1.1_Review of Anatomy & Physiology of b.

tubular reabsorption
the Renal System c. tubular secretion
2. Excretion of waste products
KIDNEY – bean shaped organ located on 3. Regulation of electrolytes [Na, K]
either side of the vertebra to the 3rd lumbar 4. Regulation of acid excretion
vertebra 5. Regulation of Water Excretion
• Regulate by selectively excreting or 6. Autoregulation of blood pressure
conserving bicarbonate and hydrogen 7. Renal Clearance
ions 8. Regulation of Red Cell Production
• Slower to respond to change 9. Secretion of Prostaglandins
• Located in the dorsal lumbar section of The kidneys are protected and anchored by
the midsection and are retroperitoneal. three concentric layers of connective tissue
• located on top of adrenal glands, are 1. renal capsule , is also known as the
covered with--and well protected by--a fibrous tunic of the kidney.
layer of fat. 2. adipose capsule surrounds the renal
• Situated between the 12th thoracic and capsule.
3rd lumbar vertebrae. 3. renal fascia which is a dense outer
• Consists of the cortex, medulla, layer
pyramids, renal calyxes and pelvis, and Nephrons- the basic functional unit of the
ureters. kidney.
• Size and weight of the kidneys is about It has 2 main parts:
300-400g. They consist of about 0.5% • Renal corpuscle (where plasma is
of body weight in humans. filtered] and renal tubules (into which
the filtered fluid (the filtrate) passes] -
KIDNEY FUNCTION which form urine by means of the 3
Functions- is to process blood plasma and process:
excrete urine. • FILTRATION – the movement of
1. Urine formation thru three processes: water and solute from the plasma in the
a.glomerular filtration






 glomerulus, across the glomerular • In females, It lies directly behind the

capsular membrane. symphysis pubis and anterior to the
• REABSORPTION- Is the movement vagina .It extends down and forward
of molecules out of the tubule and into from the bladder of about 3cm
the peri-tubular blood. • In male, the urethra extends along a
• SECRETION-the movement of winding path about 20cm.it passes
molecules out of the peritubular blood through the center of the prostate gland
and into the tubule excretion. just after leaving the bladder. Within
the prostate, it is joined by 2
Ureter – two tubes that drain urine from the ejaculatory ducts.
kidneys to the bladder, approximately 28cm
long tube which conveys urine from the 1.2_Overview of Normal Fluid &
kidney to the urinary bladder. Electrolyte Balance
Urinary bladder- it is collapsible bag located
behind the symphysis pubis; made up of Overview of Normal Fluid and Electrolyte
detrusor muscles. Balance
• - it serves as a temporary storage Functions of Water
reservoir for urine • universal solvent
• -there are 3 opening in the floor • Provides an aqueous medium for
of bladder: 2 from the ureters and 1 into cellular metabolism and proper cellular
the urethra. chemical functioning
• - serves as reservoir for urine • Ensures adequate tissue perfusion of
before it leaves the body vital substance to the cells and tissues
• - aided by the urethra, it expels • Provides a medium for excretion of
urine from the body. waste from the body
Urethra – small tube lined with mucus • provide medium for transporting
membrane from the floor of the bladder to the nutrients to cells, wastes from cells, and
exterior of the body. substances such as hormones, enzymes,

 blood platelets, and red and white blood CONCEPT of BALANCE --> Input vs
cells Output
• facilitate cellular metabolism and act as ROUTES of GAINS & LOSSES
solvent for electrolytes and Sensible & Insensible losses through:
nonelectrolytes and solvent for many • Kidney
cellular functions • Lungs
• helps regulate and maintain normal • GI
body temperature • Skin
• aids in food digestion and promote Factors that affect fluid balance
elimination • Age
• helps maintain cell shape through its • gender
high surface tension. • body fats
Sources of Water • muscle mass
• Ingested food and fluids through the Fluid Compartments: (ICF, ECF, Interstitial,
metabolism Plasma)
• Metabolic processes Hydrostatic vs Osmotic pressure
• Parenteral and enteral feedings Third spacing
Water Requirements Fluid movements
• The body’s minimum amount of water • Osmosis
required/day – 1500ml/day • Diffusion
• The body’s average daily fluid • Filtration
requirement - 2500-2600ml/day • Active & Passive transport
The Daily Source of Water Intake are: • Na-K Pump
1200 ml/day Beverages FLUID Types
1000 ml/day Hidden water in foods • Isotonic solutions
150-300 ml/day Water from oxidation • Hypotonic solutions
------------------------------------------------------- • Hypertonic solutions
2300-2500 ml/day = TOTAL Mechanisms that Regulate Homeostasis:

 How the body adapts to fluid and electrolyte ◦ Diuretic therapy – Furosemide /
changes Lasix
• Thirst mechanism Nursing Interventions
• ADH regulation mechanism 1. Assess the client’s fluid status regularly
• Aldosterone-Renin-Angiotensin System including daily weights
• ANP mechanism 2. restriction of oral & intravenous water
intake
1.3_Fluid Imbalances (Hypo & 3. irrigate NGTs with NSS
Hyperosmolarity, Hypovolemia and 4. replace water & Na losses with isotonic
Hypervolemia) IVF
5. Close monitoring of intake and output
I. OSMOLARITY IMBALANCE 6. Monitor the client’s K+ levels

1. HYPOOSMOLAR IMBALANCE / 2. HYPEROSMOLAR IMBALANCE /

HYPOOSMOLARITY- ECF water excess DEHYDRATION
S/Sx: HYPEROSMOLARITY-ECF water deficit
• swelling of cerebral cells, (exceed to 300 mOsml/L
• pulmonary edema, flushed skin, • Results from either a water deficit or an
• oliguria, extracellular solute overload
• Anorexia, Causes:
• nausea and vomiting • decrease water intake
• Bounding pulse • increase loss of water,
• Lethargy, confusion, convulsion • injudicious use of hypertonic solution,
• Decrease Na and hematocrit • near drowning in salt water
• Increase urine output Assessment of Hyperosmolar state
• Sudden weight gainManagement: SIGNS & SYMPTOMS
◦ Water restriction • Thirst
◦ Eliminate the cause • Poor skin turgor
◦ Decrease Na in the diet • Dry tongue

 • Sunken fontanels 4. Preserve skin and mucous membrane

• Increase temperature integrity
• CV symptoms 5. Encouraged increase of oral fluids
• Decreased urine especially water intake
• Decaresed weight 6. Replace water
• Increased BUN, Creatinine, Uric Acid, 7. Prevent complications of DHN
RBC, Hct. 8. Monitor serum Na and Hgb values
• Decrease LOC 9. Measure and record intake and output
• Muscle weakness and urine specific gravity
Nursing Diagnosis 10. Administer IV fluids as indicated
• Fluid volume deficit
• Risk for injury II. ISOTONIC FLUID IMBALANCES
• Risk for impaired skin integrity 1. HYPOVOLEMIA (Extracellular Fluid
• Activity intolerance Volume Deficit)
GOAL OF CARE --> Resulting from both Na & water losses
1. Maintain adequate fluid volume PREDISPOSING/CONTRIBUTING
2. Assess: tissue dehydration, FACTORS
hypovolemia, hypoxia, shrinkage of 1. Excessive fluid losses (Vomiting,
brain cells gastric suctioning, diarrhea, polyuria,
3. Eliminate cause diaphoresis, wounds or burns,
4. Replace water intraoperative fluid loss, hemorrhage)
5. Maintain skin integrity 2. Insufficient/decreased fluid intake
Nursing Interventions 3. Systemic infections, fever
1. Eliminate the cause of the imbalance 4. Kidney disease, DKA, HHNC, diabetes
2. Check VS upon admission and every insipidus, SIADH
2-4 hours 5. Adrenal insufficiency, pancreatitis,
3. Assess capillary refill, skin turgor and cirrhosis/ascites
the status of the mucous membranes. Patient Assessment

 Diagnostic studies --> serum/urine Na+,
CBC, glucose, CHON, BUN, Crea, urine sp.
gravity
Treat & manage hypovolemic shock
• 1.If the patient is hemorrhaging, efforts
are made to stop the bleeding.
• 2.If the cause of the hypovolemia is
diarrhea or vomiting, medications to
treat diarrhea and vomiting are
administered
• 3.Fluid and blood replacement with
crystalloids 0.9% sodium chloride
(NSS), lactated ringer’s, and hypertonic
saline (3%, 5%, 7.5%)
• 4.A modified trendelenburg position
or elevating the legs promotes the
return of venous blood.
NURSING ACTIONS/ INTERVENTIONS
Independent
• 1.Monitor vital signs and CVP. Note
presence/degree of postural BP
changes. Observe for temperature
elevations/fever.
• 2.Palpate peripheral pulses; note
capillary refill, skin color/temperature.
Assess mentation.
• 3.Monitor urinary output. Measure/
estimate fluid losses from all sources,
e.g., gastric losses, wound drainage,
diaphoresis.
• 4.Provide safety precautions as
indicated, e.g., use of side rails, bed in
low position, frequent observation, soft
restraints (if required).
• 5.Investigate reports of sudden/sharp
chest pain, dyspnea, cyanosis, increased
anxiety, restlessness.
Collaborative
• 1.Assist with identification/treatment of
underlying cause.
• 2.Monitor laboratory studies as
indicated, e.g., electrolytes, glucose,
pH/PCO2, coagulation studies.
• 3.Administer IV solutions as indicated:
• 4.Isotonic solutions, e.g., 0.9% NaCl
(normal saline), 5% dextrose/water;
• 5.Colloids, e.g., dextran, Plasmanate/
albumin, hetastarch (Hespan);
• 6.Whole blood/packed RBC
transfusion,
• 7.Administer sodium bicarbonate, if
indicated.
• 8. Provide tube feedings, including free
water as appropriate.
2. HYPERVOLEMIA (Extracellular Fluid
Volume Excess)

 • Resulting from both Na & water • dyspnea, shortness of breath

retention • Mental confusion
PREDISPOSING/CONTRIBUTING NURSING ACTIONS/ INTERVENTIONS
FACTORS • Monitor weight and vital signs.
• Excess sodium intake including • Assess for edema.
sodium-containing foods, medications, • Auscultate lungs and heart sounds,
or fluids (PO/IV) assess breath sounds.
• Excessive, rapid administration of • Monitor fluid intake and output.
hypertonic (or possibly isotonic) • Monitor laboratory findings.
parenteral fluids • Place in Fowler’s position.
• Increased release of antidiuretic • Administer diuretics as ordered.
hormone (ADH); • Restrict fluid intake as indicated.
• Excessive adrenocorticotropic hormone • Restrict dietary sodium as ordered.
(ACTH) production, • Implement measures to prevent skin
• Hyperaldosteronism breakdown.
• Decreased plasma proteins • Note presence of neck and peripheral
• Chronic kidney disease/acute renal vein distension, along with pitting
failure (ARF) edema, dyspnea.
• Heart failure (HF) • Maintain accurate I&O. Note decreased
CLINICAL MANIFESTATIONS urinary output, positive fluid balance
• Weight gain (intake greater than output) on 24-hr
• Fluid intake greater than output calculations.
• Full, bounding pulse; • Weigh as indicated. Be alert for acute
• tachycardia or sudden weight gain.
• Increased blood pressure • Give oral fluids with caution. If fluids
• Increase central venous pressure are restricted, set up a 24-hr schedule
• Distended neck and peripheral veins; for fluid intake.
• slow vein emptying
• Moist crackles (rales) in lungs;

 • Monitor infusion rate of parenteral

fluids closely; administer via control
device/pump as necessary.
• Encourage coughing/deep-breathing
exercises.
• Maintain semi-Fowler’s position if
dyspnea or ascites is present.
• Turn, reposition, and provide skin care
at regular intervals.
• Encourage bedrest. Schedule care to
provide frequent rest periods.
• Provide safety precautions as indicated,
e.g., use of side rails, bed in low
position, frequent observation, soft
restraints (if required).