DISTRUBANCES, ELECTROLYTE IMBALANCES, RENAL AND KIDNEY DISORDERS

(within minutes) and mitigates changes in pH from
the primary metabolic disorder. Management is
aimed at correcting the underlying etiology.

 Metabolic alkalosis is the process that results in the

loss of hydrogen ions (H+) or the gain of HCO3-. In
primary metabolic alkalosis, arterial blood gas will
show:
 pH > 7.4
 Partial pressure of CO2 (PCO2) > 40 mm Hg
 HCO3- > 28 mEq/L

PATHOPHYSIOLOGY

 A common cause of metabolic alkalosis is severe

vomiting or gastric suction that causes loss of
stomach HCl (hydrogen and chloride ions). The
MEDICAL MANAGEMENT disorder also occurs in pyloric stenosis, in which only
gastric fluid is lost. Gastric fluid has an acid pH
 Treatment is directed at correcting the metabolic (usually 1 to 3), and loss of this highly acidic fluid
imbalance. If the problem results from excessive pulls H+ ions from the bloodstream to replenish the
intake of chloride, treatment is aimed at eliminating gastric acid. As a result, the bloodstream loses H+
the source of the chloride. When necessary, ions and becomes alkalotic. Other situations
bicarbonate is given; however, the administration of predisposing to metabolic alkalosis include those
sodium bicarbonate during cardiac arrest can result associated with loss of potassium, such as diuretic
in paradoxical intracellular acidosis. Hyperkalemia therapy that promotes excretion of potassium (e.g.,
may occur with acidosis and hypokalemia with thiazides, furosemide), and ACTH secretion (as in
reversal of the acidosis and subsequent movement hyperaldosteronism and Cushing’s syndrome)
of potassium back into the cells. Therefore, the (Emmett & Szerlip, 2017a; Norris, 2019).
serum potassium level is monitored closely, and  Hypokalemia produces alkalosis in two ways: (1)
hypokalemia is corrected as acidosis is reversed when the bloodstream is low in K+, the nephrons
(Mount, 2017c) reabsorb K+ into the bloodstream and secrete H+
 In chronic metabolic acidosis, low serum calcium into the tubule fluid which is excreted in the urine and
levels are treated before the chronic metabolic (2) when the bloodstream is low in K+, intracellular
acidosis is treated to avoid tetany resulting from an potassium moves out of the cells into the ECF, and
increase in pH and a decrease in ionized calcium. as potassium ions leave the cells, hydrogen ions
Alkalizing agents may be given. Treatment must enter to maintain electroneutrality (Mount,
modalities may also include hemodialysis or 2017c). Excessive alkali ingestion from antacids
peritoneal dialysis (Goltzman, 2019b) containing bicarbonate or from the use of sodium
bicarbonate during cardiopulmonary resuscitation
ACUTE AND CHRONIC METABOLIC ALKALOSIS can also cause metabolic alkalosis (Emmett &
(BASE BICARBONATE EXCESS) Szerlip, 2017b).
 Chronic metabolic alkalosis can occur with long-term
 The renal system is responsible for eliminating the diuretic therapy (thiazides or furosemide), villous
daily load of non-volatile acids, which is adenoma in the GI tract, external drainage of gastric
approximately 70 millimoles per day. This daily load fluids, significant potassium depletion, cystic fibrosis,
comes primarily from anaerobic metabolism, and the chronic ingestion of milk and calcium
absorption of acids, and excretion of base from the carbonate (Emmett & Szerlip, 2017b).
GI system. Metabolic alkalosis develops when there
is an increase in serum HCO3- levels. Metabolic
alkalosis also occurs when there is an increased loss
of acid, either renally or through the upper GI tract
(e.g., vomiting), increased intake of HCO3-, or a
reduced ability to secrete HCO3- when needed.
Respiratory compensation occurs very quickly

BSN 3A | PBL GROUP 1 10

BSN 3A | PBL GROUP 1

NCM112 LECTURE
MEDICAL-SURGICAL NURSING

FLUID DISTRUBANCES, ELECTROLYTE IMBALANCES, RENAL AND KIDNEY DISORDERS

CLINICAL MANIFESTATIONS - Licorice ingestion (glycyrrhizic acid)
- Liddle syndrome
- Bartter and Gitelman syndromes
o Severe hypokalemia (K+ < 2)
 Other tests:
 Basic metabolic panel (BMP):
o Allows assessment of HCO3-
o Important for managing electrolytes,
especially K+
 Arterial blood gas
The clinical presentation is dependent on the underlying  Testing relevant to the suspected underlying
etiology. Symptoms may include: etiology
 Vomiting
 BP abnormalities: MEDICAL MANAGEMENT
 Hypertension (primary mineralocorticoid
excess) Treatment is aimed at the underlying etiology.
 Hypotension (↓ effective circulating volume)  Attempt to improve renal HCO3- excretion to resolve
 Hypokalemia alkalosis:
 Hypocalcemia:  In patients without edema (true volume
depletion): volume repletion with isotonic
saline
 Tetany  In patients with ↓ effective circulating volume
 Chvostek sign: contraction of facial muscles (e.g., heart failure):
when the facial nerve is tapped o Potassium chloride
 Trousseau sign: carpopedal spasm with o K+-sparing diuretics (e.g., amiloride)
inflation of the BP cuff 
 Changes in mental status/seizures o Avoid isotonic saline as it will worsen
 Findings consistent with a prerenal state: symptoms without improving alkalosis.
 Congestive heart failure:  Correct electrolyte abnormalities, especially:
-Chest pain  K+
-Dyspnea on exertion  Cl-
-↑ Jugular venous distension  Na+ (through fluid management)
-Pulmonary edema(crackleson lung exam)  Consider dialysis in patients with CKD.
-Peripheral edema
ACUTE AND CHRONIC RESPIRATORY ACIDOSIS
 Cirrhosis:
(CARBONIC ACID EXCESS)
 Jaundice
 Ascites  The respiratory system is responsible for eliminating
 Hepatomegaly with/without splenomegaly the volatile acid carbon dioxide (CO2), which is
 Telangiectasias produced via aerobic metabolism. The body
produces approximately 15,000 mmol of CO2 daily,
DIAGNOSTIC FINDINGS which is the majority of daily acid production; the
remainder of the daily acid load (only about 70 mmol
 The etiology of metabolic alkalosis is usually
of nonvolatile acids) is excreted through the kidneys.
ascertainable from the history alone. Urine Cl- can
In the setting of hypoventilation, this acid load is not
be helpful in cases in which the patient is reluctant to
adequately blown off, and respiratory acidosis
provide a full history (e.g., self-induced vomiting in
occurs. Renal compensation occurs after 3–5 days,
eating disorders) or for less common etiologies (e.g.,
as the kidneys attempt to increase the serum
Conn, Bartter, and Gitelman syndromes).
bicarbonate levels. Patients are often asymptomatic,
or they may present with neuropsychiatric
 Urine chloride:
manifestations or mild dyspnea. Diagnosis is made
 Urine Cl- < 20 mEq/L: body Cl- is also
with arterial blood gas measurement. Management
depleted, typically in volume depletion:
involves treating the underlying etiology, stabilizing
o Vomiting
the patient, and avoiding respiratory sedatives.
o Nasogastric suction
 Respiratory acidosis is the process that results in an
 Urine Cl- > 20 mEq/L: Body Cl- level is
accumulation of carbon dioxide (CO2) due to
normal, typically in patients with volume
abnormal gas exchange in the lungs. In primary
expansion:
respiratory acidosis, the arterial blood gas will show:
o Mineralocorticoid excess:
 pH < 7.35
- Cushing's syndrome (hypercortisolism)
-Conn syndrome (primary hyperaldosteronism)

BSN 3A | PBL GROUP 1 11

BSN 3A | PBL GROUP 1

NCM112 LECTURE
MEDICAL-SURGICAL NURSING

FLUID DISTRUBANCES, ELECTROLYTE IMBALANCES, RENAL AND KIDNEY DISORDERS

 PCO2 (partial pressure of carbon dioxide) > other diagnostic measures include monitoring of
45 mm Hg (i.e., hypercapnia) serum electrolyte levels, chest x-ray for determining
respiratory infection or other disease, and a drug
PATHOPHYSIOLOGY screen if an overdose is suspected. ECG monitoring
is recommended to identify any cardiac involvement
 Respiratory acidosis is due to inadequate excretion as a result of COPD (Feller-Kopman &
of CO2 with inadequate ventilation, resulting in Schwartzstein, 2017).
elevated plasma CO2 concentrations and,
consequently, increased levels of carbonic acid. In MEDICAL MANAGEMENT
addition to an elevated PaCO2, inadequate
ventilation usually causes a decrease in PaO2. Acute  Assess the ABCs:
respiratory acidosis occurs in emergency situations,  Ensure that the airway is secure.
such as acute pulmonary edema, aspiration of a  Administer supplemental O2.
foreign object, atelectasis, pneumothorax, and  Ventilatory support as needed
overdose of sedatives, as well as in nonemergent  Treat the underlying etiology; examples include:
situations, such as sleep apnea associated with  COPD exacerbation: bronchodilators and
severe obesity, severe pneumonia, and acute corticosteroids
respiratory distress syndrome. Respiratory acidosis  Pneumonia in neuromuscular disorders:
commonly occurs in patients with severe chronic antibiotics
obstructive pulmonary disease (COPD) when  Avoid respiratory sedatives.
patients acutely decompensate due to respiratory
infection or heart failure. Respiratory acidosis can ACUTE AND CHRONIC RESPIRATORY ALKALOSIS
also occur in diseases that impair respiratory muscle (CARBONIC ACID DEFICIT)
function and cause hypoventilation. These disorders
 The respiratory system is responsible for eliminating
include severe scoliosis, muscular dystrophy,
the volatile acid carbon dioxide (CO2), which is
multiple sclerosis, myasthenia gravis, and Guillain-
produced via aerobic metabolism. The body
Barré syndrome (Feller-Kopman & Schwartzstein,
2017). produces approximately 15,000 mmol of CO2 daily,
which is the majority of daily acid production; the
CLINICAL MANIFESTATIONS remainder of the daily acid load (only about 70 mmol
of nonvolatile acids) is excreted through the kidneys.
 Clinical presentation of hypercapnia: When hyperventilation occurs, excess carbon
 Neurologic: dioxide is blown off and respiratory alkalosis
o Anxiety/paranoia 
o Headaches  develops. The kidneys respond by decreasing serum
o Somnolence bicarbonate (HCO3–) through increased HCO3–
o Delirium excretion or decreased excretion of H+. Patients
o Coma present with an increased respiratory rate, dyspnea,
 Pulmonary: dyspnea (usually mild) light-headedness and potentially psychologic
 Diagnosis: primarily with an arterial blood gas (ABG): symptoms. Diagnosis involves a thorough history, an
 Acute respiratory acidosis: exam, and an arterial blood gas measurement.
o pH < 7.35 Management focuses on addressing the underlying
o PaCO2 > 45 mm Hg abnormalities, stabilizing patients in acute distress,
o Normal HCO3– and potentially a small dose of short-acting
 Chronic respiratory acidosis (compensated): benzodiazepines.
o pH < 7.4 (low or near-normal)  Respiratory alkalosis refers to the process that
o PaCO2 > 45 mm Hg results in a decreased level of carbon dioxide (CO2)
o HCO3– elevated within the blood.

ASSESSMENT AND DIAGNOSTIC FINDINGS PATHOPHYSIOLOGY

 In respiratory acidosis, ABG analysis reveals a pH  Respiratory alkalosis is caused by hyperventilation,

less than 7.35, a PaCO2 greater than 45 mm Hg, and which causes excessive loss or “blowing off” of CO2
variation in the bicarbonate level, depending on the and, hence, there is a decrease in the plasma
duration of the acute respiratory acidosis. When carbonic acid concentration (see carbonic acid
compensation occurs over a prolonged period and equation). Causes include extreme anxiety such as
renal retention of bicarbonate has fully occurred, the panic disorder, hypoxemia, salicylate intoxication,
bicarbonate neutralizes the acidosis. Arterial pH is gram-negative sepsis, and inappropriate ventilator
within the lower limits of normal (e.g., pH 7.35). settings.
Depending on the cause of respiratory acidosis,

BSN 3A | PBL GROUP 1 12

BSN 3A | PBL GROUP 1

NCM112 LECTURE
MEDICAL-SURGICAL NURSING

FLUID DISTRUBANCES, ELECTROLYTE IMBALANCES, RENAL AND KIDNEY DISORDERS

 Chronic respiratory alkalosis results from chronic MIXED ACID–BASE DISORDERS
hypocapnia which leads to decreased serum H+ ion,
resulting in alkalosis. Chronic hepatic insufficiency  Patients can simultaneously experience two or more
and cerebral tumors can cause chronic independent acid–base disorders. A normal pH in the
hyperventilation that leads to chronic respiratory presence of changes in the PaCO2 and plasma
alkalosis (Schwartzstein, Richards, Edlow, et al., HCO3− concentration immediately suggests a mixed
2018) disorder. An example of a mixed disorder is the
simultaneous occurrence of metabolic acidosis due
CLINICAL MANIFESTATIONS to lactic acid accumulation and respiratory acidosis
due to hypoventilation. Both of these disorders result
 Tachypnea in excessive acid accumulation in the bloodstream
 Dyspnea due to respiratory failure and cardiac arrest (Emmett
 Dizziness/light-headedness & Palmer, 2018b).
 Paresthesias (perioral, hands/feet) due to decreased
ionized calcium COMPENSATION
 Psychologic symptoms:
 Generally, the pulmonary and renal systems
 Anxiety
compensate for each other to return the pH to
 Fear
normal. In a single acid–base disorder, the system
 Impending doom
not causing the problem tries to compensate by
 Highly variable presentation, based on underlying
returning the ratio of bicarbonate to carbonic acid to
etiology; for example:
the normal 20:1. The lungs compensate for
 High-altitude illness: findings consistent with
metabolic disturbances by changing CO2 excretion;
pulmonary and/or cerebral edema
hypoventilation accumulates CO2, hyperventilation
 Sepsis: fever, hypotension, findings
causes loss of CO2. The kidneys compensate for
consistent with originating infection (e.g.,
respiratory disturbances by altering bicarbonate
cough or dysuria)
reabsorption and H+ secretion (Norris, 2019;
 Pulmonary embolism: calf pain, unilateral
Theodore, 2019).
lower-extremity edema
 In respiratory acidosis, excess hydrogen in the blood
DIAGNOSTIC FINDINGS is excreted in the urine in exchange for bicarbonate
ions which are conserved. In respiratory alkalosis,
Diagnosing a respiratory alkalosis typically requires a the renal excretion of bicarbonate increases, and
thorough history and exam and an arterial blood gas hydrogen ions are retained. In metabolic acidosis,
measurement. the lungs compensate by increasing the ventilation
 Arterial blood gas: rate and the kidneys retain bicarbonate. In metabolic
 Acute respiratory alkalosis (uncompensated): alkalosis, the respiratory system compensates by
o pH > 7.45 decreasing ventilation to conserve CO2 and increase
o PaCO2 < 35 mm Hg the PaCO2, which in turn increases carbonic acid.
o Normal HCO3– Because the lungs respond to acid–base disorders
 Chronic respiratory alkalosis (compensated): within minutes, compensation for metabolic
imbalances occurs faster than renal compensation
o pH > 7.4 (slightly high or near-normal) for respiratory imbalances (Norris, 2019; Theodore,
o PaCO2 < 35 mm Hg 2019).
o HCO3– decreased
BLOOD GAS ANALYSIS
 Electrolytes: Abnormalities are common and may
lead to complications.
 Blood gas analysis is often used to identify the
 Basic metabolic panel
specific acid–base disturbance and the degree of
 Magnesium
compensation that has occurred. The analysis is
 Phosphate
usually based on an arterial blood sample; however,
 Chest X-ray: to rule out other causes of tachypnea
if an arterial sample cannot be obtained, a mixed
venous sample may be used (Theodore, 2019).
MEDICAL MANAGEMENT
Results of ABG analysis provide information about
 Assess and address the ABCs (airway, breathing, alveolar ventilation, oxygenation, and acid–base
and circulation) if patient is in acute distress. balance. It is necessary to evaluate the
concentrations of serum electrolytes (e.g., sodium,
 Attempt to correct the underlying abnormality.
potassium, chloride) along with ABG data because
 Small dose of short-acting benzodiazepine
electrolytes are commonly affected by acid–base
imbalances. The health history, physical
examination, previous blood gas results, and serum

BSN 3A | PBL GROUP 1 13

BSN 3A | PBL GROUP 1

NCM112 LECTURE
MEDICAL-SURGICAL NURSING

FLUID DISTRUBANCES, ELECTROLYTE IMBALANCES, RENAL AND KIDNEY DISORDERS

electrolytes should always be part of the assessment
used to determine the cause of the acid–base
disorder (Larkin & Zimmanck, 2015). Responding to
isolated sets of blood gas results without these data
can lead to serious errors in interpretation. Treatment
of the underlying condition usually corrects acid–
base disorders.

PARENTERAL FLUID THERAPY

 When patients cannot take oral fluid or oral feedings,

their status is termed NPO (nil per os), meaning
nothing by mouth.
 In patients who are NPO, parenteral fluid therapy,
also termed IV fluid therapy, is used to administer
fluids. IV fluid therapy can be initiated to replace
fluids in various clinical settings such as hospitals,
outpatient diagnostic and surgical settings, clinics,
and home health care. IV fluids can also be used to
administer medications and provide nutrients.

PURPOSE

 The choice of an IV solution depends on the purpose

of its administration. Generally, IV fluids are given to
achieve one or more of the following goals:

 To provide water, electrolytes, and nutrients to

meet daily requirements.
 To replace water and correct electrolyte
deficits.
 To administer medications and blood
products.

BSN 3A | PBL GROUP 1 14

BSN 3A | PBL GROUP 1

NCM112 LECTURE
MEDICAL-SURGICAL NURSING

FLUID DISTRUBANCES, ELECTROLYTE IMBALANCES, RENAL AND KIDNEY DISORDERS

 IV solutions contain dextrose and/or electrolytes NORMAL SALINE SOLUTION
mixed in various proportions with water. Pure,
electrolyte-free water can never be given by IV  Normal saline (0.9% sodium chloride) solution
because it rapidly enters RBCs and causes them to contains water, sodium, and chloride.
rupture  Because the osmolality is entirely contributed by
electrolytes, the solution remains within the ECF and
TYPES OF INTRAVENOUS SOLUTIONS expands the intravascular volume.
 For this reason, normal saline solution is often used
 IV solutions are categorized as isotonic, hypotonic,
to correct an extracellular volume deficit but is not
or hypertonic, according to whether their total
identical to ECF.
osmolality is the same as, less than, or greater than
 It is used with administration of blood transfusions
that of blood, respectively.
and to replace large sodium losses, such as in burn
 Electrolyte solutions are considered isotonic if the
injuries.
total electrolyte content (anions + cations) is between
 It should not be used in heart failure, pulmonary
250 and 375 mEq/L, hypotonic if the total electrolyte
edema, renal impairment, or sodium retention.
content is less than 250 mEq/L, and hypertonic if the
 Normal saline does not supply calories.
total electrolyte content is greater than 375 mEq/L.

OTHER ISOTONIC SOLUTION

ISOTONIC FLUIDS
 Several other solutions contain ions in addition to
 Fluids that are classified as isotonic have a total
sodium and chloride and are somewhat similar to the
osmolality close to that of the ECF and do not cause
ECF in composition.
cells to shrink or swell.
 Lactated Ringer’s solution contains potassium and
 When isotonic fluids are administered they expand
calcium in addition to sodium chloride.
the ECF volume.
 It is used to correct dehydration, blood loss, and
 An isotonic solution is a crystalloid solution (water
sodium depletion and to replace GI losses.
containing soluble mineral salts).
 Plasma is a colloidal solution. A colloidal solution is
a mixture of fluid containing insoluble large particles, HYPOTONIC SOLUTIONS
such as proteins.
 Colloidal solutions exert oncotic pressure;  One purpose of hypotonic solution is to replace fluid,
crystalloids do not exert oncotic pressure because it is hypotonic compared with plasma.
 Another purpose of hypotonic solution is to provide
Note: It is important for the nurse to recognize that in free water. At times, hypotonic sodium solutions are
blood loss, 3 L of isotonic fluid (crystalloid solution) used to treat hypernatremia and other hyperosmolar
is needed to replace 1 L of conditions.
blood (colloidal solution).  Half-strength saline (0.45% sodium chloride) solution
is frequently used.
 Isotonic fluids expand the water volume in the  Patients with any type of cardiac implantable
intravascular space, patients with heart failure or electronic device need to be screened to determine
hypertension who receive isotonic solutions should if they can safely undergo MRI.
be carefully monitored for signs of fluid overload.  The nurse should educate the patient regarding what
to expect during and after the procedure.
D5W  The patient should be prepared to lie on a cold, hard
table that slides into an enclosed small tube.
 A solution of D5W is unique in that it may be both  The nurse should inform the patient that they will
isotonic and hypotonic. hear noises, including periodic banging and popping
 It is essential to consider this action of D5W, sounds.
especially if the patient is at risk for increased  Patients with claustrophobia may be prescribed a
intracranial pressure. sedative prior to the procedure.
 During fluid resuscitation, this solution should not be  Patients should be instructed to close their eyes
used because hyperglycemia can result. before entering the tube, and to keep them closed,
 Therefore, D5W is used mainly to supply water and as this may decrease claustrophobic symptoms.
to correct an increased serum osmolality.
 About 1 L of D5W provides less than 170 kcal and is
HYPERTONIC FLUIDS
a minor source of the body’s daily caloric
requirements.  Hypertonic fluids include 3% NaCl and IV mannitol.

BSN 3A | PBL GROUP 1 15

BSN 3A | PBL GROUP 1

NCM112 LECTURE
MEDICAL-SURGICAL NURSING

FLUID DISTRUBANCES, ELECTROLYTE IMBALANCES, RENAL AND KIDNEY DISORDERS

 If a patient is sodium depleted, a hypertonic sodium FLUID OVERLOAD
IV solution might be used.
 If a patient is experiencing acute cerebral edema, IV  Overloading the circulatory system with excessive IV
mannitol is often used fluids causes increased blood pressure and central
 Hypertonic solutions pull water from the interstitial venous pressure.
and intracellular compartments into the bloodstream.  Signs and symptoms of fluid overload include moist
These solutions draw water out of intracellular crackles on auscultation of the lungs, cough,
compartments causing cellular dehydration. restlessness, distended neck veins, edema, weight
 Normal saline and lactated Ringer’s solution are gain, dyspnea, and rapid, shallow respirations.
considered isotonic solutions. When 5% dextrose  Its treatment includes decreasing the IV rate,
(D5W) is added to normal saline solution or lactated monitoring vital signs frequently, assessing breath
Ringer’s solution, the total osmolality exceeds that of sounds, and placing the patient in a high Fowler
the ECF. position.
 Saline solutions are also available in osmolar  The primary provider is contacted immediately. This
concentrations greater than that of the ECF. complication can be avoided by using an infusion
 These solutions draw water from the ICF to the ECF pump and by carefully monitoring all infusions.
and cause cells to shrink.
 As a result, these solutions must be given cautiously
and usually only when the serum osmolality has AIR EMBOLISM
decreased to dangerously low levels.
 It is most often associated with cannulation of central
 Hypertonic solutions exert an osmotic pressure
veins and directly related to the size of the embolus
greater than that of the ECF.
and the rate of entry.
 Air entering into central veins gets to the right
OTHER INTRAVENOUS THERAPIES ventricle, where it lodges against the pulmonary
valve and blocks the flow of blood from the ventricle
 When the patient is unable to tolerate food, into the pulmonary arteries.
nutritional requirements are often met using the IV  Treatment calls for immediately clamping the
route. cannula and replacing a leaking or open infusion
 Solutions may include high concentrations of glucose system, placing the patient on the left side in the
(such as 50% dextrose in water), protein, or fat to Trendelenburg position, assessing vital signs and
meet nutritional requirements. breath sounds, and administering oxygen.
 Many medications are also delivered by the IV route,  Air embolism can be prevented by using locking
either by continuous infusion or by intermittent bolus adapters on all lines, filling all tubing completely with
directly into the vein. solution, and using an air detection alarm on an IV
 Because IV medications enter the circulation rapidly, infusion pump.
administration by this route is potentially hazardous

Note: The nurse must assess the patient for a history PHLEBITIS
of allergic reactions to medications. Although
 Phlebitis, or inflammation of a vein, can be
obtaining drug allergy information is important when
categorized as chemical, mechanical, or bacterial;
administering any medication,
however, two or more of these types of irritation often
occur simultaneously.
 Phlebitis can be prevented by using aseptic
It is especially critical with IV administration, because
technique during insertion, using the appropriate
the medication is delivered directly into the
size cannula or needle for th vein, considering the
bloodstream. This can trigger an immediate
composition of fluids and medications when
hypersensitivity reaction.
selecting a site, observing the site hourly for any
NURSING MANAGEMENT OF THE PATIENT RECEIVING complications, anchoring the cannula or needle well,
INTRAVENOUS THERAPY and changing the IV site according to agency policy
and procedures.
 In many settings, the ability to perform venipuncture
to gain access to the venous system for
administering fluids and medication is an expected THROMBOPHLEBITIS
nursing skill.
 This responsibility includes selecting the appropriate  Thrombophlebitis refers to the presence of a clot plus
venipuncture site and type of cannula and being inflammation in the vein.
proficient in the technique of vein entry.  Treatment includes discontinuing the IV infusion;
applying a cold compress first to decrease the flow

BSN 3A | PBL GROUP 1 16

BSN 3A | PBL GROUP 1

NCM112 LECTURE
MEDICAL-SURGICAL NURSING

FLUID DISTRUBANCES, ELECTROLYTE IMBALANCES, RENAL AND KIDNEY DISORDERS

of blood, followed by a warm compress; elevating the based on measures of kidney function and urine
extremity; and restarting the line in the opposite tests, and it is classified into stages based on the
extremity. level of kidney damage and the degree of reduction
 If the patient has signs and symptoms of in the glomerular filtration rate (GFR). The condition
thrombophlebitis, the IV line should not be flushed can be caused by a variety of factors, including
(although flushing may be indicated in the absence diabetes, high blood pressure, and certain genetic or
of phlebitis to ensure cannula patency and to prevent autoimmune disorders. Treatment may include
mixing of incompatible medications and solutions). medications, lifestyle changes, and in severe cases,
dialysis or kidney transplantation.

HEMATOMA PATHOPHYSIOLOGY

 Hematoma results when blood leaks into tissues  Chronic kidney disease (CKD) is a progressive and
surrounding the IV insertion site. irreversible deterioration in renal function, with the
 Leakage can result if the vein wall is perforated loss of nephrons, the functional unit of the kidney,
during venipuncture, the needle slips out of the vein, over time. The pathophysiology of CKD involves
a cannula is too large for the vessel, or insufficient complex interactions between different factors,
pressure is applied to the site after removal of the including genetic, environmental, and metabolic
needle or cannula. factors. The most common causes of CKD are
 Treatment includes removing the needle or cannula diabetes and hypertension, which can lead to
and applying light pressure with a sterile, dry damage to the small blood vessels and the nephrons
dressing; applying ice for 24 hours to the site to avoid in the kidneys. Other causes include
extension of the hematoma; elevating the extremity glomerulonephritis, polycystic kidney disease, and
to maximize venous return, if tolerated; assessing obstructive uropathy. As the nephrons are damaged,
the extremity for any circulatory, neurologic, or motor the kidneys' ability to filter waste products and
dysfunction; and restarting the line in the other excess fluid from the blood is reduced, leading to a
extremity if indicated. build-up of toxic substances in the body. This can
cause a variety of symptoms, including fatigue,
weakness, nausea, and fluid retention. In addition to
CLOTTING AND OBSTRUCTION the loss of renal function, CKD can also lead to a
number of other complications, including anemia,
 Blood clots may form in the IV line as a result of bone disease, and cardiovascular disease. These
kinked IV tubing, a very slow infusion rate, an empty complications are thought to be related to a
IV bag, or failure to flush the IV line after intermittent combination of factors, including inflammation,
medication or solution administrations. oxidative stress, and altered hormone levels. Overall,
 If blood clots in the IV line, the infusion must be CKD is a complex and multifactorial condition that
discontinued and restarted in another site with a new requires ongoing management and monitoring to
cannula and administration set. prevent further kidney damage and to manage its
 The tubing should not be irrigated or milked. Neither associated complications.
the infusion rate nor the solution container should be
raised, and the clot should not be aspirated from the RISK FACTORS
tubing.
 Clotting of the needle or cannula may be prevented  Diabetes: Diabetes is the leading cause of CKD.
by not allowing the IV solution bag to run dry, taping High blood sugar levels can damage blood vessels
the tubing to prevent kinking and maintain patency, in the kidneys, making them less effective at filtering
maintaining an adequate flow rate, and flushing the waste.
line after intermittent medication or other solution  High blood pressure: High blood pressure damages
administration. the blood vessels in the kidneys and can lead to
CKD.
KIDNEY DISORDERS  Family history of kidney disease: If you have a family
history of kidney disease, you may be at increased
risk of developing CKD.
CHRONIC KIDNEY DISEASE
 Age: The risk of CKD increases as you get older.
 Chronic kidney disease (CKD) is a long-term  Smoking: Smoking damages blood vessels
condition in which the kidneys are damaged and throughout the body, including those in the kidneys,
cannot filter blood as effectively as they should. This and can increase the risk of CKD.
leads to a build-up of waste and fluid in the body,  Obesity: Being overweight or obese can increase the
which can cause a range of symptoms and risk of CKD.
complications over time. CKD is typically diagnosed

BSN 3A | PBL GROUP 1 17

BSN 3A | PBL GROUP 1

NCM112 LECTURE
MEDICAL-SURGICAL NURSING

FLUID DISTRUBANCES, ELECTROLYTE IMBALANCES, RENAL AND KIDNEY DISORDERS

 Cardiovascular disease: People with cardiovascular conducted to check for protein or blood in the urine,
disease are at increased risk of developing CKD. which can be a sign of kidney damage.
 Certain ethnic groups: African Americans, Native  Imaging tests: Imaging tests, such as an ultrasound,
Americans, and Hispanics are at higher risk of CT scan, or MRI, may be conducted to check the size
developing CKD than other ethnic groups. and shape of the kidneys and to detect any
 Prolonged use of certain medications: Some abnormalities or blockages.
medications, such as nonsteroidal anti-inflammatory  Kidney biopsy: A kidney biopsy may be performed to
drugs (NSAIDs), can damage the kidneys if used for obtain a sample of kidney tissue for analysis if the
long periods. cause of CKD is uncertain.

CLINICAL MANIFESTATIONS MANAGEMENT AND TREATMENT

 Fatigue and weakness: As the kidneys become less  Medications: Medications may be prescribed to treat
effective at removing waste products, toxins can conditions that can cause kidney damage, such as
build up in the body, causing fatigue and weakness. high blood pressure, diabetes, and high cholesterol.
 Fluid retention: The kidneys play a key role in Medications may also be used to control symptoms
regulating the body's fluid balance. As they become associated with CKD, such as anemia and bone
damaged, fluid can build up in the body, leading to disease.
swelling in the legs, ankles, feet, and face.  Dietary changes: A diet low in sodium, protein, and
 High blood pressure: The kidneys are also involved phosphorus can help reduce the workload on the
in regulating blood pressure. When they are kidneys and prevent further damage. It is also
damaged, blood pressure can rise. important to consume enough calories to maintain a
 Decreased urine output: As CKD progresses, the healthy weight and to limit the intake of fluids.
kidneys may produce less urine or stop producing  Blood pressure control: High blood pressure is a
urine altogether. common complication of CKD and can worsen
 Changes in urine: Urine may be foamy or contain kidney damage. Controlling blood pressure through
blood or protein as a result of kidney damage. medication, lifestyle changes, and regular monitoring
 Anemia: The kidneys produce a hormone called is essential to prevent further damage.
erythropoietin that stimulates the production of red  Blood sugar control: For people with diabetes,
blood cells. As the kidneys become damaged, they maintaining tight control of blood sugar levels is
produce less erythropoietin, leading to anemia. essential to prevent or slow the progression of CKD.
 Bone disease: CKD can lead to bone disease  Regular monitoring: Regular check-ups with a
because the kidneys are involved in regulating healthcare provider are important to monitor kidney
calcium and phosphorus levels in the body. function and to adjust treatment plans as needed.
 Itching: Build-up of waste products in the blood can  Dialysis: In advanced stages of CKD, when the
cause skin itching. kidneys are no longer able to function properly,
 Nausea and vomiting: As toxins build up in the body, dialysis may be necessary to filter waste products
it can cause nausea and vomiting. from the blood.
 Shortness of breath: As fluid builds up in the lungs, it  Kidney transplant: For some people with advanced
can cause shortness of breath. CKD, a kidney transplant may be an option. This
involves surgically implanting a healthy kidney from
ASSESSMENT AND DIAGNOSTIC FINDINGS a donor.

 Medical history: A complete medical history is NURSING INTERVENTIONS

important in the diagnosis of CKD. Risk factors for
CKD, such as diabetes, high blood pressure, family  Monitor and manage fluid and electrolyte balance:
history of kidney disease, and previous kidney CKD can affect the body's ability to regulate fluid and
infections or diseases, will be assessed. electrolyte levels, leading to imbalances. Nurses
 Physical examination: A physical examination will be should monitor the patient's fluid intake and output,
conducted to check for signs of kidney disease, such assess for signs of fluid overload or dehydration, and
as high blood pressure, swelling in the legs or ankles, administer IV fluids and medications as needed to
and anemia. maintain electrolyte balance.
 Blood tests: Blood tests, such as a complete blood  Control blood pressure: High blood pressure is a
count (CBC), serum creatinine, and blood urea common complication of CKD and can further
nitrogen (BUN), will be conducted to measure the damage the kidneys. Nurses should monitor blood
levels of waste products in the blood. An abnormal pressure regularly and administer antihypertensive
result could indicate kidney damage or disease. medications as prescribed.
 Urine tests: Urine tests, such as a urinalysis and
urine albumin-to-creatinine ratio (ACR), will be

BSN 3A | PBL GROUP 1 18

BSN 3A | PBL GROUP 1

NCM112 LECTURE
MEDICAL-SURGICAL NURSING

FLUID DISTRUBANCES, ELECTROLYTE IMBALANCES, RENAL AND KIDNEY DISORDERS

 Administer medications as prescribed: Patients with and underlying medical conditions such as diabetes
CKD may require medications to manage symptoms, and lupus. When the glomeruli are damaged, they
control blood pressure, and reduce the risk of become more permeable to protein, allowing protein
complications. Nurses should ensure that patients to leak out of the blood and into the urine. This results
are taking their medications as prescribed and
monitor for any adverse reactions. in decreased levels of protein in the blood, leading to
 Monitor and manage nutrition: Patients with CKD a drop in the oncotic pressure (the pressure that
may have specific dietary needs, such as limiting keeps fluid inside the blood vessels) and the
protein, phosphorus, and potassium intake. Nurses development of edema. The liver responds to the low
should work with a registered dietician to develop a protein levels by producing more proteins, including
nutrition plan that meets the patient's needs and cholesterol and triglycerides, leading to their
provide education on how to manage their diet. increased levels in the blood. In addition to
proteinuria, other common features of nephrotic
 Manage anemia: CKD can lead to anemia, which can
syndrome include hypoalbuminemia (low levels of
cause fatigue and weakness. Nurses should monitor
the protein albumin in the blood), hyperlipidaemia
the patient's hemoglobin levels and administer
(high levels of lipids such as cholesterol and
erythropoietin-stimulating agents or iron
triglycerides in the blood), and edema. Treatment of
supplements as prescribed.
nephrotic syndrome depends on the underlying
 Educate patients on self-care: Patients with CKD
cause and may include medications to control blood
need to be involved in their care and understand how
pressure, reduce proteinuria, and prevent
to manage their condition. Nurses should provide
complications such as infections and blood clots.
education on self-care, such as monitoring blood
pressure, managing medications, and following a RISK FACTORS
renal diet.
 Monitor and manage dialysis: Patients with  Primary glomerular disease: This is the most
advanced CKD may require dialysis to filter waste common cause of nephrotic syndrome, and it occurs
and excess fluid from the blood. Nurses should when the small blood vessels in the kidneys become
monitor the patient during dialysis and assess for any inflamed and damaged. The primary glomerular
complications, such as infection or hypotension. diseases that can lead to nephrotic syndrome include
 Assess and manage complications: CKD can lead to minimal change disease, focal segmental
a variety of complications, such as cardiovascular glomerulosclerosis (FSGS), and membranous
disease, anemia, and bone disease. Nurses should nephropathy.
assess for these complications and implement  Secondary glomerular disease: This is a less
appropriate interventions to manage them. common cause of nephrotic syndrome, and it occurs
as a result of an underlying medical condition such
NEPHROTIC SYNDROME as diabetes, lupus, or amyloidosis.
 Infections: Certain infections, such as hepatitis B and
C, HIV, and malaria, can increase the risk of
 Nephrotic syndrome is a condition characterized by developing nephrotic syndrome.
high levels of protein in the urine (proteinuria), low  Medications: Some medications, such as
levels of protein in the blood, swelling (edema), and nonsteroidal anti-inflammatory drugs (NSAIDs),
high levels of cholesterol and triglycerides. It is antibiotics, and ACE inhibitors, can increase the risk
usually caused by damage to the tiny blood vessels of developing nephrotic syndrome.
in the kidneys, which can lead to the loss of large  Genetic factors: Certain genetic mutations can
amounts of protein in the urine. The condition can be increase the risk of developing nephrotic syndrome,
caused by a variety of underlying health problems, such as mutations in the NPHS1, NPHS2, and WT1
such as diabetes, lupus, and certain infections or genes.
medications. Nephrotic syndrome is typically treated  Age: Nephrotic syndrome is more common in
with medications that help reduce proteinuria and children than in adults.
inflammation, as well as other supportive measures  Gender: Boys are more likely to develop nephrotic
such as dietary changes and rest. syndrome than girls.
 Race and ethnicity: Nephrotic syndrome is more
PATHOPHYSIOLOGY common in people of African American, Hispanic,
and Asian descent than in Caucasians.
 The pathophysiology of nephrotic syndrome involves
damage to the glomeruli, which are tiny blood CLINICAL MANIFESTATIONS
vessels in the kidneys responsible for filtering waste
products and excess fluid from the blood. This  Edema: One of the most common clinical
damage may be due to various causes, such as manifestations of nephrotic syndrome is edema or
immune system disorders, infections, medications, swelling. It usually starts in the lower extremities,

BSN 3A | PBL GROUP 1 19

BSN 3A | PBL GROUP 1

NCM112 LECTURE
MEDICAL-SURGICAL NURSING

FLUID DISTRUBANCES, ELECTROLYTE IMBALANCES, RENAL AND KIDNEY DISORDERS

such as the ankles and feet, and can spread to other drugs are corticosteroids, such as prednisone, which
parts of the body, including the face and abdomen. help reduce inflammation and decrease proteinuria.
 Proteinuria: Nephrotic syndrome is also Other medications that may be used include
characterized by proteinuria, which means that large diuretics, ACE inhibitors, and angiotensin receptor
amounts of protein are excreted in the urine. This blockers.
results in foamy urine and can lead to low protein  Dietary changes: Dietary changes, such as reducing
levels in the blood. salt intake, may be recommended to help control
edema and hypertension, which are common
 Hypoalbuminemia: As a result of proteinuria, the complications of nephrotic syndrome.
level of albumin, a protein made by the liver that  Immunosuppressive therapy: If the underlying cause
helps to maintain the fluid balance in the body, of nephrotic syndrome is an autoimmune disorder,
decreases in the blood, leading to hypoalbuminemia. such as lupus or vasculitis, immunosuppressive
 Hyperlipidaemia: Nephrotic syndrome can also therapy may be prescribed to suppress the immune
cause an increase in the level of lipids, such as system and reduce inflammation.
cholesterol and triglycerides, in the blood.  Plasmapheresis: In some cases, plasmapheresis, a
 Fatigue and weakness: Due to the loss of protein in procedure in which the plasma is removed from the
the urine, the body may not have enough protein to blood and replaced with a protein solution, may be
maintain muscle mass, leading to fatigue and recommended to remove excess antibodies and
weakness. other proteins from the blood.
 Decreased urine output: In some cases, nephrotic  Kidney transplant: If nephrotic syndrome is caused
syndrome can lead to decreased urine output or by irreversible kidney damage, a kidney transplant
oliguria. may be the best option for treatment.
 Increased risk of infections: As a result of decreased
levels of immunoglobulin’s in the blood, patients with NURSING INTERVENTIONS
nephrotic syndrome are at an increased risk of
developing infections.  Monitor fluid and electrolyte balance: Monitor the
patient's intake and output, assess the patient's fluid
ASSESSMENT AND DIAGNOSTIC FINDINGS status, and monitor for signs of electrolyte
imbalances such as hyperkalemia and
 Medical history: The healthcare provider will ask hyponatremia.
about the patient's medical history, including any  Administer medications: Administer medications as
past or present kidney problems, infections, or other ordered by the healthcare provider, such as diuretics
medical conditions. to manage edema, angiotensin-converting enzyme
 Physical exam: The healthcare provider will perform (ACE) inhibitors to lower blood pressure, and
a physical exam to look for signs of swelling, immunosuppressant medications to manage
particularly in the legs, feet, and ankles. They will inflammation.
also listen to the patient's lungs and heart to check  Monitor vital signs: Monitor the patient's blood
for signs of fluid buildup. pressure, pulse rate, and respiratory rate regularly,
 Urine tests: Urine tests are done to measure the as hypertension is a common complication of
amount of protein in the urine. A 24-hour urine nephrotic syndrome.
collection may be done to get an accurate  Assess for edema: Assess the patient for edema,
measurement of protein excretion. particularly in the face, legs, and feet. Measure and
 Blood tests: Blood tests are done to measure the document the circumference of affected body parts,
level of protein, cholesterol, and triglycerides in the and monitor the patient's weight daily.
blood. Blood tests may also be done to check for  Promote skin integrity: Keep the skin clean and dry,
kidney function and to look for signs of infections or and apply moisturizing lotion to prevent cracking and
other medical conditions. dryness.
 Kidney biopsy: A kidney biopsy is a procedure in  Provide education: Educate the patient on the
which a small piece of kidney tissue is removed and importance of adhering to medication regimens,
examined under a microscope to look for signs of following a low-sodium diet, and monitoring their fluid
damage or disease. intake.
 Imaging tests: Imaging tests such as ultrasound, CT  Monitor laboratory values: Monitor the patient's
scan, or MRI may be done to check for signs of laboratory values, such as serum albumin levels,
kidney damage or to look for other possible causes serum creatinine levels, and urine output, and report
of the patient's symptoms. any abnormalities to the healthcare provider.

MANAGEMENT AND TREATMENT ACUTE KIDNEY INJURY

 Medications: The mainstay of treatment for nephrotic  is a rapid loss of renal function due to damage to the
syndrome is medication. The most commonly used kidneys.

BSN 3A | PBL GROUP 1 20

BSN 3A | PBL GROUP 1

NCM112 LECTURE
MEDICAL-SURGICAL NURSING

FLUID DISTRUBANCES, ELECTROLYTE IMBALANCES, RENAL AND KIDNEY DISORDERS

 Depending on the duration and severity of AKI, a wide
range of potentially life-threatening metabolic
complications can occur, including metabolic acidosis as
well as fluid and electrolyte imbalances.
 problem seen in patients who are hospitalized and those
in outpatient settings.
 The term acute kidney injury has replaced the term acute
renal failure because it better describes this syndrome,
in both those who require RRT and also in those patients
who experience minor changes in renal function.

NOTE: A widely accepted criterion for AKI is a 50% or greater

increase in serum creatinine above baseline (normal
creatinine is less than 1 mg/dL) (The Acute Dialysis Quality
Initiative, 2004). Urine volume may be normal, or changes
may occur including nonoliguria (greater than 800 mL/day), CATEGORIES OF ACUTE KIDNEY INJURY
oliguria (less than 400 mL/day or 0.5 mL/kg/h over 6 hours),
or anuria (less than 50 mL/day) (Odom, 2017).  PRERENAL - hypoperfusion of kidney; occurs in
60% to 70% of cases, is the result of impaired blood
PATHOPHYSIOLOGY flow that leads to hypoperfusion of the kidney
commonly caused by volume depletion (burns,
 Although the exact cause of AKI and oliguria is not
hemorrhage, GI losses), hypotension (sepsis,
always recognized, many people suffer from them.
shock), and obstruction of renal vessels, ultimately
There is sometimes a specific underlying cause.
leading to a decrease in the GFR (Odom, 2017).
Some of the risk factors may be reversible if they are
 INTRARENAL - actual damage to kidney tissue; the
detected and treated early before kidney function is
result of actual parenchymal damage to the
compromised. Hypovolemia, hypotension, reduced
glomeruli or kidney tubules.
cardiac output and heart failure, obstruction of the
 Acute tubular necrosis (ATN), or AKI in which
kidney or lower urinary tract by tumor, blood clot, or
there is damage to the kidney tubules, is the most
kidney stone, and bilateral obstruction of the renal
common type of intrinsic AKI. Characteristics of
arteries or veins are all examples of conditions that
ATN are intratubular obstruction, tubular back leak
reduce blood flow to the kidney and impair kidney
(abnormal reabsorption of filtrate and decreased
function. Increased BUN and creatinine levels,
urine flow through the tubule), vasoconstriction, and
oliguria, and other symptoms may be reversed if
changes in glomerular permeability. These
these diseases are treated and rectified before the
processes result in a decrease of GFR, progressive
kidneys are irreparably damaged. Although renal
azotemia, and fluid and electrolyte imbalances.
stones are not a prevalent cause of AKI, they do
CKD, diabetes, heart failure, hypertension, and
occur on occasion. AKI risk may be increased.
cirrhosis can contribute to ATN.
Some inherited stone disorders, primary struvite
stones, as well as infection-related urolithiasis.  POSTRENAL - obstruction to urine flow; usually
Urinary tract anatomic and functional abnormalities, results from obstruction distal to the kidney by
as well as spinal cord damage, may occur conditions such as renal calculi, strictures, blood
and induce recurring obstructions as well as crystal- clots, benign prostatic hyperplasia, malignancies,
specific injury to tubular epithelial cells and and pregnancy. Pressure rises in the kidney
interstitial renal cells (Odom, 2017). tubules, and eventually the GFR decreases.

CLASSIFICATIONS OF ACUTE KIDNEY INJURY PHASES OF ACUTE KIDNEY INJURY

 Classification criteria for AKI include assessment of  INITIATION - begins with the initial insult and ends
three grades of severity and two outcome-level when oliguria develops.
classifications. This 5-point system is known as the  OLIGURIA - is accompanied by an increase in the
RIFLE classification system. RIFLE stands for risk, serum concentration of substances usually excreted
injury, failure, loss, and ESKD (Bellomo et al., 2004). by the kidneys (urea, creatinine, uric acid, organic
Risk, injury, and failure are considered grades of acids, phosphorus, and the intracellular cations
AKI severity, whereas loss and ESKD are [potassium and magnesium]). In this phase, uremic
considered outcomes of loss that require some form symptoms first appear and life-threatening
of RRT, at least temporarily (Bellomo et al., 2004). conditions such as hyperkalemia develop.
 DIURESIS - is marked by a gradual increase in urine
output, which signals that glomerular filtration has
started to recover. Laboratory values stabilize and
eventually decrease. Although the volume of urinary

BSN 3A | PBL GROUP 1 21

BSN 3A | PBL GROUP 1

NCM112 LECTURE
MEDICAL-SURGICAL NURSING

FLUID DISTRUBANCES, ELECTROLYTE IMBALANCES, RENAL AND KIDNEY DISORDERS

output may reach normal or elevated levels, renal PREVENTION
function may still be markedly abnormal since the
filtration of urea and creatinine has not yet  Continually assess renal function (urine output, laboratory
commenced. values) when appropriate.
 Because uremic symptoms may still be present, the  Monitor central venous and arterial pressures and hourly
need for expert medical and nursing management urine output of patients who are critically ill to detect the
continues. The patient must be observed closely for onset of kidney dysfunction as early as possible.
dehydration during this phase; if dehydration occurs,  Pay special attention to wounds, burns, and other
the uremic symptoms are likely to increase and an precursors of sepsis.
elevated serum BUN and creatinine will be noted.  Prevent and treat infections promptly. Infections can
 RECOVERY - signals the improvement of renal produce progressive kidney damage.
function and may take 3 to 12 months. Laboratory  Prevent and treat hypotensive shock promptly with blood
values return to the patient’s normal level. Although and fluid replacement.
a permanent 1% to 3% reduction in the GFR may  Provide adequate hydration to patients at risk for
occur, it is not clinically significant. However, in those dehydration, including:
patients with preexisting CKD, an episode of AKI  Before, during, and after surgery
may necessitate beginning CRRT.  Patients undergoing intensive diagnostic studies
requiring fluid restriction and contrast agents (e.g.,
CLINICAL MANIFESTATIONS
barium enema, IV pyelograms), especially older
patients who may have marginal renal reserve or
 The patient may appear critically ill and lethargic.
CKD.
Central nervous system signs and symptoms include
drowsiness, headache, muscle twitching, and  Patients with neoplastic disorders or disorders of
seizures. Table 48-3 summarizes common clinical metabolism (e.g., gout) and those receiving
characteristics in all three categories of AKI. chemotherapy with potential tumor lysis syndrome
Patients with skeletal muscle injuries (e.g., crush
injuries, compartment syndrome).
 Patients with heat-induced illnesses (e.g., heat
stroke, heat exhaustion).
 To prevent infections from ascending in the urinary tract,
give meticulous care to patients with indwelling catheters.
Remove catheters as soon as possible.
 To prevent toxic drug effects, closely monitor dosage,
duration of use, and blood levels of all medications
metabolized or excreted by the kidneys.

MEDICAL MANAGEMENT

Treatment is aimed at replacing renal function temporarily to

minimize potentially lethal complications and reduce potential
causes of increased kidney injury with the goal of minimizing
long-term loss of renal function. Management includes
eliminating the underlying cause; maintaining fluid balance;
avoiding fluid excesses; and, when indicated, providing RRT.

ASSESSMENT AND DIAGNOSTIC FINDINGS Prerenal azotemia is treated by optimizing renal perfusion,
whereas postrenal failure is treated by relieving the
 Assessment of the patient with AKI includes obstruction. Intrarenal or intrinsic azotemia is treated with
evaluation for changes in the urine, diagnostic tests supportive therapy, with removal of causative agents,
that evaluate the kidney contour, and a variety of aggressive management of pre- and postrenal failure, and
laboratory values. avoidance of associated risk factors.
 ULTRASONOGRAPHY - a critical component of the
evaluation of patients with kidney disease.  HEMODIALYSIS - a procedure that circulates the
 SONOGRAM OR NONCONTRAST CT SCAN - may patient’s blood through an artificial kidney [dialyzer]
show evidence of anatomic changes. to remove waste products and excess fluid.
 SERUM CREATININE LEVELS - useful in  PERITONEAL DIALYSIS - a procedure that uses the
monitoring kidney function and disease progression patient’s peritoneal membrane (the lining of the
and increase with glomerular damage. peritoneal cavity) as the semipermeable membrane
to exchange fluid and solutes.

BSN 3A | PBL GROUP 1 22

BSN 3A | PBL GROUP 1

NCM112 LECTURE
MEDICAL-SURGICAL NURSING

FLUID DISTRUBANCES, ELECTROLYTE IMBALANCES, RENAL AND KIDNEY DISORDERS

 CONTINOUS RENAL REPLACEMENT THERAPY - PATHOPHYSIOLOGY
methods used to replace normal kidney function by
circulating the patient’s blood through a hemofilter.  As renal function declines, the end products of protein
metabolism (normally excreted in urine) accumulate
PHARMACOLOGIC THERAPY in the blood. Uremia develops and adversely affects
every system in the body. The greater the buildup of
 SODIUM POLYSTYRENE SULFONATE - treats waste products, the more pronounced the symptoms.
elevated potassium levels by exchanging sodium The rate of decline in renal function and progression
ions for potassium ions in the intestinal tract. of ESKD is related to the underlying disorder, the
 IV DEXTROSE 50%, INSULIN, AND CALCIUM urinary excretion of protein, and the presence of
REPLACEMENT - may be given to shift potassium hypertension. The disease tends to progress more
back into the cells. rapidly in patients who excrete significant amounts of
protein or have elevated blood pressure than in those
NURSING MANAGEMENT without these conditions (Mahaffey, 2017).
 The nurse monitors for complications, participates in CLINICAL MANIFESTATIONS
emergency treatment of fluid and electrolyte imbalances,
assesses the patient’s progress and response to  Cardiovascular Disease
treatment, and provides physical and emotional support.  Peripheral Neuropathy
 The nurse keeps family members informed about the  Severe pain and discomfort
patient’s condition, helps them understand the treatments,  Restless leg and burning feet
and provides psychological support.
 The nurse continues to provide nursing care indicated for ASSESSMENT AND DIAGNOSTIC FINDINGS
the primary disorder (e.g., burns, shock, trauma,
obstruction of the urinary tract).  GLOMERULAR FILTRATION RATE - As the GFR
 The nurse monitors the patient’s serum electrolyte levels decreases (due to nonfunctioning glomeruli), the
and physical indicators of these complications during all creatinine clearance decreases, whereas the serum
phases of the disorder. creatinine and BUN levels increase. Serum creatinine
 The nurse monitors fluid status by paying careful attention is a more sensitive indicator of renal function than
to fluid intake (IV medications should be given in the BUN. The BUN is affected not only by kidney disease
smallest volume possible), urine output, apparent edema, but also by protein intake in the diet, catabolism
distention of the jugular veins, alterations in heart sounds (tissue and RBC breakdown), parenteral nutrition, and
and breath sounds, and increasing difficulty in breathing. medications such as corticosteroids.
 The nurse takes steps to reduce the patient’s metabolic  SODIUM AND WATER RETENTION - The kidney
rate. Fever and infection, both of which increase the cannot concentrate or dilute the urine normally in
metabolic rate and catabolism, are prevented and treated ESKD. Appropriate responses by the kidney to
promptly; blood, urine and wound cultures are ordered as changes in the daily intake of water and electrolytes,
indicated. therefore, do not occur. Some patients retain sodium
 Attention is given to pulmonary function, and the patient is and water, increasing the risk for edema, heart failure,
assisted to turn, cough, and take deep breaths frequently and hypertension. Hypertension may also result from
to prevent atelectasis and respiratory tract infection. activation of the renin–angiotensin–aldosterone axis
Drowsiness and lethargy may prevent the patient from and the concomitant increased aldosterone secretion.
moving and turning without encouragement and Other patients have a tendency to lose sodium and
assistance. run the risk of developing hypotension and
 Asepsis is essential with invasive lines and catheters to hypovolemia. Vomiting and diarrhea may cause water
minimize the risk of infection and increased metabolism. depletion, which may worsen the uremic state.
An indwelling urinary catheter is avoided whenever  ACIDOSIS METABOLIC - acidosis occurs in ESKD
possible due to the high risk of UTI associated with its use, because the kidneys are unable to excrete increased
but may be required to provide ongoing data required to loads of acid. Decreased acid secretion results from
accurately monitor fluid I&O. the inability of the kidney tubules to excrete ammonia
(NH3 −) and to reabsorb sodium bicarbonate (HCO3
END-STAGE KIDNEY DISEASE OR CHRONIC KIDNEY −). There is also decreased excretion of phosphorus
DISEASE and other organic acids.
 ANEMIA - Anemia develops as a result of inadequate
 When a patient has sustained enough kidney damage erythropoietin production, the shortened lifespan of
to require RRT on a permanent basis, the patient has RBCs, nutritional deficiencies, and the patient’s
moved into the fifth or final stage of CKD, also referred tendency to bleed, particularly from the GI tract.
to as ESKD. Erythropoietin, a substance normally produced by the
kidneys, stimulates bone marrow to produce RBCs. In
ESKD, erythropoietin production decreases and

BSN 3A | PBL GROUP 1 23

BSN 3A | PBL GROUP 1

NCM112 LECTURE
MEDICAL-SURGICAL NURSING

FLUID DISTRUBANCES, ELECTROLYTE IMBALANCES, RENAL AND KIDNEY DISORDERS

profound anemia results, producing fatigue, angina, cannot maintain a reasonable quality of life with
and shortness of breath (Evans, 2017). conservative treatment.
 CALCIUM AND PHOSPHORUS IMBALANCE -
Another abnormality seen in ESKD is a disorder in PHARMACOLOGIC THERAPY
calcium and phosphorus metabolism. Serum calcium
and phosphate levels have a reciprocal relationship in  CALCIUM AND PHOSPHORUS BINDERS -
the body: As one increases, the other decreases. With Hyperphosphatemia and hypocalcemia are treated
a decrease in filtration through the glomerulus of the with medications that bind dietary phosphorus in the
kidney, there is an increase in the serum phosphorus GI tract. Binders such as calcium carbonate or
level and a reciprocal or corresponding decrease in calcium acetate are prescribed, but there is a risk of
the serum calcium level. The decreased serum hypercalcemia. This medication binds dietary
calcium level causes increased secretion of phosphorus in the intestinal tract; one to four tablets
parathormone from the parathyroid glands. However, are given with the first bite of food to be effective.
in kidney disease, the body cannot respond normally  ANTIHYPERTENSIVE AND CARDIOVASCULAR
to the increased secretion of parathormone. As a AGENTS - Hypertension is managed by intravascular
result, calcium leaves the bone, often producing bone volume control and a variety of antihypertensive
changes and bone disease as well as calcification of agents. Heart failure and pulmonary edema may also
major blood vessels in the body. In addition, the active require treatment with fluid restriction, low-sodium
metabolite of vitamin D (1,25- diets, diuretic agents, inotropic agents, and dialysis.
dihydroxycholecalciferol) normally manufactured by The metabolic acidosis of ESKD usually produces no
the kidney decreases as kidney disease progresses symptoms and requires no treatment. However,
(Brooks, 2017). sodium bicarbonate supplements or dialysis may be
needed to correct the acidosis if it causes symptoms.
COMPLICATIONS  ERYTHROPOIETIN - Anemia associated with ESKD
is treated with erythrocyte-stimulating agents
 ANEMIA due to decreased erythropoietin production, (recombinant human erythropoietin).
decreased RBC lifespan, bleeding in the GI tract from
irritating toxins and ulcer formation, and blood loss in NURSING MANAGEMENT
the dialysis circuit and dialyzer after HD has been
completed.  Nursing care is directed toward assessing fluid status
 BONE DISEASE AND METASTATIC AND and identifying potential sources of imbalance,
VASCULAR CALCIFICATIONS due to retention of working with a renal dietitian to implement a dietary
phosphorus, low serum calcium levels, and abnormal program to ensure proper nutritional intake within the
vitamin D metabolism. limits of the treatment regimen, and engaging the
 HYPERKALEMIA due to decreased excretion, patient by encouraging increased self-care and
metabolic acidosis, catabolism, and excessive greater independence. It is extremely important to
potassium intake from diet, medications, or IV provide explanations and information to the patient
solutions. and family concerning ESKD, treatment options, and
 HYPERTENSION due to sodium and water retention potential complications. A great deal of emotional
and malfunction of the renin–angiotensin–aldosterone support is needed by the patient and family because
system. of the numerous changes experienced. A social
 PERICARDITIS, PERICARDIAL EFFUSION, AND worker is also a vital part of the interprofessional care
PERICARDIAL TAMPONADE due to retention of at the dialysis center. Specific interventions, along
with rationale and evaluation criteria, are presented in
uremic waste products and inadequate dialysis.
more detail in the plan of nursing care for the patient
MEDICAL MANAGEMENT with ESKD.

RENAL REPLACEMENT THERAPIES

 The goal of management is to maintain kidney
function and homeostasis for as long as possible.  Renal replacement therapy is a term used to
Management is accomplished primarily with encompass life-supporting treatments for renal
medications and diet therapy, although dialysis may failure. Renal replacement therapy replaces
also be needed to decrease the level of uremic waste nonendocrine kidney function in patients with renal
products in the blood and to control electrolyte failure. Techniques include intermittent
balance. The close collaboration of a renal dietitian is hemodialysis, continuous hemofiltration and
essential in dietary therapy. hemodialysis, and peritoneal dialysis. All modalities
 DIALYSIS The patient with increasing symptoms of exchange solute and remove fluid from the blood,
kidney disease is referred to a dialysis and using dialysis and filtration across permeable
transplantation center early during progressive kidney membranes.
disease. Dialysis is usually initiated when the patient

BSN 3A | PBL GROUP 1 24

BSN 3A | PBL GROUP 1

NCM112 LECTURE
MEDICAL-SURGICAL NURSING

FLUID DISTRUBANCES, ELECTROLYTE IMBALANCES, RENAL AND KIDNEY DISORDERS

 Dialysis and filtration can be done intermittently or  Detecting cardiac and respiratory
continuously. Continuous therapy is used exclusively Complications
for acute renal failure; benefits over intermittent  Controlling electrolyte levels and Diet
therapy are improved tolerability as a result of slower  Managing discomfort and pain
removal of solute and water.  Monitoring BP
 Preventing infection
DIALYSIS
 Caring for the catheter site
 Dialysis is a treatment for individuals whose kidneys  Administering medications
are failing. When you have kidney failure, your  Providing psychological support -pt andfamily
kidneys don’t filter blood the way they should.
Dialysis does the work of your kidneys.
PRESCRIPTION MANAGEMENT

WHO NEEDS DIALYSIS  Understand your medications

 Keep your medications organized
 People who have kidney failure end- stage  Stick with your treatment plan
renal disease (ESRD)  Take all the medication you were prescribed.
 Tell your doctor if you’re having side effects.
 Injuries and conditions like high blood  Check with your doctor first before you stop taking
pressure, diabetes and lupus can damage your medication.
kidneys, leading to kidneydisease.  Ask your doctor if your prescription needs to be
refilled.

TWO TYPES OF DIALYSIS ACTIVITY RESTRICTION WHILE ON DIALYSIS

 Hemodialysis  Limit exercise or certain physical activities when the

 Peritoneal Dialysis abdomen fills with dialysis solution. Otherwise,
exercise is typically OK for people on dialysis.
HEMODIALYSIS  You should ask your provider about participating in
specific activities or sports.
 With hemodialysis, a machine removes blood
from your body, filters it through a dialyzer NOTE: Dialysis only replaces part of your kidney function.
(artificial kidney) and returns thecleaned blood Hemodialysis and peritoneal dialysis allow people with
to your body. This 3- to 5-hour process may kidney failure to feel better and continue doing the things
take place in a hospitalor a dialysis center three they enjoy, but neither replaces all the jobs that healthy
times a week. kidneys do.

 You can also do hemodialysis at home. You

HEMODIALYSIS DIALYZERS
may need at-home treatments four to seven
times per week for fewer hourseach session. HEMODIALYSIS
PERITONEAL DIALYSIS  It is used for patients who are acutely ill and require
short-term dialysis for days to weeks until kidney
 With peritoneal dialysis, tiny blood vessels function resumes, as in patients with AKI, and for
inside the abdominal lining (peritoneum) filter patients with advanced CKD and ESKD who
blood through the aid of a dialysis solution. This require long-term or permanentRRT.
solution is a type of cleansing liquid that  Prevents death but does not cure kidney disease
contains water, salt, and other additives. and does not compensate for the loss of endocrine
or metabolic activities of the kidneys.
Two ways to do this treatment:  The objectives of HD are to extract toxic
 Automated peritoneal dialysis uses amachine nitrogenous substances from the blood and to
remove excess fluid.
called a cycler.
 Continuous ambulatory
DIALYZERS
peritoneal dialysis (CAPD) takes place
manually.  Also referred to as an artificial kidney.
 Hollow-fiber devices containing thousands of tiny
capillary tubes that carry the blood through the
NURSING RESPONSIBILITIES: HOSPITALIZED PATIENT artificial kidney.
 Dialyzers have undergone many technologic
 Protecting the vascular access changes in performance and biocompatibility.
 Precautions during, I.V therapy
 Monitoring symptoms of uremia

BSN 3A | PBL GROUP 1 25

BSN 3A | PBL GROUP 1

NCM112 LECTURE
MEDICAL-SURGICAL NURSING

FLUID DISTRUBANCES, ELECTROLYTE IMBALANCES, RENAL AND KIDNEY DISORDERS

VASCULAR ACCESS  Other complications of dialysis may include the
following:
 Access to the patient’s vascular system must be o Episodes of shortness of breath
established to allow blood to be removed, o Hypotension
cleansed, and returned to the patient’s vascular o Painful muscle cramping
system at the rapid rates of 300 and 500 mL/min.
Several types of access can be surgically created o Exsanguination
or placed during procedures performed in o Arrhythmias
interventional radiology suites or at the bedside. o Air embolism
o Chest pain
o Dialysis disequilibrium
VASCULAR ACCESS DEVICES

 Immediate access to the patient’s circulation for NURSING MANAGEMENT

acute HD is achieved by inserting a double- lumen,
noncuffed, large-bore catheter into the right or left  The nurse in the dialysis unit has an important
internal jugular or femoral vein of either leg by the role in monitoring, supporting, assessing, and
physician, nurse practitioner, or physician educating the patient.
assistant.
 This method of vascular access involves some risk
(e.g., hematoma, bleeding, pneumothorax, PHARMACOLOGICAL THERAPY
infection, thrombosis of the vein, inadequate flow).
 The catheter is removed when no longer needed.  Many medications are removed from the blood
during HD.
 Medications that are water soluble are readily
ARTERIOVENUS FISTULA removed during HD treatment, and those that are fat
soluble or adhere to other substances (like albumin)
 The preferred method of permanent vascular are not dialyzed out very well.
access for dialysis.  Patients undergoing HD who require medications
 This is created surgically (usually in theforearm) (e.g., cardiac glycosides, antibiotic agents,
by anastomosing (joining) an artery to a vein, antiarrhythmic medications, antihypertensive
either side to side or end to side. agents) are monitored closelyto ensure that blood
 Needles are inserted into the vessel to obtain and tissue levels of these medications are
blood flow which is adequate to pass through the maintained without toxic accumulation.
dialyzer.
 Many medications that are taken once daily should
 The patient is encouraged to perform hand be administered after the dialysistreatment.
exercise.
NUTRITIONAL AND FLUID THERAPY
ARTERIOVENUS GRAFT
 Diet is important for patients on HD.
 Can be created by subcutaneously interposing a
 Restriction of fluid is also part of the dietary
biologic, semi biologic, or synthetic graft material
prescription because fluid accumulation may
between an artery and vein.
occur, leading to fluid volume excess, heart failure,
 Patients with compromised vascular systems and pulmonary edema.
(e.g., from diabetes) often require a graft because
 With the initiation of HD, the patient usually
their native vessels may not be suitable for
requires some restriction of dietary sodium,
creation of an AVF. potassium, phosphorus, and fluid intake.
 Stenosis, infection, and thrombosis are the most
 The goal for patients on HD is to keep their
common complications of this access.
interdialytic (between dialysis treatments) weight
gain less than 4% of their estimated dry weight
(Gonyea, 2017).
COMPLICATIONS

 Although HD can prolong life, it does not alter the MEETING PSYCHOLOGICAL NEEDS
natural course of the underlying CKD, nor does it
completely replace kidney function. The CKD
complications previously discussed will continue to  Patients requiring long-term HD, as theyengage in
worsen and require treatment. psychosocial adaptation, tend to feel mired in a
cyclical routine (Lin, Han, & Pan, 2015).
 The regimented lifestyle that frequents dialysis
 Many people undergoing HD experience major
treatments and restrictions in food and fluid intake
sleep problems that further complicate their overall impose can be demoralizing to the patient and
health status. Early-morning or late-afternoon family.
dialysis may bea risk factor for developing sleep  Dialysis alters the lifestyle of the patient and
disturbances. family.

BSN 3A | PBL GROUP 1 26

BSN 3A | PBL GROUP 1

NCM112 LECTURE
MEDICAL-SURGICAL NURSING

FLUID DISTRUBANCES, ELECTROLYTE IMBALANCES, RENAL AND KIDNEY DISORDERS

 The nurse needs to give the patient and family the functional status, and quality of life (Browne &
opportunity to express feelings of anger and Johnstone, 2017).
concern about the limitations that the disease and  Many patients with CKD can resume relatively
treatment impose, possible financial problems, normal lives, doing the things that are important to
and job insecurity. them: traveling, exercising, working, or actively
participating in family activities.
PROMOTING HOME, COMMUNITY-BASED, AND
 Outcome goals for renal rehabilitation include
TRANSITIONAL CARE
employment for those able to work, improved
physical functioning of all patients, improved
 High-quality transitional care is especially
important for older adults with multiple chronic understanding about adaptation and options for living
conditions and complex therapeutic regimens, as well, increased control over the effects of kidney
well as for their family caregiver. disease and dialysis, and resumption of activities
 Communication about prognosis and patientgoals by enjoyed before dialysis.
a dedicated team with time and expertise leads to
CONTINUOUS RENAL REPLACEMENT THERAPY
decision making, clarity of the care plan, and
consistent follow-through.
 CRRT is a method used to replace normalkidney
function in patients who are hemodynamically
EDUCATING PATIENTS ABOUT SELF-CARE
unstable by circulating thepatient’s blood through a
hemofilter and returning it to the patient.
 Preparing a patient for HD is essential.
 Continuous renal replacement therapy (CRRT)is a
 Assessment helps identify the learning needs of the
method of slower, continuous dialysis to allow solute
patient and family members.
and fluid homeostasis. There are different
 The diagnosis of ESKD and the need for dialysis
is a big adjustment for the patient and family. techniques of CRRT that are distinguished by their
method of solute removal,each detailed below. The
 Many patients with ESKD have clinical
choice of CRRT is primarily based on provider
depression, and chronic uremia contributes to a
shortened attention span, a decreased level of preference insteadof specific patient characteristics
concentration, and altered perception. or outcome data. This activity details the principles,
indications, and complications of CRRT, and it
 The nurse needs to convey a nonjudgmental
attitude to enable the patient and family to discuss discusses when to consider initiating CRRT andwhen
options and their feelings about those options. to discontinue it. It highlights the role of the inter-
professional team in managing patients on CRRT.
HOME HEMODIALYSIS  CRRT may be indicated for patients with acute or
chronic kidney disease who are too clinicallyunstable
 Most patients who undergo HD do so in an for traditional HD, for patients with fluid overload
outpatient setting, but home HD is an option for secondary to oliguric (low urine output) kidney
some. disease, and for patients whose kidneys cannot
 Home HD requires a highly motivated patient who handle their acutely high metabolic or nutritional
is willing to take responsibility for the needs. Some forms of CRRT may not require dialysis
procedure and can adjust each treatment to meet machines or dialysis personnel to carry out the
the body’s changing needs.
procedures and can be initiated quickly in the critical-
 The health care team never forces a patient to use
home HD, because this treatment requires care unit. The methods are similar, as they require
changes in the home and family. access to the circulation and blood to pass through
 The patient undergoing home HD and the an artificial filter. A hemofilter (an extremely porous
caregiver assisting that patient must be trained to blood filter containing a semipermeable membrane)
prepare, operate, and disassemble the dialysis is used in all types.
machine; maintain and clean the equipment;
administer medications (e.g., heparin) into the SEVERAL TYPES OF CRRT
machine lines; and handle emergency problems
(HD dialyzer rupture, electrical or mechanical
problems, hypotension, shock, and seizures)  These are available and widely used incritical-
(Harwood & Dominski, 2017). care units.
 Before home HD is initiated, the home
environment, household and community
resources, and ability and willingness of the
patient and family to carry out this treatment are
assessed.

CONTINUING AND TRANSITIONAL CARE

 The health care team’s goal in treating patients with

CKD is to maximize their vocational potential,

BSN 3A | PBL GROUP 1 27

BSN 3A | PBL GROUP 1

NCM112 LECTURE
MEDICAL-SURGICAL NURSING

FLUID DISTRUBANCES, ELECTROLYTE IMBALANCES, RENAL AND KIDNEY DISORDERS

 Devices for administering continuous renal embolization, and blood loss that occurs with the
replacement therapy (CRRT) offer an integrated filter or circuit changes.
fluid warmer for the heating of infusion and
dialysate fluids, a weighing or volumetric HOW CRRT WORKS?
measuring system to reduce the possibility of
error in assessing fluid balance, and a battery  CRRT does some of the work normally done by
backup that allows treatments to continue when healthy kidneys. It gently filters and cleans your
the patient is moved. child’s blood by removing waste products and extra
 The involvement of specialists external to fluid. This keeps chemicals and electrolytes, like
conventional intensive care staff with expertise potassium and phosphorus, in your child’s blood
in critically ill patients is not a new practice. The balanced. CRRT does not actually improve your
following is a list of external groups involved in child’s kidney function, but instead it keeps
the interprofessional management of patients everything in line in your child’s body until the
on CRRT:
kidneys recover function.
o Respiratory care practitioners
o Nutritional support team  A central venous catheter (CVC) is placed in one of
o Clinical pharmacology your child’s large veins. This is usually in the neck or
o Diagnostic and interventional radiology groin.
o Cardiology  The CVC is connected to a machine that circulates
o Rehabilitation and physiotherapy some of your child’s blood in a loop outside the body.
After the blood has been filtered and cleaned, it is
sent back into the body. Nationwide Children’s
COMPLICATIONS Hospital uses 2 types of machines for CRRT:
PrisMax™ and Aquadex®.
 As with every procedure, CRRT has risks, and these
should be communicated to the patient or family BEFORE CRRT
when considering initiation. Firstly, the risks
associated with intravascular lines include  Placement of the dialysis catheter (CVC) is a sterile
hemorrhage, AV fistula, infection, or thrombosis. procedure. It is done by an intensive care unit (ICU)
The risks of the therapy itself include electrolyte doctor or a radiology doctor skilled in catheter
disturbances, clearance of trace elements or placement. The doctor placing the catheter will
antibiotics, hypothermia, and hypotension. decideif the parents may stay during the procedure.
 Although hypotension should occur less commonly
than in IHD, hypotension may occur if the net DURING CRRT
ultrafiltration rate exceeds the intravascular filling
Your child will be connected to the CRRT machine thewhole
rate. Monitoring of electrolytes and acid-base
time. The machine is run by specially trained nurses in the
status should be done every 6 to 12 hours when
ICU.
starting CRRT. If remaining stable after the first 24
to 48 hours, the interval may be increased to 12 to  The machine works best if your child doesn’t move
24 hours. The exception, as discussed above, is a lot. They may be given medicines, called
when using citrate as regional anticoagulation sedatives, to keep them still so the CRRT goes
because this requires frequent monitoring of smoothly.
ionized calcium levels.  There are situations when your child will be taken
 The removal of medications during CRRT is off(disconnected) from the CRRT machine. These
variable, and so it is advised to check the dose of include:
required drugs when on CRRT. This practice is  If they need to have a test or a procedure. The
machine will be restarted afterward.
critical when it comesto administering antibiotics, as
 Routine change of the tubing and filter to keep the
the troughconcentrations of these medications will
system operating well. This only requires a short
determine their bacteriocidal or bacteriostatic
time off the machine.
effectiveness. Most affected are water-soluble  Sometimes small blood clots get in the filter and
antimicrobials, aminoglycosides, and beta-lactam tubing and stop the machine from working well. A
antibiotics. Many patients who meet indications for nurse will change the tubing and filter if this
CRRT will do so because of sepsis, meaning that happens.
appropriate antibioticdosage is vital.  The machine’s alarm may go off during CRRT.
 CRRT will result in amino acid, micronutrient, and Most of the alarms are not because of an
water-soluble vitamin loss. Patients are also often in emergency. They are usually meant to alert the
asubstantial negative nitrogen balance. Appropriate nurse(s) to changesolution bags. The machine may
caloric and protein intake with supplementation of also alarm to let the nurse know to change your
water-soluble vitamins should be ensured. child’s position or check the catheter to help the
treatment run smoothly.
 Finally, the risks associated with the extracorporeal
circuit include hypersensitivity to the circuit, air

BSN 3A | PBL GROUP 1 28

BSN 3A | PBL GROUP 1

NCM112 LECTURE
MEDICAL-SURGICAL NURSING

FLUID DISTRUBANCES, ELECTROLYTE IMBALANCES, RENAL AND KIDNEY DISORDERS

AFTER CRRT  The peritoneal catheter can be inserted in
interventional radiology, in the operating room, or,
 As your child gets better, the team may try some rarely, at the bedside.
time off CRRT. This is to see how well your child’s
kidneys work. If kidney support is still needed, Preparing the Equipment
CRRT may need to be restarted, or they may be
 The nurse consults with the physician to determine
changed to a less frequent type of dialysis called
the concentration of dialysate to be used and the
hemodialysis. This is done for shorter periods of
medications to be added.
time (3 to 5 days perweek).
o Heparin may be added to prevent fibrin
 If you have questions about your child’s kidney
formation and resultant occlusion of the
functionor the CRRT treatment, please talk to your
peritoneal catheter.
child’s kidney doctor (nephrologist).
o Potassium chloride may be prescribed to
PERITONEAL DIALYSIS prevent hypokalemia.
o Antibiotic agents may be added to treat
Peritoneal dialysis (PD) is one type of dialysis treatment for peritonitis (inflammation of the peritoneal
kidney failure. It uses a fluid that you put in your belly and membrane) caused by infection.
then remove to clean your blood. It can be done at home.
o Insulin is rarely added to PD fluid due to
 The goals of PD are to remove toxic substances and widespread use of subcutaneous insulin
metabolic wastes and to reestablish normal fluid and pumps and sliding scales.
electrolyte balance.  In a hospital setting, to prevent contamination, a
 PD may be the treatment of choice for patients with pharmacist generally adds all medications to the
kidney disease who are unable or unwilling to dialysate bags in the pharmacy under a laminar flow
undergo HD or kidney transplantation. hood.
 Patients with diabetes or cardiovascular disease,  In the home setting, the nurse instructs the patient or
many older patients, and those who may be at risk family on how to aseptically add medications to PD
for adverse effects of systemic heparin are likely fluid.
candidates for PD.  The dialysate is warmed to body temperature to
 Severe hypertension, heart failure, and pulmonary prevent patient discomfort and abdominal pain and
edema not responsive to usual treatment regimens to dilate the vessels of the peritoneum to increase
have been successfully treated with PD. urea clearance.
 Immediately before initiating dialysis, using aseptic
In PD, the peritoneal membrane that covers the abdominal
technique, the nurse assembles the dialysate with
organs and lines the abdominal wall serves as the
attached tubing and drainage bag.
semipermeable membrane. Sterile dialysate fluid, containing
dextrose and electrolytes, is introduced into the peritoneal  All PD dialysate fluid, tubing, and drainage bags are
cavity through an abdominal catheter at established intervals. manufactured as closed systems and no spiking of
Once the sterile solution is in the peritoneal cavity, uremic solution is needed.
toxins such as urea and creatinine begin to be cleared from  The tubing is primed with the prepared dialysate to
the blood. prevent air from entering the catheter and peritoneal
cavity, which would cause abdominal discomfort and
PROCEDURE interfere with instillation and drainage of the fluid.

Preparing the Patient Inserting the Catheter

 Assess the patient’s physical and psychological  The peritoneal catheter is inserted in the operating
status, mental status, previous experience with room or radiology suite to maintain surgical asepsis
dialysis, and understanding of and familiarity with the and minimize the risk of contamination.
procedure.  Catheters for long-term use are usually soft and
 The nurse and surgeon or interventional radiologist flexible and made of silicone with a radiopaque strip
or nephrologist explains the procedure to the patient. to permit visualization on x-ray.
 The nurse assists the provider in obtaining signed  These catheters have three sections:
consent for insertion of the catheter. Baseline vital o an intraperitoneal section, with numerous
signs, weight, and serum electrolyte levels are openings and an open tip to allow dialysate
recorded. to flow freely.
 The patient is instructed to empty the bladder and o a subcutaneous section that passes from
bowel to reduce the risk of puncture of internal the peritoneal membrane and tunnels
organs during the insertion procedure. through muscle and subcutaneous fat to the
skin.
 A prophylactic antibiotic agent will be given to
prevent infection.

BSN 3A | PBL GROUP 1 29

BSN 3A | PBL GROUP 1

NCM112 LECTURE
MEDICAL-SURGICAL NURSING

FLUID DISTRUBANCES, ELECTROLYTE IMBALANCES, RENAL AND KIDNEY DISORDERS

oan external section for connection to the o The first sign of peritonitis is cloudy
manufacturer specific transfer set which dialysate effluent. Diffuse abdominal pain
then connects to the dialysate tubing with and rebound tenderness often occur later.
attached dialysate. Hypotension and other signs of shock may
 Most adult catheters have 2 cuffs made of Dacron also occur with advancing infection.
polyester. o The patient with peritonitis may be treated
 The cuffs stabilize the catheter, limit movement, as an inpatient or outpatient (most
prevent leaks, and provide a barrier against common), depending on the severity of the
microorganisms. infection and the patient’s clinical status.
 One cuff is placed just distal to the peritoneum, and o Antibiotic therapy continues for 14 to 21
the other cuff is placed subcutaneously. The days.
subcutaneous tunnel (5 to 10 cm long) further o During an episode of peritonitis, the patient
protects against bacterial infection. loses large amounts of protein through the
peritoneal membrane due to inflammation
Performing the Exchange and increased permeability.
o Attention must be given to educating the
All types of PD involve a series of exchanges or cycles. An
patient to detect and promptly seek
exchange is the entire cycle including drainage of the effluent
treatment for peritonitis.
(fluid), instillation of the dialysate, and dwell. This cycle is
repeated throughout the course of the dialysis.
 Leakage: leakage of dialysate through the catheter
 The dialysate is infused by gravity into the peritoneal site may occur even after a healing period.
cavity. A period of about 10 minutes is usually o Usually, the leak stops spontaneously when
required to infuse 2 to 3 L of fluid. dialysis is withheld for several days, giving
 A sterile cap is applied to the transfer set and the the tissue the opportunity to heal around the
patient can perform ADLs. catheter cuffs and to seal the insertion
tunnel.
 The prescribed dwell, or equilibration time, allows
o It is important to reduce factors that might
diffusion and osmosis to occur.
delay healing, such as undue abdominal
 At the end of the prescribed dwell, the patient
muscle activity (bending, lifting over 5 lb)
performs hand hygiene, dons a mask, removes the
and straining during bowel movements.
sterile cap, unclamps the transfer set, and the
o In many cases, leakage can be avoided by
solution drains from the peritoneal cavity by gravity
using small volumes (500 mL) of dialysate,
through a closed system.
gradually increasing the volume up to 2000
 Drainage is usually completed in 20 to 30 minutes.
to 3000 mL.
 The drainage fluid is normally colorless or straw-
colored and should not be cloudy. Bloody or pink-
 Bleeding: Bleeding is also common during the first
colored drainage may be seen in the first few
few exchanges after a new catheter insertion
exchanges after insertion of a new catheter, but
because some blood enters the abdominal cavity
should not occur after that time.
following insertion. The bleeding most often clears up
The number of cycles or exchanges and their frequency are after several exchanges.
prescribed based on monthly laboratory values and the o Most often, bleeding stops in 1 to 2 days
presence of uremic symptoms. and requires no specific intervention.
o More frequent exchanges and the addition
The exchanges can be performed manually during the waking of heparin to the dialysate during this time
hours by the patient (continuous ambulatory peritoneal may be necessary to prevent blood clots
dialysis [CAPD]) or via the use of a PD machine (cycler) that from obstructing the catheter.
automatically performs exchanges, usually while the patient is
sleeping at night (continuous cycling peritoneal dialysis LONG-TERM COMPLICATIONS
[CCPD]).
 Hypertriglyceridemia, likely due to the use of glucose
COMPLICATIONS containing dialysate, is common in patients on long-
term PD.
Most complications of PD are often minor; however, several,  Other complications that may occur with long-term
if unattended, can have serious consequences. PD include abdominal hernias (incisional, inguinal,
diaphragmatic, and umbilical), likely resulting from
ACUTE COMPLICATIONS continuously increased intra-abdominal pressure.
The persistently elevated intra-abdominal pressure
 Peritonitis: is the most common and serious
also aggravates symptoms of hiatal hernia and
complication of PD. hemorrhoids.

BSN 3A | PBL GROUP 1 30

BSN 3A | PBL GROUP 1

NCM112 LECTURE
MEDICAL-SURGICAL NURSING

FLUID DISTRUBANCES, ELECTROLYTE IMBALANCES, RENAL AND KIDNEY DISORDERS

 Mechanical problems occasionally occur and may the tubing set, disconnects the tubing set, and
interfere with instillation or drainage of the dialysate. applies a new sterile cap to the transfer set, making
Formation of clots and fibrin in the peritoneal it a closed system.
catheter and constipation are factors that may
contribute to these problems. Complications

 To reduce the risk of peritonitis, the patient (and all

APPROACHES
caregivers) must use meticulous aseptic care to
ACUTE INTERMITTENT PERITONEAL DIALYSIS avoid contaminating the catheter, fluid, or tubing and
to avoid accidentally disconnecting the catheter from
 Indications for acute intermittent PD, a variation of the tubing.
PD, include uremic signs and symptoms (nausea,  Whenever a connection or disconnection is made,
vomiting, fatigue, altered mental status), fluid hand hygiene must be performed and a mask worn
overload, acidosis, and hyperkalemia. by anyone within 6 ft of the area to avoid
 Exchange times range from 30 minutes to 2 hours. contamination with airborne bacteria.
 Acute intermittent PD is not indicated for long-term  Excess manipulation should be avoided, and
patient management, but for specific situations such meticulous care of the catheter exit site is provided
as patients who are referred late in the course of using a standardized protocol.
CKD (CKD stage 5) and require immediate dialysis.  At home, a patient is taught to use clean technique
 The nurse uses a flow sheet on paper or within the for exit site care.
electronic health record to document each exchange  In the hospital, due to the increased risk of infection,
and records vital signs, dialysate concentration, sterile technique is employed by the nurse and
medications added, exchange volume, dwell time, patient.
dialysate fluid balance for each exchange (fluid lost
or gained), and cumulative fluid balance.
 The nurse also carefully assesses skin turgor and CONTINUOUS CYCLIC PERITONEAL DIALYSIS
mucous membranes to evaluate fluid status and
 It uses a machine called a cycler to provide the fluid
monitor the patient for edema. Daily weight is the
exchanges. It is programmed to deliver an
most accurate indicator of fluid volume status
established amount of PD solution that will dwell in
 The nurse must ensure that the PD catheter remains the peritoneal cavity for a programmed period of time
secure and that the dressing remains dry and is before it drains from the peritoneal cavity via gravity.
changed on a routine basis.
 CCPD may combine overnight intermittent PD with a
 The patient and family are educated about the prolonged dwell time during the day.
procedure and are kept informed about progress
 Every evening, the patient connects the peritoneal
(fluid loss, weight loss, laboratory values).
catheter to tubing on the cycler machine, usually just
CONTINUOUS AMBULATORY PERITONEAL DIALYSIS before the patient goes to sleep for the night.
(CAPD) Because the machine is very quiet, the patient can
sleep, and the extra-long tubing allows the patient to
 This works on the same principles as other forms of move and turn normally.
PD: diffusion and osmosis. Less extreme fluctuations  In the morning, the patient disconnects from the
in the patient’s laboratory values occur with CAPD cycler. This process is done every day to achieve the
than with intermittent PD or HD because the dialysis effects of dialysis required.
is constantly in progress. The serum electrolyte  CCPD has a lower infection rate than other forms of
levels often remain in the normal range PD because there are fewer opportunities for
contamination with bag changes and tubing
Procedure disconnections.
 The patient performs exchanges four or five times a  It also allows the patient to be free from exchanges
day, 24 hours a day, 7 days a week, at intervals throughout the day, making it possible to engage in
scheduled throughout the day. work and activities of daily living more freely.
 A closed Y-shaped system is most commonly used.
NURSING MANAGEMENT
 To perform an exchange, the patient (or person
doing the exchange) washes their hands, dons a MEETING PSYCHOSOCIAL NEEDS
mask, and then removes the cap from the transfer
set while maintaining sterility.  Patients who elect to do PD may experience altered
 The open end of the “Y” set is connected to the end body image because of the presence of the
of the transferset and the dialysate is drained into the abdominal catheter, bag, tubing, and cycler. The
attached empty sterile bag (effluent) (over about 20 nurse may arrange for the patient to talk with other
to 30 minutes). Then the attached dialysate is patients who have adapted well to PD.
infused, the patient clamps off the transfer set and

BSN 3A | PBL GROUP 1 31

BSN 3A | PBL GROUP 1

NCM112 LECTURE
MEDICAL-SURGICAL NURSING

FLUID DISTRUBANCES, ELECTROLYTE IMBALANCES, RENAL AND KIDNEY DISORDERS

 Patients undergoing PD may also experience altered  The nurse continues to reinforce and clarify
sexuality patterns and sexual dysfunction. The education about PD and ESKD and assesses the
patient and partner may be reluctant to engage in patient’s and family’s progress in coping with the
sexual activities, partly because of the catheter being procedure.
psychologically “in the way” of sexual performance.
 Questions by the nurse about concerns related to INFECTIONS OF THE URINARY TRACT
sexuality and sexual function often provide the
 caused by pathogenic microorganisms in the
patient with a welcome opportunity to discuss these
urinary tract
issues and a first step toward assisting in their
 NORMAL URINARY TRACT: sterile above urethra
resolution
 Classified by location
PROMOTING HOME, COMMUNITY-BASED, AND  LOWER URINARY TRACT: bladder & structures
TRANSITIONAL CARE below bladder
 UPPER URINARY TRACT: kidneys & ureters
 Patients are educated as inpatients or outpatients to  second most common infection in the body
perform PD once their condition is medically stable.  CATHETER-ASSOCIATED URINARY TRACT
Education generally takes 5 days to 2 weeks. INFECTIONS (CAUTI): hospital acquired infection
 Patients are taught according to their own learning o associated with indwelling urinary
ability and knowledge level and only as much at one catheters.
time as they can handle without feeling o UTI that occurs while the patient had an
uncomfortable or becoming saturated. indwelling urinary catheter in place for
 Because of protein loss with PD, the patient is more than 2 calendar days on the day that
instructed to eat a highprotein (1.2 to 1.3g/kg/day), the infection was detected.
low phosphorus, nutritious diet (NKF KDOQI, 2000).
 The patient is also encouraged to increase their daily LOWER URINARY TRACT INFECTION
fiber intake to help prevent constipation, which can
 Bladder & structures below the bladde
impede the flow of dialysate into or out of the
peritoneal cavity.  Bladder: sterile
 Patients may gain 3 to 5 lb within a month of initiating  Mechanisms that protects the sterility of the
PD, so they may be asked to limit their carbohydrate bladder:
intake to avoid weight gain. o physical barrier of the urethra assists in
keeping bacteria away from the bladder
 Potassium and fluid restrictions are not usually
o antibacterial enzymes and antibodies
necessary. Patients commonly lose at least 1 to 2 L
o antiadherent effects mediated by the
of fluid over and above the volume of dialysate
infused into the abdomen during a 24-hour period, mucosal cells of the bladder
permitting a moderate fluid intake.  LOWER UTIs include:
o BACTERIAL CYSTITIS: inflammation of
CONTINUING AND TRANSITIONAL CARE urinary bladder
o BACTERIAL PROSTATITIS: inflammation
 Follow-up care through phone calls, visits to the of prostate gland
dialysis clinic, outpatient department, and continuing o BACTERIAL URETHRITIS: inflammation
home care assists patients in the transition to home of the urethra
and promotes their active participation in their own
health care. PATHOPHYSIOLOGY
 Patients often check with the nurse to see if they are
making the correct choices about dialysate or control  For infection to occur, bacteria must gain access to
of blood pressure, or simply to discuss a problem. the bladder, attach to and colonize the epithelium of
 If a referral is made for home care, the home health the urinary tract to avoid being washed out with
nurse assesses the home environment and suggests voiding, evade host defense mechanisms, and
modifications to accommodate the equipment and initiate inflammation. Many UTIs result from fecal
facilities needed to carry out PD. organisms ascending from the perineum to the
 The nurse assesses the patient’s and family’s urethra and the bladder and then adhering to the
understanding of PD and evaluates their technique mucosal surfaces.
in performing PD.
RISK FACTORS
 Assessments include checking for changes related
to kidney disease; any complications such as
 Female gender
peritonitis; medication management; and treatment
 Diabetes
related problems such as heart failure, inadequate
 Pregnancy
drainage, and weight gain or loss.
 Neurologic disorders

BSN 3A | PBL GROUP 1 32

BSN 3A | PBL GROUP 1

NCM112 LECTURE
MEDICAL-SURGICAL NURSING

FLUID DISTRUBANCES, ELECTROLYTE IMBALANCES, RENAL AND KIDNEY DISORDERS

 Gout o bacteria (often from fecal contamination)
 Altered states caused by incomplete emptying of colonize the periurethral area and
the bladder and urinary stasis subsequently enter the bladder by means
 Decreased natural host defenses or of the urethra
immunosuppression  increased incidence of UTI to those who engage in
 Inability or failure to empty the bladder completely penile-vaginal intercourse
 Inflammation or abrasion of the urethral mucosa o due to short urethra
 Instrumentation of the urinary tract (e.g.,
CLINICAL MANIFESTATIONS
catheterization, cystoscopic procedures)
 Obstructed urinary flow caused by: UNCOMPLICATED UTI
o Congenital abnormalities
o Urethral strictures  burning on urination
o Contracture of the bladder neck  urinary frequency (more than every 3 hrs)
o Bladder tumors  urinary urgency
o Calculi (stones) in the ureters or kidneys  nocturia
o Compression of the ureters  incontinence
BACTERIAL INVASION OF THE URINARY TRACT  suprapubic or pelvic pain
 hematuria
 Bacterial removal: due to increased normal slow  back pain
shedding of bladder epithelial cells
COMPLICATED UTI
 Glycosaminoglycan (GAG): hydrophilic protein;
attracts water forming a water barrier that serves as  asymptomatic bacteriuria to gram-negative sepsis
defensive layer between bladder & urine with shock
 Urinary immunoglobulin A (IgA): provides barrier to
bacteria GERONTOLOGIC CONSIDERATIONS
REFLUX  Bacteriuria increases with age and disability
 women are affected more frequently than men
 URETHROVESICAL REFLUX: obstruction of free-
 In older adults, structural abnormalities secondary
flowing urine
to decreased bladder tone, neurogenic bladder
o Backward flow of urine from urethra to the
(dysfunctional bladder) secondary to stroke, or
bladder
autonomic neuropathy of diabetes may prevent
o COUGHING, SNEEZING, OR
complete emptying of the bladder and increase the
STRAINING: the bladder pressure
risk of UTI
increases, which may force urine from the
 ABSENCE OF ESTROGEN: postmenopausal
bladder into the urethra
women are susceptible to colonization & increased
o caused by dysfunction of the bladder neck
adherence of bacteria to vagina & urethra
or urethra
o Oral or topical estrogen has been used
o When the ureterovesical valve is impaired
by congenital causes or ureteral  incidence of bacteriuria also increases in men with
abnormalities, the bacteria may reach the confusion, dementia, or bowel or bladder
kidneys and eventually destroy them incontinence.
 URETHROVESICAL ANGLE AND URETHRAL  BACTERIAL PROSTATITIS: common cause of
CLOSURE PRESSURE: altered w/ menopause recurrent UTI in older males
(increased infection in postmenopausal women) o Resection of prostate gland (management)

UROPATHOGENIC BACTERIA FACTORS THAT CONTRIBUTE TO UTI IN OLDER

ADULTS
 BACTERIURIA: presence of bacteria in the urine.
 Cognitive impairment
 a clean-catch midstream urine specimen is the
 Frequent use of antimicrobial agents
measure used to establish bacteriuria.
 High incidence of multiple chronic medical
ROUTES OF INFECTION conditions
 Immune compromised
 3 ways:  Immobility and incomplete emptying of bladder
o Transurethral route (ascending infection)  Low fluid intake and excessive fluid loss
o Bloodstream (hematogenous spread)  Obstructed flow of urine (e.g., urethral strictures,
o Fistula from the intestine (direct extension) neoplasms, clogged
 TRANSURETHRAL: most common route of  indwelling catheter)
infection

BSN 3A | PBL GROUP 1 33

BSN 3A | PBL GROUP 1

NCM112 LECTURE
MEDICAL-SURGICAL NURSING

FLUID DISTRUBANCES, ELECTROLYTE IMBALANCES, RENAL AND KIDNEY DISORDERS

 Poor hygiene practices CELLULAR STUDIES

 Escherichia coli: most common seen in OLDER  Pyuria: WBC in urine

patients in COMMUNITY or HOSPITAL o Seen with renal calculi, interstitial nephritis
 Proteus, Klebsiella, Pseudomonas, or & renal tuberculosis
Staphylococcus: seen in px w/ INDWELLING
CATHETERS OTHER STUDIES
 Enterococcus: seen in px who are
PREVIOUSLY TREATED w/ ANTIBIOTICS  multiple-test dipstick often includes testing for
WBCs, known as the leukocyte esterase test, and
nitrite testing
SIGNS & SYMPTOMS IN POSTMENOPAUSAL WOMEN &  X-ray images, computed tomography (CT) scan,
OLDER ADULTS ultrasonography, and kidney scans are useful
diagnostic tools.
 Malaise  CT SCAN: detect pyelonephritis or abscesses
 Nocturia  ULTRASONOGRAPHY & KIDNEY SCANS:
 Urinary incontinence detecting obstruction, abscesses, tumors, and cysts
 Complain of foul-smelling urine
 Burning, urgency, & fever MEDICAL MANAGEMENT
 ONSET OF UTI: delirium & incontinence
DRUG CLASSES GENERIC MAJOR
ASSESSMENT AND DIAGNOSTIC FINDINGS NAME INDICATIONS
Anti-infective, Nitrofurantoin UTI
 Bacterial colony counts urinary tract Cephalexin Genitourinary
 Cellular studies Bactericidal Infection
Cephalosporin Cefadroxil UTI
 Urine culture
Fluoroquinolone Ciprofloxacin UTI
 UNCOMPLICATED UTI: strain of bacteria
Ofloxacin Pyelonephritis
determines antibiotic of choice Norfloxacin
Gatifloxacin
URINE CULTURES
Fluoroquinolone levofloxacin Uncomplicated
UTI
 useful for documenting a UTI and identifying the
Penicillin ampicillin UTI—not
specific organism present.
amoxicillin commonly used
 INFECTION: colony count >100,000 CFU/ml alone due to
 GROUPS OF PATIENTS SHOULD HAVE URINE Escherichia coli
CULTURES OBTAINED WHEN BACTERIURIA IS resistance
PRESENT Pyelonephritis
o All children UTI—not
o All men (because of the likelihood of commonly used
structural or functional alone due to E.
o abnormalities) coli resistance
o Patients who have been recently Trimethoprim– Co-trimoxazole UTI
hospitalized or who live in longterm care sulfamethoxazole Pyelonephritis
combination
facilities
Urinary analgesic Phenazopyridine For relief of
o Patients who have undergone recent
agen burning, pain,
instrumentation (including catheterization)
and other
of the urinary tract symptoms
o Patients with diabetes associated with
o Patients with prolonged or persistent UTI
symptoms
o Patients with three or more UTIs in the
previous year NURSING MANAGEMENT
o Women who are postmenopausal
o Women who are pregnant  To relieve pain:
o Women who are sexually active o Antispasmodic agents: relieving bladder
o Women who have new sexual partners irritability and pain
o Women with a history of compromised o Analgesic agents and the application of
immune function or renal heat to the perineum help relieve pain and
o Problem spasm

BSN 3A | PBL GROUP 1 34

BSN 3A | PBL GROUP 1

NCM112 LECTURE
MEDICAL-SURGICAL NURSING

FLUID DISTRUBANCES, ELECTROLYTE IMBALANCES, RENAL AND KIDNEY DISORDERS

o Encouraged to drink liberal amounts of  Acute pyelonephritis and chronic pyelonephritis
fluids (water and cranberry juice are the are thought to be the most likely type, with interstitial
best choices) to promote renal blood flow nephritis (inflammation of the kidney) and kidney
and to flush the bacteria from the urinary abscesses also a potential cause.
tract  Upper UTIs are a common cause of urosepsis.
o Coffee, tea, citrus, spices, colas, alcohol  Pyelonephritis is a bacterial infection of the renal
should be avoided pelvis, tubules, and interstitial tissue of one or both
o Void every 2 to 3 hours kidneys. Causes involve either the upward spread of
bacteria from the bladder or spread from systemic
PREVENTING RECURRENT UTI
sources reaching the kidney via the bloodstream.
 HYGIENE
ACUTE PYELONEPHRITIS
o Shower rather than bathe in the tub
because bacteria in the bathwater may  usually leads to enlargement of the kidneys with
enter the urethra. interstitial infiltrations of inflammatory cells.
o Clean the perineum and urethral meatus  Abscesses may be noted on or within the renal
from front to back after each bowel capsule and at the corticomedullary junction.
movement. This will help reduce
 Eventually, atrophy and destruction of tubules and
concentrations of pathogens at the urethral
the glomeruli may result.
opening and, in women, the vaginal
opening. CLINICAL MANIFESTATIONS
 FLUID INTAKE
o Drink liberal amounts of fluids daily to flush – Chills
out bacteria. It may be helpful to include at – Fever
least one glass of cranberry juice per day. – Leukocytosis
o Avoid coffee, tea, colas, alcohol, and other – Bacteriuria
fluids that are urinary tract irritants. – Pyuria
 VOIDING HABITS – Low back pain
o Void every 2 to 3 hours during the day, – Flank pain
and completely empty the bladder. This – Nausea and vomiting
prevents overdistention of the bladder and – Headache
compromised blood supply to the bladder – Malaise
wall. Both predispose the patient to urinary – Painful urination
tract infection. Precautions expressly for – Lower urinary tract involvement, such as urgency
women include voiding immediately after and frequency, are common.
penile-vaginal intercourse.
ASSESSMENT AND DIAGNOSTIC FINDINGS
 INTERVENTIONS
o Take medication exactly as prescribed. – Ultrasound study or a CT scan may be performed
Special timing of administration may be to locate an obstruction in the urinary tract.
required. – An IV pyelogram may be indicated if functional and
o Keep in mind that if bacteria continue to structural renal abnormalities are suspected.
appear in the urine, long-term antimicrobial – Radionuclide imaging with gallium citrate and
therapy may be required to prevent indium-111 (111In)–labeled WBCs may be useful to
colonization of the periurethral area and identify sites of infection that may not be visualized
recurrence of infection. on CT scan or ultrasound.
o For recurrent infection, consider daily – Urine culture and sensitivity tests are performed
consumption of cranberry juice or to determine the causative organism so that
capsules. appropriate antimicrobial agents can be prescribed.
o If prescribed, test urine for presence of
bacteria following manufacturer’s and MEDICAL MANAGEMENT
health care provider’s instructions.
o Notify the primary provider if fever occurs – Patients with acute uncomplicated pyelonephritis are
or if signs and symptoms persist. most often treated on an outpatient basis if they are
o Consult the primary provider regularly for not exhibiting acute symptoms of sepsis,
follow-up. dehydration, nausea, or vomiting.
– For outpatients, a 2-week course of antibiotic agents
UPPER URINARY TRACT INFECTIONS is recommended because renal parenchymal
disease is more difficult to eradicate than mucosal
 Upper UTIs are much less common than those in the
bladder infections. Commonly prescribed agents
lower urinary tract.

BSN 3A | PBL GROUP 1 35

BSN 3A | PBL GROUP 1

NCM112 LECTURE
MEDICAL-SURGICAL NURSING

FLUID DISTRUBANCES, ELECTROLYTE IMBALANCES, RENAL AND KIDNEY DISORDERS

include many of the same medications prescribed for – Long-term use of prophylactic antimicrobial therapy
the treatment of UTIs. may help limit recurrence of infections and kidney
– Following acute pyelonephritis treatment, the patient scarring.
may develop a chronic or recurring symptomless – Impaired kidney function alters the excretion of
infection persisting for months or years. After the antimicrobial agents and necessitates careful
initial antibiotic regimen, the patient may need monitoring of kidney function, especially if the
antibiotic therapy for up to 6 weeks if a relapse medications are potentially toxic to the kidneys.
occurs.
– A follow-up urine culture is obtained 2 weeks after NURSING MANAGEMENT
completion of antibiotic therapy to document clearing
– The patient may require hospitalization or may be
of the infection.
treated as an outpatient.
– Hydration with oral or parenteral fluids is essential in
– When the patient requires hospitalization, fluid intake
all patients with UTIs when there is adequate kidney
and output are carefully measured and recorded.
function. Hydration helps facilitate “flushing” of the
Unless contraindicated, 3 to 4 L of fluids per day is
urinary tract and reduces pain and discomfort.
encouraged to dilute the urine.
– Decrease burning on urination
CHRONIC PYELONEPHRITIS – Prevent dehydration
– The nurse assesses the patient’s temperature every
— Repeated bouts of acute pyelonephritis may lead to 4 hours and administers antipyretic and antibiotic
chronic pyelonephritis. agents as prescribed.
— When pyelonephritis becomes chronic, the kidneys
become scarred, contracted, and nonfunctioning.
— Chronic pyelonephritis is a cause of chronic kidney ADULT VOIDING DYSFUNCTION
disease that can result in the need for renal
replacement therapy (RRT) such as transplantation
or dialysis.
URINARY INCONTINENCE
CLINICAL MANIFESTATIONS
 sudden, intense urge to urinate followed by an
– No symptoms of infection unless an acute involuntary loss of urine
exacerbation occurs.  unintentional passing of urine
– Fatigue  loss of bladder control
– Headache
– Poor appetite TYPES/SYMPTOMS OF URINARY INCONTINENCE
– Polyuria
– Excessive thirst 1. Stress Incontinence: urine leaks out at times when
– Weight loss. bladder is under pressure (e.g. coughing or laughing)
– Persistent and recurring infection may produce 2. Urge Incontinence: urine leaks as an intense or
progressive scarring of the kidney, resulting in sudden urge to pee
chronic kidney disease. 3. Overflow Incontinence (chronic urinary
retention): unable to fully empty the bladder. There
ASSESSMENT AND DIAGNOSTIC FINDINGS is an obstruction or blockage in the bladder.
4. Total Incontinence: bladder cannot pass urine at all
– The extent of the disease is assessed by an IV
urogram. CAUSES OF URINARY INCONTINENCES
– Measurements of creatinine clearance, blood urea
nitrogen, and creatinine levels.  Pregnancy or vaginal birth
 Obesity
COMPLICATIONS  Family history
 Increasing age
– End-stage kidney disease (from progressive loss of
 Urinary tract infection (UTI)
nephrons secondary to chronic inflammation and
scarring).  Constipation
– Hypertension  Enlarged prostate
– Formation of renal calculi (from chronic infection with  Neurological disorders (can interfere with nerve
urea-splitting organisms). signals involved in bladder control)

MEDICAL MANAGEMENT

– Bacteria, if detected in the urine, are eradicated if

possible.

BSN 3A | PBL GROUP 1 36

BSN 3A | PBL GROUP 1

NCM112 LECTURE
MEDICAL-SURGICAL NURSING

FLUID DISTRUBANCES, ELECTROLYTE IMBALANCES, RENAL AND KIDNEY DISORDERS

TREATMENT  What was the time of the last voiding, and how much
urine was voided?
NON-SURGICAL  Is the patient voiding small amounts of urine
frequently?
1. Lifestyle changes (losing weight, cutting down on
 Is the patient dribbling urine?
caffeine or alcohol)
 Does the patient complain of pain or discomfort in the
2. Pelvic floor exercises (strengthening pelvic floor
lower abdomen? (Discomfort may be relatively mild
muscles by squeezing them)
if the bladder distends slowly.)
3. Bladder training (learning ways to wait longer
 Is the pelvic area rounded and swollen (could
between needing to urinate and passing urine)
indicate urine retention and a distended bladder)?
SURGICAL  Does percussion of the suprapubic region elicit
dullness (possibly indicating urine retention and a
1. Sling procedure - used to reduce pressure on the distended bladder)?
bladder or strengthen the muscles that control  Are other indicators of urinary retention present, such
urination as restlessness and agitation?
2. Enlarging the bladder or implanting a device that  Does a postvoid bladder ultrasound test reveal
stimulates the nerve that controls the detrusor residual urine?
muscles.  The patient may verbalize an awareness of bladder
fullness and a sensation of incomplete bladder
PREVENTION
emptying.
 Maintain a healthy weight  Signs and symptoms of UTI (hematuria, urgency,
frequency, and nocturia) may be present.
 Practice pelvic floor exercises
 A series of urodynamic studies may be performed to
 Avoid bladder irritants (such as caffeine, alcohol,
acidic foods). identify the type of bladder dysfunction and to aid in
determining appropriate treatment.
 Eat more fiber, which can prevent constipation
 A voiding diary can be used to provide a written
URINARY RETENTION record of the amount of urine voided and the
frequency of voiding.
 Urinary retention is the inability to empty the bladder
completely during attempts to void.  Postvoid residual urine may be assessed by using
 Chronic urine retention often leads to overflow either straight catheterization or an ultrasound
incontinence bladder scanner is considered diagnostic of urinary
 In a healthy adult younger than 60 years, complete retention.
bladder emptying should occur with each voiding,  Normally, residual urine amounts to no more than 50
with no residual. mL in the middle-aged adult and less than 50 to 100
 In adults older than 60 years, 50 to 100 mL of mL in the older adult
residual urine may remain after each voiding
because of the decreased contractility of the detrusor COMPLICATIONS
muscle.
 Urinary retention can occur postoperatively in any  The retention of urine can lead to chronic infections
patient, particularly if the surgery affected the that, if unresolved, predispose the patient to renal
perineal or anal regions and resulted in reflex spasm calculi (urolithiasis or nephrolithiasis), pyelonephritis,
of the sphincters. sepsis, or hydronephrosis.
 General anesthesia reduces bladder muscle  Urine leakage can lead to perineal skin breakdown,
innervation and suppresses the urge to void, especially if regular hygiene measures are
impeding bladder emptying. neglected.
NURSING MANAGEMENT
PATHOPHYSIOLOGY  Strategies are instituted to prevent overdistention of
the bladder and to treat infection or correct
 Urinary retention may result from diabetes, prostatic obstruction.
enlargement, urethral pathology (infection, tumor,  The nurse explains to the patient why normal voiding
calculus), trauma (pelvic injuries), pregnancy, or is not occurring and monitors urine output closely.
neurologic disorders (e.g., stroke, spinal cord injury,
 The nurse also provides reassurance about the
multiple sclerosis, Parkinson’s disease).
temporary nature of retention and successful
 Some medications cause urinary retention either by management strategies.
inhibiting bladder contractility or by increasing
 Promoting Urinary Elimination [Nursing measures to
bladder outlet resistance
encourage normal voiding patterns include providing
privacy, ensuring an environment and body position
ASSESSMENT AND DIAGNOSTIC FINDINGS conducive to voiding, and assisting the patient with

BSN 3A | PBL GROUP 1 37

BSN 3A | PBL GROUP 1

NCM112 LECTURE
MEDICAL-SURGICAL NURSING

FLUID DISTRUBANCES, ELECTROLYTE IMBALANCES, RENAL AND KIDNEY DISORDERS

the use of the bathroom or bedside commode, rather  The two types of neurogenic bladder are spastic (or
than a bedpan, to provide a more natural setting for reflex) bladder and flaccid bladder.
voiding.]  Spastic bladder is the more common type and is
 If his condition allows, the male patient may stand caused by any spinal cord lesion above the voiding
beside the bed to use the urinal; most men find this reflex arc (upper motor neuron lesion). The result is
position more comfortable and natural. a loss of conscious sensation and cerebral motor
 applying warmth to relax the sphincters (e.g., sitz control.
baths, warm compresses to the perineum, showers),  A spastic bladder empties on reflex, with minimal or
giving the patient hot caffeine-free beverage and no controlling influence to regulate its activity.
offering encouragement and reassurance.  Flaccid bladder is caused by a lower motor neuron
 Simple trigger techniques, such as turning on the lesion, commonly resulting from trauma. This form of
water faucet while the patient is trying to void, may neurogenic bladder is also increasingly being
also be used. Other examples of trigger techniques recognized in patients with diabetes.
are stroking the abdomen or inner thighs, tapping  The bladder continues to fill and becomes greatly
above the pubic area, and dipping the patient’s distended, and overflow incontinence occurs.
hands in warm water.  The bladder muscle does not contract forcefully at
 After surgery or childbirth, prescribed analgesic any time. Because sensory loss may accompany a
agents should be given because pain in the perineal flaccid bladder, the patient feels no discomfort.
area can make voiding difficult.
 When the patient cannot void, bladder scanning is ASSESSMENT AND DIAGNOSTIC FINDINGS
used to assess for distention, then straight  Evaluation for neurogenic bladder involves
catheterization (as prescribed) is used to prevent measurement of fluid intake, urine output, and
overdistention of the bladder residual urine volume; urinalysis; and assessment of
 In the case of prostatic obstruction, attempts at sensory awareness of bladder fullness and degree of
catheterization (by the urologist) may not be motor control. Comprehensive urodynamic studies
successful, requiring insertion of a suprapubic are also performed.
catheter (catheter inserted through a small
abdominal incision into the bladder) COMPLICATIONS
 After urinary drainage is restored, bladder retraining
is initiated for the patient who cannot void  The most common complication of neurogenic
spontaneously. bladder is infection resulting from urinary stasis and
catheterization.
 Other complications include renal calculi, impaired
 Promoting Home, Community-Based, and skin integrity, and urinary incontinence or retention.
Transitional Care
 modifications to the home environment can provide MEDICAL MANAGEMENT
simple and effective ways to assist in treating urinary  Several long-term objectives appropriate for all types
incontinence and retention. For example, the patient of neurogenic bladders include preventing
may need to remove obstacles, such as throw rugs overdistention of the bladder, emptying the bladder
or other objects, to provide easy, safe access to the regularly and completely, maintaining urine sterility
bathroom. with no stone formation, and maintaining adequate
 Other modifications that the nurse may recommend bladder capacity with no reflux.
include installing support bars in the bathroom;  Specific interventions include continuous,
placing a bedside commode, bedpan, or urinal within intermittent, or self-catheterization (discussed later in
easy reach; leaving lights on in the bedroom and this chapter); the use of an external condomtype
bathroom; and wearing clothing that is easy to catheter; a diet low in calcium (to prevent calculi);
remove quickly. and encouragement of mobility and ambulation.
NEUROGENIC BLADDER  A liberal fluid intake is encouraged to reduce the
urinary bacterial count, reduce stasis, decrease the
 Neurogenic bladder is a dysfunction that results from
a disorder or dysfunction of the nervous system and  concentration of calcium in the urine, and minimize
leads to urinary incontinence. the precipitation of urinary crystals and subsequent
 It may be caused by spinal cord injury, spinal tumor, stone formation.
herniated vertebral disc, multiple sclerosis,  A bladder retraining program may be effective in
congenital disorders (spina bifida or treating a spastic bladder or urine retention.
myelomeningocele), infection, or complications of  The use of a timed, or habit, voiding schedule may
diabetes be established.
 To further enhance emptying of a flaccid bladder, the
PATHOPHYSIOLOGY patient may be taught to “double void.” After each

BSN 3A | PBL GROUP 1 38

BSN 3A | PBL GROUP 1

NCM112 LECTURE
MEDICAL-SURGICAL NURSING

FLUID DISTRUBANCES, ELECTROLYTE IMBALANCES, RENAL AND KIDNEY DISORDERS

voiding, the patient is instructed to remain on the or tape, and the area around the catheter is covered
toilet, relax for 1 to 2 minutes, and then attempt to with a sterile dressing.
void again in an effort to further empty the bladder  The catheter is connected to a sterile closed
drainage system, and the tubing is secured to
PHARMACOLOGIC THERAPY prevent tension on the catheter. This may be a
temporary measure to divert the flow of urine from
 Parasympathomimetic medications, such as the urethra when the urethral route is impassable
bethanechol, may help to increase the contraction of (because of injuries, strictures, prostatic obstruction),
the detrusor muscle. after gynecologic or other abdominal surgery when
bladder dysfunction is likely to occur, and
SURGICAL MANAGEMENT
occasionally after pelvic fractures.
 Surgery may be carried out to correct bladder neck  A permanent indwelling suprapubic catheter may be
needed in the patient who is incontinent following a
contractures or vesicoureteral reflux, or to perform a
spinal cord injury
urinary diversion procedure.
 Suprapubic bladder drainage may be maintained
URINARY CATHETERS continuously for several weeks.
 When the patient’s ability to void is to be tested, the
 When urine cannot be eliminated naturally and must catheter is clamped for 4 hours, during which time
be drained artificially, catheters may be inserted the patient attempts to void.
directly into the bladder, the ureter, or the renal pelvis  After the patient voids, the catheter is unclamped,
and the residual urine is measured. If the amount of
Catheterization is performed to achieve the following: residual urine is less than 100 mL on two separate
occasions (morning and evening), the catheter is
 Assist with postoperative drainage in urologic and
usually removed.
other surgeries
 if the patient complains of pain or discomfort, the
 Provide a means to monitor accurate urine output in
suprapubic catheter is usually left in place until the
patients who are critically ill
patient can void successfully
 Promote urinary drainage in patients with neurogenic
 Patients can usually void sooner after surgery than
bladder dysfunction, urine retention, or at end-of-life
those with urethral catheters, and they may be more
care
comfortable.
 Prevent urinary leakage in patients with stage III to
 The catheter allows greater mobility, permits
IV pressure injuries
measurement of residual urine without urethral
 Relieve urinary tract obstruction
instrumentation, and presents less risk of bladder
NOTE: An indwelling urinary catheter should be placed only if infection.
necessary because catheterization commonly leads to  The suprapubic catheter is removed when it is no
CAUTI. longer required, and a sterile dressing is placed over
the site.
INDWELLING CATHETERS  The patient requires liberal amounts of fluid to
prevent encrustation around the catheter.
 Use strict aseptic technique during insertion of the  Other potential problems include the formation of
smallest catheter possible bladder stones, acute and chronic infections, and
 Secure the catheter to prevent movement problems collecting urine.
 Frequently inspect urine color, odor, and consistency  A wound-ostomy continence (WOC) nurse may be
 Perform daily perineal care with soap and water consulted to assist the patient and family in selecting
Maintain a closed system the most suitable urine collection system and to
 Follow the manufacturer’s instructions when using educate them about its use and care.
the catheter port to obtain urine specimens
Discontinue use as soon as feasible NURSING MANAGEMENT
 Assessing the Patient and the System: Patients at
high risk for CAUTI need to be identified and
SUPRAPUBIC CATHETERS monitored carefully.
 They are observed for signs and symptoms of
 Suprapubic catheterization allows bladder drainage CAUTI: cloudy malodorous urine, hematuria, fever,
by inserting a catheter or tube into the bladder chills, anorexia, and malaise. Any drainage and
through a suprapubic (above the pubis) incision or excoriation in the area around the urethral orifice is
puncture noted. Urine cultures provide the most accurate
 The catheter or suprapubic drainage tube is then means of assessing a patient for infection.
threaded into the bladder and secured with sutures
PREVENTING INFECTION

BSN 3A | PBL GROUP 1 39

BSN 3A | PBL GROUP 1

NCM112 LECTURE
MEDICAL-SURGICAL NURSING

FLUID DISTRUBANCES, ELECTROLYTE IMBALANCES, RENAL AND KIDNEY DISORDERS

RETRAINING THE BLADDER WHEN AN INDWELLING,
 Certain principles of care are essential to prevent
infection in patients with a closed urinary drainage  urinary catheter is in place, the detrusor muscle
system does not actively contract the bladder wall to
 Avoid contamination of the drainage spout. A stimulate emptying because urine is continuously
receptacle in which to empty the bag is provided for draining from the bladder. As a result, the detrusor
each patient. Avoid routine catheter changes. may not immediately respond to bladder filling
 The catheter is changed only to correct problems when the catheter is removed, resulting in either
such as leakage, blockage, or encrustations. Avoid urine retention or urinary incontinence. This
unnecessary handling or manipulation of the condition, known as postcatheterization detrusor
catheter by the patient or staff. instability, can be managed with bladder retraining
 Carry out hand hygiene before and after handling  Immediately after the indwelling catheter is
the catheter, tubing, or drainage bag. removed, the patient is placed on a timed voiding
 Ensure a free flow of urine to prevent infection. schedule, usually every 2 to 3 hours.
Improper drainage occurs when the tubing is  At the given time interval, the patient is instructed
kinked or twisted, allowing pools of urine to collect to void. The bladder is then scanned using a
in the tubing loops. portable ultrasonic bladder scanner, and if the
 Evaluate the benefit of placing an indwelling urinary bladder has not emptied completely, straight
catheter versus the risk of the patient developing a catheterization may be performed
catheter-associated urinary tract infection (CAUTI).  After a few days, as the nerve endings in the
 If the collection bag must be raised above the level bladder wall become resensitized to the bladder
of the patient’s bladder, clamp the drainage tube. filling and emptying, bladder function usually
This prevents backflow of contaminated urine into returns to normal. If the patient has had an
the patient’s bladder from the bag. indwelling catheter in place for an extended period
 Monitor the patient’s voiding when the catheter is (e.g., greater than 1 month), bladder retraining will
removed. The patient must void within 8 hours; if take longer; in some cases, function may never
unable to void, the patient may require return to normal, and long-term intermittent
catheterization with a straight catheter. catheterization may become necessary.
 Never disconnect the tubing to obtain urine ASSISTING WITH INTERMITTENT SELF-
samples, to irrigate the catheter, or to ambulate or CATHETERIZATION.
transport the patient.
 Never irrigate the catheter routinely. If the patient is  Intermittent self-catheterization provides periodic
prone to obstruction from clots or large amounts of drainage of urine from the bladder.
sediment, use a three-way system with continuous  By promoting drainage and eliminating excessive
irrigation. Never leave the catheter in place longer residual urine, intermittent catheterization protects
than is necessary to decrease the risk of CAUTI. the kidneys, reduces the incidence of UTIs, and
Obtain a urine specimen for culture at the first sign improves continence.
of infection.  It is the treatment of choice in some patients with
 To prevent contamination of the closed system, spinal cord injury and other neurologic disorders,
never disconnect the tubing. The drainage bag such as multiple sclerosis, when the ability to
must never touch the floor. empty the bladder is impaired. Self-catheterization
 The bag and collecting tubing are changed if promotes independence, results in few
contamination occurs, if urine flow becomes complications, and enhances self-esteem and
obstructed, or if tubing junctions start to leak at the quality of life.
connections.
 To reduce the risk of bacterial proliferation, empty
the collection bag at least every 8 hours through
the drainage spout—more frequently if there is a
large volume of urine.
 Use scrupulous aseptic technique during insertion
of the catheter. Use a preassembled, sterile, closed
urinary drainage system of the smallest catheter
size possible to minimize trauma.
 Wash the perineal area with soap and water at
least twice a day; avoid a to-and-fro motion of the
catheter.
 Dry the area well, but avoid applying powder
because it may irritate the perineum

BSN 3A | PBL GROUP 1 40

BSN 3A | PBL GROUP 1