THE URINARY SYSTEM & FLUID BALANCE  Control blood volume and blood pressure by regulating the

(Sir Andre De Veyra) volume of urine produced

 Regulate the concentration of major ions in the body fluids
THE URINARY SYSTEM: (e.g. Electrolytes such as sodium, potassium, chloride,
 Consists of: etc.)
o 2 kidneys  Regulate the pH of the extracellular fluid
o 2 ureters  Regulate the concentration of the red blood cells in the
o Urinary bladder blood
o Urethra  Participate (with the skin and liver) in regulating vitamin D
 Major function: Control the composition and volume of synthesis
body fluids
ANATOMY OF THE KIDNEY:

BEAN-SHAPED

 Review of the function of the Urinary System:

RETROPERITONEAL
1. EXCRETION: Remove the waste products from the
body.
2. BLOOD VOLUME CONTROL: Regulates the volume
of water removed from the body and to produce urine
which would affect the blood pressure.
3. ION CONCENTRATION REGULATION
4. PH REGULATION: The kidney helps in maintaining
the balance of the pH of the body and it comes
second to the lungs in response to the abnormalities
such as acidosis and alkalosis.
5. RED BLOOD CELL PRODUCTION: In as much as it
produces erythropoietin, which is necessary for RBC
production. So, for patients with kidney disorders such
as chronic kidney disease, these are people with low
RBC count, low hemoglobin count, which is one thing
that we need to monitor amongst patients with renal
disorders. So, for those with CKD (Chronic Kidney  The kidneys are bean-shaped organs. The size of it is like
Disease), we inject erythropoietin to them. It is a clenched fist, it is the estimated or the approximate size
injected subcutaneously in order to facilitate the of the kidneys.
production of red blood cells.  A connective tissue wherein the renal capsules surrounds
each kidney and around each renal capsule is a thick layer
 The kidneys can suffer from extensive damage but still of fat which protects the kidney from mechanical shock.
maintain their extremely important role in the maintenance  On the medial side of each kidney is the hilum, where the
of homeostasis renal arteries and nerves enter and where the renal vein
 As long as about 35% of one kidney remains functional — and ureter exit the kidney.
survival is possible  The kidney is divided into an outer cortex and an inner
 Complete kidney failure = death will ensue if without medulla, which surrounds the inner sinus.
medical treatment  The bases of several cone-shaped renal pyramids are
located at the boundary between the cortex and the
FUNCTIONS OF THE URINARY SYSTEM: medulla.
(p.s. bagan inulets la hya han naka violet ha igbaw)
 Excrete waste products

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 The tip of the renal pyramid extends toward the center of
the kidney and is surrounded by a calyx
 Calyces are extensions of the renal pelvis, which is the
expanded end of the ureter within the renal sinus.
 The calyces from all renal pyramids would join together to
form a large funnel called the renal pelvis.
 The renal pelvis would now become narrow, to form a
small tube which is called the ureter.

NEPHRON: FUNCTIONAL UNIT OF THE KIDNEY

 Parts of EACH nephron:
o Renal corpuscle
o Proximal convoluted tubule
o Loop of Henle
o Distal convoluted tubule
 Filtration membrane is formed by the glomerular
capillaries, basement membrane and podocytes of the
Bowman capsule

(P.S. ini na pic nakadto han ppt ni sir pero gin skip la niya
so…)

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 RENAL BLOOD SUPPLY:
1. RENAL ARTERIES: Which branch off from the
abdominal aorta and would enter the kidneys.
2. INTERLOBAR ARTERIES: It would pass between the
renal pyramids and would give rise to the arcuate
arteries. It also branches off the arcuate arteries to
project into the cortex.
3. AFFERENT ARTERIOLES: Arises from branches of
the interlobular arteries and extend to the glomerular
capillaries.
4. EFFERENT ARTERIOLES: Extends from the
glomerular capillaries to the peritubular capillaries.
5. VASA RECTA: Specialized portions of peritubular
capillaries which extends deep into the medulla of the
kidney and surrounds the loop of Henle.
6. The veins on the other hand, runs through parallel of
the arteries. Basically, kun ano an gin again han
arteries, it is basically the same with the renal veins.
 REMEMBER: Juxtaglomerular Apparatus
 Formed where the distal tubules come in contact with
the afferent arterioles next to the Bowman’s Capsule.
URINE PRODUCTION
 Urine is produced by filtration, tubular reabsorption and
tubular secretion
1. FILTRATION
 Renal filtrate passes from the glomerulus into the
Bowman capsule and contain no blood cells and few
blood proteins
 Filtration pressure is responsible for the filtrate
formation
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 Increased sympathetic activity = decreases blood flow
to the kidney, decreases filtrate formation, and
decreases urine production
 In times of fight and flight response, wherein your
sympathetic activity is increased, then you can say that
urine production decreases during that time because of
the decreased blood flow to the kidney. If there is
decreased blood flow to the kidney, there is decreased
filtrate formation.
 Decreased sympathetic activity = has the opposite
effect
2. TUBULAR REABSORPTION
 99% of the filtrate volume is reabsorbed by the body;
1% becomes urine
 That filtrate (99%) contains the water, some of the ions
that are essential and needed by the body.
 Reabsorbed substances: proteins, amino acids,
glucose, fructose, Na+ (Sodium), K+ (Potassium),
HCO3- (Bicarbonate) and Cl- (Chloride).
 These are ions, electrolytes and substances needed by
the body and so, even if it passes through the kidney, it
would not go out of the glomerulus and be excreted with
the urine because these are reabsorbed.
 65% of the filtrate volume is reabsorbed in the
descending limb of the loop of Henle
 19% is reabsorbed in the distal convoluted tubule and
collecting duct.
 Majority of the reabsorption happens on the descending
loop of Henle.
 For example, in cases where there is too much glucose,
just like in cases of diabetes mellitus, the glucose is
reabsorbed. But, only to the capacity of the renal system.
The excess, which is already beyond the capacity of the
renal system would no longer be absorbed and it would go
out and excreted via the urine. Precisely the reason why,
people with diabetes mellitus, you can see that there is
glycosuria or the presence of glucose in the urine because
glucose is already excessive that is already beyond the
absorption capacity of the renal system. But normally,
glucose, protein and amino acids are reabsorbed by the
renal system.
3. TUBULAR SECRETION
 Hydrogen ions, some by-products of metabolism and
some drugs are actively secreted into the nephron.
 Remember that hydrogen ions are also secreted into the
nephron and some of which would be excreted via the
urine and some of it would be buffered.
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REGULATION OF URINE CONCENTRATION AND VOLUME
 Kidneys maintain the concentration of the body fluids by
increasing water reabsorption from the filtrate when the
body fluid concentration increases
 If the body fluid concentration is increased, meaning, it is
saturated with so much solute, the tendency of the body is
to reabsorb more water. It is also the capacity to reduce
water reabsorption from the filtrate when the body fluid
concentration decreases. Body fluid concentration
decreases meaning, there is little solute so it would reduce
water reabsorption and facilitate its’ excretion. Now, the
volume and composition of the urine would change
depending on the conditions of the body.
 Reducing water reabsorption from the filtrate when the
body fluid concentration decreases
 Volume and composition of urine changes, depending on
conditions in the body.
 Urine production also maintains blood volume and
therefore blood pressure
 If there is much fluid retained in the body, expect that the
blood pressure would also increase.
 3 major hormonal mechanisms are involved in regulating
urine concentration and volume:
 Renin-angiotensin-aldosterone (RAA) mechanism
 Antidiuretic hormone (ADH) mechanism
 Atrial natriuretic hormone (ANH) mechanism
 Each mechanism is activated by different stimuli, but they
work together to achieve homeostasis
 RAA and ANH mechanisms – more sensitive to changes
in the blood pressure. Change in bp would activate these
2 mechanisms.
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 ADH – more sensitive to changes in blood concentration.
If the blood is too concentrated, then, it would facilitate
retention of fluid so that it may be diluted somehow.
RENIN-ANGIOTENSIN-ALDOSTERONE MECHANISM
 Renin and angiotensin: help regulate aldosterone
secretion
 Renin
o Enzyme secreted by cells of the juxtaglomerular
apparatuses in the kidneys
o Acts on Angiotensinogen (plasma CHON produced by
the liver)  converts it to Angiotensin I (needed for
conversion to Angiotensin II by ACE)  Angiotensin-
Converting Enzyme (ACE)  Angiotensin II (potent
vasoconstrictor thereby, it tends to increase the BP.)
 In cases for example, the client is having deficient blood
volume, the RAA is initiated and stimulated. Renin will be
converted to Angiotensin I, then Angiotensin I would be
converted to Angiotensin II through ACE and would
facilitate vasoconstriction which would further help in
increasing the BP.
o Angiotensin II: acts on the adrenal cortex, so that the
adrenal cortex which is found on the top of the kidney,
would secrete aldosterone.
o Aldosterone: Increases the rate of active transport on
Na+ in the distal convoluted tubules and collecting
ducts.
 In other words, in a much simple term, aldosterone would
facilitate the active transport of sodium and remember
WHERE SODIUM IS, WATER WILL FOLLOW, so there
would be more water retention and there would be further
increase of BP. In order to prevent further increase in BP.
We give ACE Inhibitors to the patient. It inhibits the
conversion of Angiotensin I to Angiotensin II which is a
potent vasoconstrictor so, BP increase would be
prevented. Remember that this mechanism is activated in
times wherein the patient is having deficient blood volume,
deficient fluid volume and the BP is dropping.
ANTIDIURETIC HORMONE MECHANISM
 Antidiuretic Hormone
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 o Secreted by the posterior pituitary gland
o Regulates the amount of water reabsorbed by the  RAA (decreased BP)
distal convoluted tubules and collecting ducts (19%)  ANH (increased BP)
 Release is regulated by the hypothalamus (Pituitary Gland
is under the order of the hypothalamus)
 Baroreceptors that monitor blood pressure also influence
ADH secretion

 Antidiuretic meaning, it prevents diuresis. It prevents

excretion of fluid.
 In the antidiuretic hormone, when the ADH level
increases, the permeability of the water of the distal
tubules and the collecting duct increases and more water
is reabsorbed. So, there is more water retention.
 The release of the ADH from the posterior pituitary is
regulated by the hypothalamus because certain cells of
the hypothalamus are sensitive to the changes in the
solute concentration and the interstitial fluid within the
hypothalamus.
 Meaning, if the body, particularly the hypothalamus
senses that the it is too much concentrated or there is too
much solute, it will release more ADH to add more fluid to
the solute so that it would not be so much concentrated.
The, there will be water retention. So, if there will be
deficient in ADH, there will be excessive urination, to the
extent that the client would suffer from fluid and electrolyte
imbalance, less concentration in the body “diabetes
insipidus”.

 Homeostasis is disturbed by the increasing blood pressure

and volume and acts as stimulus to the cardiac muscle
cells as the receptors to facilitate the release of ANP and
ATRIAL NATRIURETIC HORMONE MECHANISM
BNP and it would result kidneys and blood vessels in
 Atrial Natriuretic Hormone
response to ANP, there is increased sodium loss in urine,
o Secreted from cardiac muscles in the right atrium of
increased water loss in urine, reduced thirst, inhibition of
the heart when blood pressure in the right atrium
ADH, aldosterone, epinephrine and norepinephrine
increases above normal
release. It would now result in decreased bp and blood
o Acts on the kidney to decrease Na+ reabsorption (if
volume and homeostasis will be achieved.
there is decrease in Na+ reabsorption then it also
decreases water reabsorption thereby decreasing the URINE MOVEMENT
BP) Anatomy and Histology of the Ureters, Urinary Bladder, and
Urethra
 ANH would be released from the cardiac muscle and it
 Ureters
would at on the kidney, directly on the kidney, to decrease
o Small tubes that carry urine from the renal pelvis of
sodium reabsorption thereby decreasing water
the kidney to the posterior inferior portion of the
reabsorption and also facilitating a decrease in BP.
urinary bladder
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  Ability to voluntary inhibit micturition develops at the age of
 Ureters enter through the inferior posterior portion of the 2-3 years
bladder because at the anterior inferior portion, the urethra
is there.

 Urinary bladder
o Hollow, muscular container that lies in the pelvic
cavity just posterior to the pubic symphysis
o It stores urine (few mL to 1L)

 Bladder is composed of transitional epithelium that when it

is not full, and it is not distended, it is cuboidal transitional
in different layers but if stretched, it becomes squamous-
like.

o Trigone: triangle-shaped portion of the urinary bladder

located between the opening of the ureters and the
opening of the urethra
 Urethra
o Tube that carries urine from the urinary bladder to the
outside of the body
o Males: Extends to the end of the penis (approximately
20 cm)
o Females: Shorter (approximately 4 cm) and opens
into the vestibule anterior to the vaginal opening
 The reason why females are more prone to UTI aside from
the close proximity of the rectum to the urethra, the
females’ urethra is shorter as compared to the male. So, if
it is shorter, it takes shorter time for the invading
microorganism to ascend and cause infection and even
ascend to the bladder. For male, the urethra is longer so
the microorganisms die because of the inconducive
environment for the survival of the microorganism.
 Internal Urinary Sphincter
o Found at the junction of the urinary bladder and
urethra
o Present only in males
o Keeps the semen from entering the bladder during
sexual intercourse and direct the semen to the
urethra, out of the penis.
 This is involuntary.
 External urinary sphincter
o Skeletal muscle that surrounds the urethra as the
urethra extends through the pelvic floor
o Under voluntary control, allowing a person to start or
stop the flow of urine
 Voluntary controlled.
 However, the control of this is not present at birth and it is
learned. That is why there is “toilet training” because you
train yourself to control.
MICTURITION REFLEX
 Activated by stretch of the urinary bladder
 An automatic reflex, but it can be inhibited or stimulated by
higher centers in the brain
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COMPOSITION OF URINE:
1. Water - majority
2. Electrolytes – sodium, potassium chloride,
bicarbonate, these are the most abundant ions.
3. Also contains UREA – your urea is the end product or
the byproduct of protein metabolism about 25 grams
is produced and excreted by the body.
4. Creatinine, Phosphates, Sulfates - These 3 are the
products of protein metabolism which is need to be
excreted by the body.
5. Uric Acid is the product of nucleic acid metabolism
which also has to be excreted by the body.
 As what I have mention to you, your glucose and amino
acids are normally filtered because these are large
molecules which is not supposed to pass normally from
the glomerulus. However, your glucose may appear in the
urine if the level of your glucose is too high, that the
concentration in the glomerular filtrate exceeds the
capacity of your tubules to absorb it.
 I discussed it a while ago, pag the level of your glucose
exceeds beyond the capacity of your tubules to reabsorb it
the tendency is that it would fill out and it would be
excreted via your urine. Actually, according to study, hindi
naman kunting increase lang ng sugar mo is mag
ga’glysuria kana, its not that, actually according to study, if
your blood sugar level reaches about 200 mg/dl and
above (normal is 120 mg/dl), your blood sugar level,
expect that you will have a glycosuria, or the presence of
glucose in your urine. *
 Another is for proteins, traces of protein maybe found but
huge amount of proteins, huge amount of albumin found
in your urine is already abnormal because these are large
molecules which should have been filtered by your
glomerulus, so presence of this large molecule such as
protein may indicate damage in the glomeruli. *
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 If we go to the functions again of renal system, you have
there the ACID SECRETION, so we excrete
approximately 70 mEqs of acid each day. So more acid
usually needs to be eliminated from the body that can be
excreted directly as free acid in the urine. *
 How do we achieve this? How do we achieve excretion of
acid? This is accomplished through the renal excretion of
acid bound to the so-called CHEMICAL BUFFERS. For
example: Your hydrogen Ion is secreted by your renal
tubular cells into the filtrate and it is buffered by phosper
ions and ammonia, so an imo ammonia is now called
ammonium, meaning an ammonia mayda na kasabay or
kasalakot na acid hydrogen ions so it maybe excreted by
the body.
 Phosphate is present in the glomerular filtrate and
ammonia is produced by the cells of the renal tubules
secreted into the tubular fluid.
 The next one, another function of the renal system is THE
REGULATION OF ELECTROLYTE SECRETION. So
SODIUM, 180 liters of filtrate are formed by the glomeruli
each day. 1,100 grams of this filtrate is SODIUM
CHLORIDE and most of it is reabsorbed. (99% is
reabsorbed, only 1% becomes your urine). If sodium is
excreted in excess amount, then the one ingested by the
patient, the patient will become dehydrated, meaning an
excretion of sodium by the urine is more than the intake of
the patient, remember where sodium is, water follows.
However, if less sodium is excreted than Ingested the
patient will retain fluid, meaning gutiay la an na eexcrete
na sodium from the body so water will be retained
because the rule is where sodium is, the water follows.
 ROLE OF ALDOSTERONE: If there is an increased
aldosterone meaning more sodium is retained, less is
excreted meaning more water also is reabsorbed.
 Another Important electrolyte which is regulated by your
Renal system is your POTASSIUM. Concentration of your
potassium in the body is regulated by your kidney. It’s the
most abundant intracellular ion. The excretion of your
potassium by the kidney is increased by aldosterone level.
Increased Aldosterone secretion = Increased Potassium
excretion. One thing to monitor to patients with renal
diseases and renal failure is THE RETENTION OF THE
POTASSIUM. Remember, retention of the potassium in
the body is life threatening. So people with renal disorder
sinsasabi ng Doctor na less potassium ang intake mo, di
pwedeng kumain ng masyadong gulay, di pwedeng
kumain ng masyadong fruitss because if potassium
cannot be excreted effectively and efficiently then it may
be retained in the body, and there will be a buildup of
potassium in the body, remember the effect of potassium
to the heart. So retention of so much potassium in the
body could be life threatening.
 Another function of RS: REGULATION OF WATER
EXCRETION. Talking about OSMOLALITY. What is
Osmolality? – Osmolality has been defined as the relative
degree of dilution and concentration of the urine.
Basically, it reflects the number of particles dissolved ins
the urine. Filtrate in the glomerular capillary, an osmolality
with the blood is the same. (An filtrate na nadida ha
glomerular capillary, an iya osmolality or kadamo han
solute pareho la han kadamo han solute/osmolality hit imo
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blood) And normally it is 300 milliosmoles per liter or 300
mmol/L. As filtrate passes to the tubules, to the collecting
ducts, the osmolality may vary from 50 – 1,200 mmol/L
which would reflect the maximal diluting and concentrating
ability of your kidney.
 Glucose and your protein has the capacity to pull water
across the glomerulus and the tubules and increased the
volume of your urine which is the explanation why people
with diabetes may commonly have POLYURIA. (Kay nag
sspillage man an glucose ngadto ha urine so an glucose
has the capacity to pull out water nga didi kamo sabay
kayo sakin sama kayo, so the tendency nag popolyuria an
imo pasyente na mayda diabetes) The tendency because
of polyuria, your patient will experience POLYDIPSIA -
excessive thirst because of excessive excretion of fluid
from your body.
 URINE SPECIFIC GRAVITY – reflects both the quantity
and miniature of particles (Glucose, Protein, IV contrast
agents etc.) Normal Urine Specific Gravity: 1.015 – 1.025.
If it is increases, meaning so much of solute and it is too
concentrated. It may be an indicative that the patient is
having dehydration.
 RENAL CLEARANCE – is most commonly used to
evaluate how well the kidney functions in terms of
excretion.
Formula to compute Renal Clearance:
Urine concentration of a substance x urine
Renal Clearance=
plasma concentration of that
Example:
 Plasma concentration: .1 ml
 Urine concentration of a substance: 15 ml
 Urine volume in a given time: 1ml/min.
15 ml x 1 ml/min
Renal Clearance=
.1 ml
¿=500 ml/min❑
 Meaning, 500 ml of blood are completely cleared from
that particular substance in 1 minute.
 *Take note that Few substances are actually
completely cleared from the blood during a single
pass through the kidney. It takes time for it to be
cleared.
 Very useful for us is the CREATININE CLEARANCE.
Creatinine is a dangerous waste product brought about by
protein metabolism. So glomerular filtration maybe
assessed through your creatinine clearance. Normal
Glomerular filtration rate (GFR in Adult: 100-120 ml/min.
that’s about 1.67 – 2ml per second).
 One function of your Urinary System: STORAGE OF
URINE IN VOIDING. If there is over distention of the
bladder due to disease or if there is an increase pressure
in the bladder, it may cause reflux, but normally, the urine
dire ito ma backflow or dre magrereflux to the bladder, kay
an nafacilitate ito haiya pag flow tikadto didto ha urethra,
from the ureter then the bladder then to the urethra is your
peristaltic movement. Kay ano dire nabackflow mayda ba
mga sphincter? Wala naman, hindi na siya nagbabackflow
because of a unidirectional nature of the peristaltic wave,
meaning the peristaltic wave is directed to one direction
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 meaning its going out. Now in cases were in there is over
distention of the bladder because of a disease or there is
increased pressure in the bladder, it may cause a
backflow or a reflux of your urine to the bladder and to the
kidney which may lead to a problem, an infection in the
kidney which what we call pyelonephritis or a damage to
the kidney because of the elevated pressure which is
called your Hydronephrosis. In terms of bladder pressure,
the first sensation of bladder filling is ordinarily felt or
occurs when there is already col pwelection of 100-150 ml
of urine. Again your bladder is capable of holding about 1
liter of urine, pag abot hin 100-150 ml of urine in the
bladder, you get the first sensation of bladder filling then
you experience the desire to void if the bladder already
contains about 200- 300ml of urine. If it reaches for about
400ml of urine, there is marked feeling of fullness in the
bladder.
 I will not discuss to you about the muscle control anymore
because I already mentioned to you a while ago your
external urinary sphincter which is under your voluntary
control and it is innervated by the nerves of the sacral
area on the spinal cord, kaya nga naman, if the spinal
cord in the sacral area is affected there will be a problem
in terms of muscle control during urination or micturition.
 Detrusor Muscle – the bladder smooth muscle. This
normally would contract to expel or help in expelling your
urine. The pressure generated in the bladder is about 50-
150 cm.
 Neural Control – contraction of the detrusor muscle or the
smooth muscle in the bladder is regulated by a reflex
involving your PNS or your Parasympathetic nervous
system. This reflex is integrated into the sacral portion of
the spinal tract. Your sympathetic nervous system on the
other hand helps in preventing semen from entering the
bladder through the help of your internal urinary sphincter
during ejaculation. If the pelvic nerves supplying the
bladder and the sphincter are destroyed, the pelvic nerves
supplying the bladder and the sphincter are destroyed,
voluntary control and reflex urination are abolished and
the tendency is that the bladder becomes over distended
with urine. The people who meet an accident which
involves the spinal cord sometimes they lose the control
already, they lose the control of urination and micturition
the tendency is that they don’t feel the need to defecate,
the bladder simply becomes over distended. So the
tendency, what we do is we insert a catheter. In cases
wherein, the patient can still feel the urge to void we do
the so called bladder training. So an bladder training, this
is also used for people who have been using a catheter
for a prolong period of time, na dire na nadidistend an
bladder, ngan dire ka na nakakafeel an urge because na
diretso man pag flow an urine to the uro bag so gin
blabladder training. So an bladder training, we clamp the
tubing from the catheter to the uro bag there’s a tubing,
we clamp it for 4 hours then we release, we allow the
bladder to distend and for the client to feel the urge to void
and then we release for 30 minutes and then we clamp
again for another 4 hours, nakaindicate naman yun sa
Doctor’s order, nasa chart yan, Do bladder training.
 The spinal pathways from the brain to the urinary system,
if this are the one’s destroyed such in cases wherein
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there’s a spinal cord injury reflex contraction of the
bladder is maintained but the voluntary control over the
process is lost so that becomes a problem. There is a
technique of which measured the tonicity and the bladder
pressure it’s called your CYSTOMETOGRAM.
BODY FLUID COMPARTMENTS
- 60% TBW of an adult male and 50% TBW of an adult
female consists of water. *In terms of body fluid, total
body weight of an adult is 60% of water for Male and
50% of water for female, lesser for female because of
adipose tissue. *
- Water and ions dissolved in the water are distributed
in the 2 fluid compartments:
1.) Intracellular
- Found within the cells
- 2/3 of the TBW
2.) Extracellular
- Found outside cells, mainly in interstitial fluid, blood
plasma and lymph
- 1/3 of the TBW
- A small portion is separated into sub-compartments:
aqueous humor and vitreous humor of the eye,
cerebrospinal fluid, synovial fluid into the joint cavities,
fluid secreted by the glands, renal filtrate and bladder
urine.
*Waray na niya gin discuss from composition of the fluid in the
body chuchu until regulation of acid-base kay gindiscuss na
daw ni Sir Mark, pero gin butang ko la didi kay nakadto kan Sir
Andre ppt*
COMPOSITION OF THE FLUID IN THE BODY FLUID
COMPARTMENTS
 Intracellular has a similar composition from cell to cell
 ICF: contains more K+, Mg2+, PO3-, SO2- and
proteins compared to the ECF
 ECF: contains more Na+, Ca2+, Cl- and HCO3- than
the ICF
 Extracellular fluid has a fairly consistent composition
from one area of the body to another
EXCHANGE BETWEEN BODY FLUID COMPARTMENTS
 Cell membranes that separate the body fluid
compartments are selectively permeable
 Water continually passes between the compartments
 Ions in the water do not readily pass through the cell
membrane
 Water movement is regulated mainly by hydrostatic
pressure differences and osmotic differences between
the compartments
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REGULATION OF EXTRACELLULAR FLUID COMPOSITION
 Homeostasis requires that the intake of substances
equals their elimination
 Ingestion = excretion
 Total amount of water and electrolytes in the body
does not change unless the person is growing,
gaining weight, or losing weight
o 2 mechanisms help regulate the levels in the ECF:
1. thirst regulation
2. Ion concentration regulation
THIRST REGULATION
 Thirst center: group of neurons in the
hypothalamus which controls water intake
 Thirst is one of the important means of regulating
ECF volume and concentration
“THIRST CASCADE”
Increased blood concentration and decrease in BP
 activates the thirst center and baroreceptors
(aortic arch, carotid sinuses, right atrium)
 increases water intake
 reduces blood concentration
and
increases blood volume
Ion
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CONCENTRATION REGULATION
 If ECF composition deviates from its normal range 
cells cannot control the movement of substances
across the cell membranes or the composition of their
ICF  abnormal cell function/cell death
 Normal ECF composition: required to sustain life
SODIUM IONS
- Dominant extracellular ions
- Recommended intake of Na+: 2.4 gm/day
- Stimuli that control aldosterone secretion influence
the reabsorption of Na+ from nephrons of the kidneys
and the total Na+ in the body fluids
- Amount aldosterone = equal amount Na+ reabsorbed
POTASSIUM IONS
- Electrically excitable tissues, such as muscles and
nerves, are highly sensitive to slight changes in the
EC K+ concentration
- EC K+ must be maintained within a narrow change
for these tissues to function normally
- Aldosterone: regulates the concentration of K+ in the
ECF
- Aldosterone secretion from the adrenal cortex = K+
secretion in the kidneys
CALCIUM IONS
- Increases and decreases in the EC concentrations of
Ca2+ have dramatic effects on the electrical
properties of excitable tissues
- Increased Ca2+ level = decreased activity (inversely
proportional)
- Parathyroid hormone (PTH)
 secreted by the parathyroid gland
 increases EC Ca2+ concentration
 elevated Ca2+ = inhibits PTH secretion and vice
versa
- Vitamin D
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  increases Ca2+ concentration in the blood by
increasing the rate of Ca2+ absorption by the
intestine
- Calcitonin
 secreted by the thyroid gland
 reduces Ca2+ concentration when it is too high
 elevated Ca2+ = triggers calcitonin secretion
PHOSPHATE AND SULFATE IONS
- Reabsorbed by active transport in the kidneys
- Rate of reabsorption is slow
- If the concentration of these ions in the filtrate
exceeds the nephron’s ability to reabsorb them, the
excess is excreted in the urine
REGULATION OF ACID-BASE BALANCE
 Concentration of H+ in the body fluids is reported as
the pH
 Body fluid pH: 7.35 – 7.45
 pH of body fluids is controlled by 3 factors:
1. Buffers
2. Respiratory system
3. Kidneys
 When the pH is not properly maintained, the result is
acidosis or alkalosis
ASSESSMENT:
 In terms of assessment, first you asked the client if the
client feels pain. Remember that pain is not all present in
all renal diseases, it could be manifested by other ways,
not necessarily may pain na nafefeel. Because pain would
occur mostly on acute conditions, say for example there is
obstruction brought about by renal calculi, there is sudden
distention of the renal capsule, these things can lead to
pain.
 KIDNEY PAIN, describe as a dull ache, or a dull pain
in the costovertebral angle or the area formed in the
ribcage and vertebral column and may extend to the
umbilicus.
 Urethral disorder characterized by Pain in the back –
which radiates to the abdomen, upper thigh to the
testes for males, and into the labia for female. It may
be brought about by urethral disorders.
 Renal colic which causes Flank pain or the pain
between the ribs and ilium – it radiates to the lower
abdomen, to the epigastrium, there is nausea and
vomiting, there is paralytic ileus. It may be brought
about by renal colic.
 Bladder Pain / Lower Abdominal Pain – pain in the
suprapubic area. It may be bladder pain. Kay ano
may bladder pain? It may be brought about by
distended bladder or maybe brought about by bladder
infection and bladder inflammation such as your
cystitis.
 Another is if you experience Urgency or tenesmus
(painful straining or there may be terminal disurea or
pain after urinating or towards the end of your
urination, at the end of your voiding, it may be usually
present in some conditions.
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 Pain in the Urethral meatus – (buho kun diin naagi it
ihi) It may be brought about by urethritis, trauma,
foreign body in the lower urinary tract most especially
pag may renal calculi na nag descend na, irritation of
the bladder neck.
 Severe scrotal Pain – severe pain in the scrotal region
for male. It may be brought about by inflammation,
edema of the epididymis or of the testicle itself or
torsion of the testicle.
 Rectal Fullness – (feeling of fullness in the perineal
area/rectum) For male may indicative of prostatitis or
your prostatic abscess.
 Back leg pain, it may be brought about by metastasis
of the cancer of the prostate to the pelvic bone. *or an
pagkalat han cancer cells from the prostate to the
pelvic bone.*
 So this are the things which you need to ask to your client.
Ano an klase han pain na imo naeexperience if there are
any. Again as what I have mention a while ago, doesn’t
mean that patient has a renal disease pain should be
present because pain is not always present in renal
problems.
 You also have to ask for the quality of the flow of the
urine. Steady ba an flow, strong ba an flow or bangin kita
may dribbling flow of urine (maihi nanaman, mawara tas
maihi nanaman, nag uutod utod) because this is an
indicative of certain conditions such as benign prostatic
hyperplasia, pag ha lalaki masakit an penile shaft,
indicative of a urethral problem, kun an ha penis, an head
part an maulol may be an indicative of prostatitis.
 For Kidney disorder it may not be accompanied by pain,
makita ka naal an imo pasyente may ada pedal edema,
periorbital edema because of so much water retention,
mayda shortness of breath, it ira tun gin yayakan
“mapunga punga pag ginahawa” ngay an kay congested
na an lungs, mayda changes in urinary elimination.

You also have to ask your client if there burning
sensation upon urination. Is there discomfort during
urination or towards the end of voiding? Is there
blood? But again, blood may not be seen with the
naked eye because some of it could only be be seen
under the microscope during urinalysis.
 Ask for changes in voiding. Because voiding should
be painless. It should be 5-6 times a day.
Occasionally once during night time and amount of
1,200-1,500 ml of urine in 24 hours.
 Ask for the frequency of urination
 Ask for the urgency or the strong desire to void.
 Ask if there is pain or dysuria during urination.
 Ask if there is hesitancy in urination (delay and
difficulty in initiating voiding. It may be brought about
by compression of the urethra, neurologic bladder or
other obstruction).
 History
………………….
(Hindi pa po done yung ASSESSMENT na part since
icontinue pala niya pagdiscuss this week daw. Thankss)
STAN! EXO! GOT7! RED VELVET! YSJ! KD!
THE URINARY SYSTEM AND FLUID BALANCE:
o Urge Incontinence: Uncontrolled loss of urine
DEFINITION OF TERMS
proceeded by a strong urge to void
(Sir Andre De Veyra)
 The common cause of stress incontinence would be: A
URINARY FREQUENCY
dysfunction of the detrusor and the sphincter.
 Voiding that occurs more often than usual when compared
with the person's usual pattern or the generally accepted
o Mixed Incontinence: A combination of stress and urge
norm of once every 3-6 hrs.
incontinence.
 Cause: Infection, disease of the urinary tract (such as
o Overflow Incontinence: Caused by a chronically
UTI), metabolic disease (such as Diabetes Mellitus in
distended flaccid bladder.
which there is an increase urination called polyuria),
o Functional or Environmental Incontinence: Problem of
hypertension, and certain medications such as diuretics.
the client in getting to the bathroom or comfort room
URGENCY on time.
 Strong desire to void
 Cause: Inflammatory lesions of the bladder, prostate, or
ENURESIS
urethra, acute bacterial infections, chronic prostatitis
 Involuntary voiding during sleep
(men), chronic posterior urethrotrigonitis (inflammation of
the urethra and trigone of the bladder) in women  Physiologic up to the age of three (3) years

BURNING ON URINATION  Physiologic most especially when urination and the night
control of urination is not yet established. However, if this
 There are different indications of this (burning on urination) happens in an adult who has already control in terms of
and it would depend on what particular or when it would voiding, it may already be an indication of abnormality. For
occur. These are: Act of urination, during and after voiding teenagers and children, if you have already established
and on urethral irritation. night bladder control, it might not be pathologic in nature,
but it may be brought about by psychological stressors in
which they have encountered. Example, stress from
 Causes:
school, etc. It may be seen amongst children,
o Urethritis (act of urination)
adolescence, who’s already able to establish night bladder
o Cystitis (inflammation of the bladder) (during and after
control.
voiding)
o Urethral irritation
POLYURIA
 A large volume of urine voided in a given time
DYSURIA
 Causes: Diabetes Mellitus, diabetes insipidus, chronic
 Pain or difficult voiding
renal disease, diuretics or excessive fluid intake
HESITANCY OLIGURIA
 Undue delay and difficulty in initiating voiding  A small volume of urine;
 Cause: compression of the urethra, neurogenic bladder,  100-500 ml/24 hours
outlet obstruction
 Causes: Serious renal dysfunction, shock, trauma,
incompatible blood transfusion, medication toxicity
NOCTURIA
 Excessive urination at night
 If you are assigned to a patient, in the ICU for example,
 Cause: decreased renal concentrating ability (found in you need to monitor the volume of urine. It is very
patients with kidney disorders), heart failure, DM, important because that’s an indication that the renal
incomplete bladder emptying. system is still functioning. In every hour, your client should
have at least 30ml of urine output. If it is already less than
URINARY INCONTINENCE 30ml, it has to be referred to the doctor because it means
 Involuntary loss of urine that the renal system is not functioning optimally and it
 Cause: injury to the external urinary sphincter (Sphincter may already be an indication of impending renal failure
controls voiding under voluntary control), acquired and probably a multiple organ disorder or failure. That is
neurogenic disease, severe urgency which results from why, it is important for nurses to meticulously monitor
infection urine volume especially to those who are critically ill and to
 Types: make sure that their urine output is at least 30ml per hour.
o Stress incontinence: Sudden leakage of urine due to
sudden strain from weakness of the sphincter ABSOLUTE ANURIA
mechanism  No urine output at all and may be brought about by
complete obstruction of the urinary tract
 It may be associated with activities that result in an
increase in intrabdominal pressure. HEMATURIA
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 Presence of RBC in the urine
May indicate:
- Cancer of the GU tract, acute glomerulonephritis,
or renal TB
- Blood dyscrasias, anticoagulant therapy,
neoplasm, trauma, extreme exercise.
- And some of which, some RBC’s are not found
grossly present in the urine. Not visible to the
naked eye at times.
PROTEINURIA (Albuminuria)
 Abnormal amounts of protein in the urine. Proteins are
usually which are supposed to be filtered by the
glomerulus and should not be able to pass through and be
excreted via your urine.
- Cause: acute and chronic renal disease.
your cancer cells, you might just spread the
cancer cells and cause metastasis. *
- Auscultation – upper quadrants to assess for
bruit (stenosis of the renal arteries)
- Inguinal area – for enlarged nodes – inguinal or
femoral hernia, varicocele
- Assess for edema *for people with renal
disorders, commonly they don’t experience pain
but it’s with other signs and symptoms for
example elevated blood pressure during the
presence of edema, like puffy eyes, periorbital
edema then there is edema on the hands then it
may be indication of an abnormal fluid retention
brought about by renal disorder*.
DIAGNOSTICS

HEALTH HISTORY URINE ANALYSIS/URINALYSIS

- Pain - You always teach the client that in terms of
- History of UTI past treatment or hospitalization collection of the specimen you do your mid-
for UTI, presence of fever and chills stream touch. So you disinfect first the meatus
- Previous cystoscopy, other tests and procedures using only one stroke and then you let the client
- Symptoms of disorders of voiding urinate and in the middle of the urination you
- Hematuria touch it using your sterile specimen container.
- Nocturia (date of onset) 1. Color and clarity
- Childhood disease (“strep throat’”, impetigo, 2. Odor
nephrotic syndrome) Remember for children, 3. Urine acidity
who had streptococcal infection one of the target, 4. Specific gravity
not just the valves of the heart, the kidneys are 5. Protein, glucose, ketone bodies
also targeted by your streptococci. 6. RBC (hematuria)
- Renal calculi 7. WBC
- Disorders that affect kidney function and the 8. Casts (cylinduria)
urinary tract function DM, HPN *chronic 9. Crystals (crystalluria)
hypertension can affect the kidney, it’s not just 10. Pus (pyuria)
the because there would be lesser amount of 11. Bacteria (bacteriuria)
blood supply going to the kidney because of the -
increase pressure*, abdominal trauma, spinal
cord injury,
- *Patients who experience spinal cord injury, back
injuries, vehicular accidents, some of them if the
spinal cord is affected would have problems in
terms of voiding and bladder control*, other
neurologic conditions.
- For FEMALE Clients: number and type of
deliveries, forceps delivery *may affect the pelvic
floor muscle tone*, contraceptive practices,
vaginal infections and discharges *may affect the
urinary tract*.
- Exposure to toxins
- History of genital lesions and STI’s *because
some of it can cause strictures in the urinary
tract*
- Any prescription of OTC medications
- History of smoking
- History of drug or alcohol abuse

PHYSICAL ASSESSMENT:
- Direct palpitation – client in supine position *one
hand under and one hand on top trying to
palpate the kidney. Take note for children with
Wilms tumor we do not palpate and percuss over
the kidney because it may cause metastasis of
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