Fluid & Electrolytes

1. LO1: Identify body fluid compartments and summarize the movement of fluids and
electrolytes throughout the compartments. (2 questions)
a. Body fluid compartments
i. Intracellular
1. Holds 60% of our body fluids
2. Potassium is major intracellular cation
a. 3.5-5.0 mEq/L
ii. Extracellular
1. Interstitial: tissues
2. Intravascular/vasculature: blood
a. Where we measure the components (RBCs, H/h,
electrolytes)
3. Sodium is major extracellular cation
a. 135-145 mEq/L
b. A change in one fluid compartment causes a cascade of changes in other
compartments
i. Capillary hydrostatic/filtration pressure, capillary colloidal osmotic
pressure, interstitial hydrostatic pressure, interstitial colloidal osmotic
pressure
ii. Na+/K+ ATPase pump
1. Helps maintain fluid and electrolyte balance/homeostasis of cells
a. Pumps 3 Na+ out and pulls 2 K+ in  keeps Na+ out 
prevents cell from swelling
2. Distinguish among hypovolemia, hypervolemia, and normovolemia
a. Body wants to maintain effective circulating volume
b. Hypovolemia
i. Loss of fluids/decreased fluid within the body
ii. Loss can be sensible or insensible
1. Sensible: measurable! Urine, vomiting
2. Insensible: not easily measured. Breathing, sweating
c. Normovolemia
d. Hypervolemia
i. Increased/gain of fluids
e. Amount of fluids within the body is reliant on
i. Intake
ii. Absorption
iii. Distribution
iv. Excretion
f. Fluid regulation mechanisms
i. Thirst mechanism
ii. ADH
iii. ANP
iv. RAAS
 v. Sympathetic nervous system
3. Define dehydration and summarize hypotonic, isotonic, and hypertonic dehydration (1
question)
a. Dehydration: the loss of fluids without the corresponding loss of salt/Na+
i. Mild dehydration: restlessness, thirst
ii. Moderate dehydration: lethargy, low BP, low skin turgor, low urine
output, irritability, increased HR
iii. Severe dehydration: low urine output, low BP, lethargy, low capillary
refill/poor perfusion, coma, difficulty arousing, cool fingers and toes,
tachycardia
Hypotonic Isotonic dehydration Hypertonic
dehydration dehydration
- Hypovolemic - Fluid volume deficit - Hypovolemic
hyponatremia - Decreased volume hypernatremia
- Loss of total but the water and - Loss of total
body water Na+ body water
where the concentration/ratio where the loss
loss of Na+ is remains normal of water is
greater than - Loss of water and greater than
the loss of the loss of Na+ is the loss of Na+
water relatively the same - Na+ >145
- Na+ <135 - Na+ 135-145

4. Identify signs and symptoms and treatments for hypovolemic, normovolemic, and
hypervolemic hyponatremia and hypernatremia.
a. Sodium imbalance/Na+ = neuro symptoms
b. With severe hyponatremia (<120): seizure precautions! 3% NaCl, raise slowly to
avoid osmotic demyelination
c. With severe hypernatremia (>150): seizure precautions! .45% NS, .22% NS, lower
slowly to avoid cerebral edema
Hypovolemic hyponatremia Normovolemic/hypervolemic
hyponatremia
Signs and symptoms Cold and clammy skin, dry/sticky Headache, apathy, muscle
mucous membranes, spasms/tremors, weight gain,
hypotension, tachycardia, high BP, seizures, coma,
personality changes, thready confusion
pulse, weight loss, irritability,
tremors, coma, seizures Apathy
Gained weight
Skin cold and clammy, dry Low LOC
membranes Inc BP
AMS/coma, agitation Tremors/spasms
Lower weight Confusion, cramps
 Tremors Headache
Low BP Seizures
Ortho hypotension
Seizures
Tachycardia, thready pulse
Treatments (1) 0.9 % NS (1) Fluid restriction!
(2) Increase salt intake (2) diuretics
(3) D/c diuretics

Hypovolemic hypernatremia Normovolemic/hypervolemic

hypernatremia
Signs and symptoms Tachycardia, hypotension, weight Restless, agitation, seizures,
loss, coma, seizures, agitation, coma, weight gain, high BP,
thirst, restless, dry/sticky mucous twitching, edema,
membranes red/flushed skin

Dry sticky membranes, dry swollen High BP

tongue Inc fluid retention/edema
Restless Gained weight
Agitation Hot, flushed skin
Seizures Seizures
Thirst Agitation/restless
Inc HR / low BP Low LOC/Coma
Coma Thirst, twitching
Treatment (1) Isotonic NS IVF (1) Isotonic IVF
(2) Increase water intake (2) Diuretics
(3) Decrease oral intake
of Na+

5. Identify appropriate clinical interventions and evaluation for a patient with different
types of fluid and electrolyte imbalance. (4 questions)
a. Assess fluid volume status, fluid volume excess, fluid volume deficit
b. Cerebral edema: too much fluid/fluid overload in the brain
i. Cytotoxic edema: swelling of the brain cells  cells rupture
ii. Evaluation: labs, neuro status
iii. Intervention: diuretics, salt intake?
c. Volume imbalance vs concentration imbalance
i. Volume imbalance: loss/gain of water and Na+
1. Water:Na+ stays normal
2. Serum osmolality stays the same
3. Two types:
a. Isotonic dehydration/fluid volume deficit
 b. Isotonic overload/fluid volume overload
ii. Concentration imbalance: loss of water only
1. Water: Na+ abnormal
2. Serum osmolality is abnormal
d. Generalized edema vs third spacing
i. Edema: excess fluid in the interstitial spaces/more generalized areas
1. Tree trunk limbs
2. Diuretics
ii. Third spacing: excess fluid in cavities/areas that are not accessible to
vasculature
1. Can occur:
a. Peritoneal cavity (ascites)
b. Pericardial sac (friction rub)
c. Pleural cavity (pleural effusion)
2. Albumin, diuretics, 3% nacl if salt is low
e. Fluid volume deficit/isotonic dehydration
i. Loss of fluids/decreased circulating blood volume
f. Fluid volume overload/isotonic overload
i. Too much fluids/increased circulating blood volume

6. Explain the different types of IV fluids and their use regarding fluid and sodium
imbalance
a. IV fluids are categorized by tonicity
i. Tonicity: the number of particles in the IV bag, the effect an IV solution
will have on intracellular and extracellular fluid compartments
b. Hypotonic
i. Have more water than solutes/particles
ii. Has less particles than ECF
iii. Will increase the water content in the extracellular space and will cause
fluid to enter the cells  cells swell
iv. Examples: .22% NS, .45% NS, D5 .45% NS (once it is in body)
c. Isotonic
i. Has the relatively the same amount of particles as the ECF
ii. Increases water and electrolyte content in the ECF and fluid will flow
between cells and ECF ~ equally  no change in cell size
iii. Examples: .9% NS, LR, D5W, D5 LR & D5 NS (once in the body)
d. Hypertonic
i. Has less water and more particles than the ECF
ii. Will increase the particles/solute concentration more in the ECF  fluid
will leave the cells to ECF  cells shrink
iii. Examples: TPN (feeding), 3% NaCl
e. D5LR, D5NS, D5 .45% are all hypertonic in the bag, but once it enters the body
the D5 is quickly metabolized and acts what comes after
7. Identify the normal serum levels of electrolytes (1 question)
 a. Sodium: 135-145 mEq/L
b. Potassium: 3.5-5.0 mEq/L
c. Calcium: 9.0-10.5 mEq/L
d. Magnesium: 1.3-2.1 mEq/L
e. Normal osmolarity= 280-295 mOsm/kg
8. Summarize signs and symptoms, assessments, interventions, and evaluation of patients
with electrolyte disturbances
a. Hyponatremia and Hypernatremia above
b. Potassium imbalance: s/s= cardiac most serious, 30 mEq over 3 hours??
Hypokalemia
Signs and symptoms Acidosis, paresthesia, cramps,
weakness, lethal cardiac
rhythms, EKG changes
Limp muscles
Leg cramps
Lethal cardiac rhythms
Low/shallow respirations
Lots of urine
Lethargy
Loss of K+ in blood/acidosis
(cause lots of H+)
Assessments Cardiac assessments: EKG,
telemetry monitoring,
MSK assessments: cramps,
strength scaling, coordination
scaling
Tx/interventions (1) Oral replacement (diet
or supplements)
(2) IV supplementation
- Check levels first
- SLOW! Infusion
- K+ diluted in NS, can
take multiple bags
- Check K+ levels in
between new bags
- Monitor for phlebitis
and extravasation
Hyperkalemia
Peaked T waves, decreased CO,
hyperactive GI muscles, N/V/D,
cramping, EKG changes, lethal
cardiac rhythms (tachy  brady 
arrest), tetany, weakness, paralysis,
paresthesia
Muscle weakness
Urine output/anuria
Respiratory distress
Decreased cardiac CO
ECG changes (ST elevation, peaked
Ts, cardiac arrhythmias)
Reflexes (hyperreflexia, areflexia)
Cardiac assessments: EKG,
telemetry monitoring (look for tall T
waves)
MSK assessments: cramps strength
scaling, coordination scaling
GI: cramping, N/V/D
(1) 10% Calcium gluconate or
calcium chloride IV slowly
(give first)
(2) Kayexalate!!!  diarrhea,
binds to potassium
(3) Insulin
(4) D50 IV/glucose
(5) Sodium bicarb IV (helps to
avoid acidosis)
(6) Albuterol (beta2 agonist 
facilitates ATPase pump)
(7) Furosemide IV
(8) Stop K+ supplements, foods,
fluids, and salts high in K+
 Hypomagnesemia
Signs and symptoms Inc BP
Personality changes
Low Ca and K
Arrythmias
Nystagmus
Tachycardia, tetany, trousseau and Chvostek, torsades

Assessments Cardiac: EKG, telemetry, torsades

MSK: nystagmus, trousseaou, Chvostek
Neuro: personality

Treatments/interventions (1) Increase oral intake (grains, nuts, leafy greens, dairy,
meat, fish, dried fruit, Mg salts)
(2) MgSO4 IM or IV

Hypocalcemia
Signs and symptoms Increased deep tendon reflexes
Paresthesia
EKG changes
Low BP
Tetany
Chvostek and trousseau signs
Arrythmias
Tired/fatigue
Seizures (increased excitability)
Assessments Cardiac: EKG, telemetry
MSK: trousseau and Chvostek signs, tetany
Neuro: seizure precautions
Tx/interventions (1) High calcium diet/calcium salts
(2) IV calcium (10% calcium chloride, calcium gluconate)

9. Discuss acute and chronic conditions that contribute to fluid and electrolyte imbalance
(1 question)
a. Summarize how acute and chronic GI losses, heart failure, and chronic renal
failure contribute to fluid and electrolyte imbalances
b. Heart failure  fluid retention/overload
c. Chronic renal failure  don’t excrete/eliminate electrolytes
d. Acute and chronic GI losses 
10. Discuss age related changes with regard to fluid and electrolyte imbalance (1)
a. Elderly and toddlers/babies are at an increased risk for dehydration/fluid and
electrolyte imbalance
 b. Elderly
i. Loss of GI secretions  do not absorb electrolytes and fluids as well?
ii. Have a decreased sense of thirst/thirst mechanism  do not drink as
much water
iii. Can have trouble reaching for food or water (physical decline, things in
their way)
c. Toddlers/babies
i. Decreased ability to communicate their needs  cannot vocalize when
thirsty
ii. Are busy and do not think about need for water
iii. Cannot readily access food and water  short, need help

Hematological Processes (15 questions)

11. Discuss the physiology of RBC make-up and functions, and normal parameters of RBC
counts (HCT, HGB) (1 question)
a. RBCs are made up of
i. 4 proteins (2 alpha and 2 beta)
ii. Hemoglobin molecules (carry iron and 4 O2 molecules)
b. RBCs functions
i. Carry oxygen throughout blood and to tissues. They are the oxygen
carrying capacity of the body
c. RBC counts
i. Hematocrit
1. Females: 37-47%
2. Males: 42-52%
ii. Hemoglobin
1. Females: 12-16
2. Males: 14-18
12. Compare and contrast the etiology, diagnosis, symptoms, and treatment of patients
with different types of anemia: hemolytic, iron deficiency, aplastic, vitamin B12
deficiency, folate deficiency, acute blood loss (5 questions)

Iron deficiency Vitamin B12 deficiency Folate deficiency

Etiology Decreased hemoglobin Impaired DNA synthesis Impaired DNA synthesis

synthesis
Decreased intake, Crohn’s, Pregnancy, low intake of
Chronic bleeding, celiac, GI surgeries folate, folate storage is low
decreased intake of iron
RBCs macrocytic, RBCs macrocytic,
RBCs hypochromic, megaloblastic, megaloblastic,
microcytic normochromic normochromic
Dx Labs/CBC: low H/h, RBCs, Labs/CBC: low H/h, RBCs Labs: low folate levels, low
ferritin H/h, RBCs
S/s
S/s S/s

S/s Cardiomegaly Ataxia s/s occur late in deficiency

Headache Paresthesia
Increased HR Weakness weakness
Pallor (most common s/s) Lethargy/fatigue beefy red tongue
SOB
Dizzy
Inc tongue size/glossitis
(2nd most common s/s)
Pica
SOB

Chronic: angular cheilitis,

dry/brittle nails
Tx (1) Iron supplements (1) Increase oral intake (1) Oral folic acid
(2) Increase oral of B12 (fish, eggs, supplements
intake (leafy meat, milk) (2) Increase intake of
greens, (2) Vit B12 folate (peanuts,
peas/beans, whole supplementation OJ/oranges, calf liver,
grains/cereals, injections beans, green veggies)
legumes, (3) IV banana bag
liver/muscle
meats)
(3) Blood transfusions

Aplastic Hemolytic Blood loss

Etiology Decreased RBC precursors
Bone marrow dysfunction
(autoimmune, infection,
cancer drugs, radiation,
chemicals/toxins)
RBCs are normochromic,
normocytic
Premature destruction of Decreased # of RBCs
RBCs
Blood loss  decreased
Meds, transfusions, number of circulating RBCs
chemicals/toxins,
infections/COVID, DIC,
obstruction in RBCs are normochromic,
microcirculation, disease of normocytic
the kidneys, spleen, liver,
antiplatelet antibodies

RBCs are normochromic,

normocytic
Dx CBC/labs: low H/h, RBCs,
low reticulocyte count, low
platelets, WBCs
S/s Pallor, petechiae
Bruising, bleeding
Weakness, fatigue, SOB
Tx (1) Blood transfusions
(2) Bone marrow
transplant
(3) Immunosuppressiv
e therapy for
autoimmune
CBC/labs: low H/h, RBCs,
high reticulocyte count
SOB
Fatigue
JAUNDICE!!!!
(1) Blood transfusions
(2) Corticosteroids
(decreases affinity for
macrophages)
(3) Fix cause
CBC/labs: low H/h, RBCs, high
reticulocyte count
Active bleed
Increased RR, HR, thready
pulse
Cold/clammy skin
Low BP/ortho hypotension
Low CO
Low volume/shock
Lactic acidosis
Life gone/death
(1) Stop bleed
(2) Blood transfusion
(3) Iron supplementation
(iron deficiency
anemia can also
occur)

13. Describe the pathophysiology, symptoms, diagnosis, and treatment of

thrombocytopenia (1 question)
a. Pathophysiology: decreased number of circulating platelets
i. Due to aplastic anemia, bone marrow dysfunction, infection, increased
sequestrant of platelets in the spleen, decreased platelet survival
(autoimmune/antiplatelet antibodies), nonimmune (mechanical injury
from mechanical valve, bypass)
b. Symptoms:
i. Bruising, bleeding, petechiae, purpura, hemorrhage, can be
asymptomatic
c. Diagnosis
i. Prolonged bleeding, bleeding of gums/mucosa, bruising (petechiae,
purpura, ecchymoses), low platelet counts in labs
d. Treatment
i. Platelet transfusion
14. Describe the ABO/Rh system (2 questions)
- Rh factor: if they have it, they are positive
o A+, B+, AB+, O+
- Individuals who are positive can receive negative blood, but negative blood cannot
receive positive
15. Discuss the types of blood products and what each is used to correct physiologically
a. Packed red blood cells
i. Cold, use within 20-30 minutes of arrival, infuse over 4 hours, type-
specific, 250-350 mL RBCs/unit, Hb has to be lower than 7 and patient
has to be symptomatic
ii. Hemoglobin 1:3 Hematocrit
iii. Used for anemias and blood loss
b. Fresh frozen plasma
i. Used for hemorrhage and warfarin/coumadin reversal, rare = volume
expander
ii. Frozen, type specific, 1 unit= 200-250 mL liquid part of blood
c. Platelets
i. Used for thrombocytopenia and aplastic anemia
d. Cryoprecipitate
i. Clotting factors VIII, XIII, factor I (fibrinogen), VWF
ii. Used for hemorrhage, von Willebrand disease, hemophilia, low
fibrinogen
e. Albumin
 i. Used as a volume expander for hypovolemic shock (increase blood
osmolarity), hypoalbuminemia
16. Identify and discuss the steps in the transfusion process (1 question)
a. Labs
b. Obtain order and informed consent
c. Cross and screen, cross and match
d. Make sure have big IV (22 g), blood tubing, .9% NS x2 and tubing
e. 2 nurses need to check blood with patient information
f. Get baseline vitals
g. Start infusion after priming the tubing with NS
i. Infuse at slow rate (50 mL/hour)
h. Stay with the patient and monitor for the first fifteen minutes. Get vitals at 15
minutes
i. Educate the patient on s/s of infusion reaction before leaving the room
j. Get vitals hourly
k. Evaluate vitals for infusion reaction, s/s, and labs to determine effectiveness
17. Integrate principles of safety into the transfusion process (3 questions)
18. Compare and contrast the signs and symptoms of different transfusions reactions (and
immediate nurse actions) (1 question)
a. Different types of transfusion reactions:
i. Allergic and anaphylaxis: sensitivity to donor plasma proteins
ii. Febrile, non-hemolytic: sensitization to donor WBCs, platelets, or plasma
proteins
iii. Acute hemolytic: ABO-incompatibility (RBCs hemolyze)
b. Symptoms of transfusion reaction:
i. Low BP
ii. Increase temp/fever
iii. Pallor/cyanosis
iv. Itchy/rash/hives
v. Dyspnea/wheezing
vi. Chills/diaphoresis
vii. Oliguria/anuria
viii. Urine dark/brown
ix. Rhabdo/muscle aches/back and chest pain
x. Thready, rapid pulse
19. Discuss alternatives to transfusions (including dietary education that can be provided to
patients) (1 question)
a. Foods high in iron:
i. Leafy green vegetables
ii. Whole grains/cereals
iii. Beans/peas
iv. Legumes
v. Liver/muscle meats
vi. Dried fruits
 b. Iron supplements
c. Erythropoietin

Urinary (14 questions + Case Study = 6 questions)

20. Identify the anatomic location and functions of the kidneys, ureters, bladder, and
urethra
a. Upper: kidneys and ureters
b. Lower: bladder, urethra
c. Kidneys: make urine
d. Ureters: carry urine from kidneys to bladder
e. Bladder: store urine
f. Urethra: excretes urethra, controls voiding
i. Longer for males (8 inch), BPH  makes it harder to urinate
ii. Females shorter (1.5 inch)  more at risk for UTIs due to shorter, closer
to anus and vagina

g.
h. Urine output
i. Normal: ~1500 mL/day
ii. Concern: <~0.5 mL/kg/hour
iii. Oliguria: <400 mL/day
21. Explain the physiologic events involved in the formation and passage of urine from
glomerular filtration to voiding (understand urine passage and voiding)
a. Formation
i. Kidneys filter waste products out of the bloodstream and produce urine
 1. Glomerulus/glomerular filtration: small round pocket within the
kidneys that uses concentration gradients to remove waste and
salts from the blood vessels that pass through it
b. Passage
i. Kidneys  ureter  bladder  urethra/urethral sphincter
22. Obtain significant subjective and objective data related to the urinary system from a
patient
a. Subjective: pain while urinating/dysuria, reported symptoms, hesitancy,
intermittency, foul-smelling urine, urinary retention/incomplete emptying,
dribbling, urgency
b. Objective: how much urine passing per hour/day, labs (urinalysis), hematuria,
cloudy urine/sediment, afebrile/febrile
23. Understand risk factors related to UTIs, symptoms associated with lower and upper
UTIs, objective findings with lower vs upper UTIs
a. Urinalysis: why nonspecific, why altered for other reasons
i. Lower UTI urinalysis
1. Specific: + leukocytes, + nitrites, WBCs >5
2. Non-specific: color, cloudy, blood, pH, specific gravity
a. Color, cloudy, specific gravity – can be affected by
dehydration
b. Color, cloudy -- can be affected by meds
c. RBCs, blood, pH – can be affected by menstrual cycle
ii. Upper UTI urinalysis
1. Specific: +leukocytes, +nitrites, WBCs >5, + casts
2. Non-specific: RBCs, blood, color, cloudy/turbidity, pH, specific
gravity
b. Risk factors UTIs
i. Personal hygiene
1. do not use vaginal sprays/douches/bubble baths
2. wipe front to back
3. urinary retention/holding pee
4. poor hydration
ii. sexual partners
1. multiple
2. not urinating after sex
3. not washing hands pre and post sex
iii. Menopause due to decreased estrogen
iv. Immunocompromised (aging, diabetes, chronic infections)
1. Diabetes: sugar in the urine = perfect breeding ground for
bacteria
v. BPH
vi. Kidney stones
vii. Catheters
c. Symptoms UTIs
 i. Upper/pyelonephritis
1. Flank pain/CVA tenderness, fever/chills, nausea/vomiting,
malaise
2. Older adults: temperature is an unreliable indicator
ii. Lower
1. Dysuria, urgency, frequency, suprapubic pressure, foul smelling
urine, cloudy urine, incomplete emptying
d. Objective findings UTIs
i. Upper
1. Systemic manifestations present
a. Febrile (not a reliable vital sign), tachycardia, tachypnea,
hypertension
2. Assessment: CVA tenderness (unilateral or bilateral)
3. Positive urinalysis:
a. Leukocytes present, nitrites present, WBCs over 5, Casts
b. Supportive/not objective: color, turbidity, specific gravity,
pH, blood
ii. Lower
1. No systemic manifestations/unremarkable vital signs
2. Assessment: abdominal discomfort, suprapubic tenderness with
palpation
3. Positive urinalysis
a. Leukocytes present, nitrites present, WBCs over 5
b. Supportive/not objective: color, turbidity, blood (could be
from other cause), pH, specific gravity
24. Risk factors, symptoms, objective findings, tx with kidney stones/nephrolithiasis
a. Damaging effects from obstruction affect the system above the obstruction
b. At risk for urosepsis, UTI, hydronephrosis, pyelonephritis, renal failure
c. Risk factors
i. Diet (lots of soda, tea, fruit juices, protein, salt. Not a lot of water intake)
1. Diet high in calcium is not supported to increase risk
ii. History of gout, kidney stones, urinary stasis or retention, metabolic
acidosis
iii. Lifestyle (obesity, sedentary, immobility)
iv. Live in warm climate (increased risk for dehydration_
d. Symptoms
i. Acute, sharp pain in flank, back or lower abdomen = RENAL COLIC
1. Pain can move as the stone moves
ii. Oliguria/anuria: stone is blocking urine flow
e. Objective Findings
i. Urinalysis
1. Specific: +casts (hyaline), +RBCs, + blood (trauma), + crystals
2. Non-specific: pH, leukocytes, nitrites
ii. Imaging (CT, x-ray, ultrasound)
 1. Primary test= CT abdominal/pelvis without contrast
iii. CBC and CMP
1. Assess for underlying infection and assess renal function
f. Treatment/nursing management
i. Pain management = priority!
1. Toradol: do not administer with ibuprofen/NSAIDs  increased
risk of GI s/s, bleeding, decreased kidney function
a. try Toradol first since it is not a opioid
2. Morphine: assess for respiratory depression, hypotension, level of
sedation (level of consciousness, drowsiness)
ii. Assess I/Os
1. Urinary output (are IVF being eliminated?)
2. 24-hour urine analysis
iii. Treatment depends on size of stone
1. Spontaneous passage
a. Stone <4 mm
b. Increase fluid (IV and oral) to try to flush stone
c. Administer Flomax (relaxes smooth muscle) and
antibiotic (if UTI is present)
d. Give patient a strainer for stone analysis
2. Surgery
a. Stones too large for passage
3. Percutaneous nephrolithotomy
a. Large kidney stones
i. Should be able to tell patients getting this cause
their stone is too large to pass spontaneously
b. Nephoscope is inserted through skin into the kidney 
stone fragments are removed, and kidney is irrigated
c. Percutaneous nephrostomy tube or ureteral stent may be
left in place to ensure the ureteral does not obstruct
4. Extracorporeal shock-wave lithotripsy
a. Noninvasive
b. Shock waves outside of body breakup stone without
damaging surrounding tissues  smaller pieces can be
passed
c. Administer anesthetic prior to procedure to prevent
severe pain
d. Complication: can lead to blocked ureter due to small
pieces passing  assess output
e. Percutaneous nephrostomy tube can be left in place to
ensure ureter does not obstruct
5. Nephrostomy tube nursing management
a. Check patency first (not kinked, draining) if:
i. Patient complains of pain to side
 ii. Excess drainage around the tube
b. Always monitor output, color, concentration, insertion
site, blood, pain
6. Post-op education
a. Expected
i. Flank pain for a few days
ii. Small amount of blood in urine 24-48 hours post-
op
b. Priority
i. Severe/acute pain  assess nephrostomy tube
patency
c. Encourage high water intake (~3L/day)
iv. Nutritional education/prevention of recurrent stone
1. High fluid intake (~3 L/day) to produce ~2.5 L/day (water is best,
reduces risk of dehydration)
2. Limit sodas, coffee, teas  increases stones
3. Decrease sodium and protein intake
25. Distinguish complicated vs uncomplicated UTI categories (which patient populations)
a. Uncomplicated: un-pregnant women, bladder involved only
b. Complicated: pregnant women, men, other organs involved
c. Treatment longer for complicated
d. Pharm dosing for complicated vs uncomplicated vs pyelonephritis
i. Uncomplicated:
1. Trimethoprim/sulfa (3-5 days)
2. Nitrofurantoin (3-5 days)
3. Cephalexin (5-7 days)
4. Fosfomycin (1 dose)
5. Other: amoxicillin, cephalosporins, ampicillin
ii. Complicated:
1. Trimethoprim/sulfa (7-10 days)
2. Nitrofurantoin (7 days)
3. Cephalexin (7-10 days)
4. Fosfomycin (3 doses)
5. Fluoroquinolones (5 days)
iii. Pyelonephritis:
1. Trimethoprim/sulfa (14 days)
2. Cefpodoxime (10-14 days)
3. Quinolones (14 days)
iv. Phenazopyridine/Pyridium = urinary tract analgesic  orange/red urine
26. Link the age-related changes of the urinary system to the differences in assessment
findings
a. Expected gerontologic changes and how this can affect clinical outcomes (UTIs,
incontinence, BPH)
i. UTIs
 1. Females: decreased elasticity and muscle tone and estrogen 
infections and incontinence
a. Note: infections AND incontinence = not expected age-
related change
b. Low estrogen  thinning of vaginal walls
2. Different s/s: nonlocalized/vague abdominal discomfort,
decreases appetite, acute cognitive impairment, fatigue,
tachycardia, afebrile
ii. Incontinence
1. Occurs due to decreased elasticity, decreased muscle tone
2. Not expected finding/age-related finding!!! Patients do not need
to live with this
iii. BPH
1. Enlarged prostate  squishes urethra  altered urinary
patterns/higher frequency/decreased emptying
a. Expected: increased prostate size
b. Unexpected: increased so much it squishes urethra
b. Understand assessment findings in the older adult (vital signs, s/s, indications of
infections)
i. Vitals signs:
1. Afebrile (temperature is unreliable with older adults)
2. Tachycardia
ii. S/s: fatigue, vague/nonlocalized abdominal discomfort, AMS, decreased
appetite, GI upset
c. Know expected age-related changes
i. Decreased elasticity and muscle tone, weakening urinary sphincter,
decreased bladder capacity
27. Describe the purpose, significance of results, and nursing responsibilities related to
diagnostic studies of the urinary system
a. CBC
i. Looks at blood cell counts, electrolytes
b. CMP
i. Looks at kidney function
c. Urinalysis
i. Looks at pH, contents of urine
ii. Clean catch – wash hands, wipe, pee a little, then collect sample
d. When should a patient provide a urine sample for a urinalysis
i. Urinary symptoms, back/flank pain, AMS, general collection
ii. Treat pain first
e. When to collect/advise a urine culture
i. If urinalysis is positive for UTI/pyelonephritis
ii. If recurring UTIs (>2-3 infections per year)
iii. Complicated UTIs
iv. Persistent bacteria even with antibiotic use
28. describe male urinary issues (BPH, TURP)
a. BPH: increased prostate size  compresses the urethra  partial or complete
obstruction  decreased urine outflow
b. Very common in biologic males over the age of 50 as the prostate gland
normally begins to enlarge
i. Expected: prostate enlarged
ii. Not expected: enlarged so much it cuts off urethra
iii. Clinical manifestations (divided into 2 groups)
1. Irritative: symptoms related to inflammation or infection
a. Nocturia is usually the first symptom the patient notices
b. Urinary frequency, urgency, dysuria, bladder pain,
overflow incontinence
2. Obstructive: symptoms related to increased effort of the bladder
as it tries to empty through the decreased diameter of the urethra
a. Decreased force of stream, difficulty starting a stream,
dribbling at the end of urination
b. Location is the most significant in development of
obstructive symptoms
i. No direct relationship with prostate size and
severity of symptoms
iv. Testing
1. Digital Rectal Exam (DRE)
a. Estimates prostate size, symmetry, consistency
b. Positive findings= symmetrically enlarged, firm and
smooth
2. Prostate-specific antigen (PSA)
a. If DRE is positive, conduct this test
b. Blood test to screen for prostate cancer
i. PSA levels may be slightly increased in patients
with BPH
ii. High PSA does not equate to cancer diagnosis
3. Transrectal ultrasound (TRUS) and Prostate biopsy
a. If DRE is positive and PSA is high, conduct this test
b. Allows for accurate assessment of prostate size and helps
distinguish between BPH and prostate cancer
4. Urine flow test: measures the volume of urine expelled from the
bladder to determine the extent of urethral blockage
5. Post-void residual: ultrasound measures urine retained post-void
(bladder scanner)
6. Urinalysis: assess for symptoms of lower UTI
v. Treatment/management
1. Complication = urinary retention, UTI
2. Medications
a. Tamsulosin/Flomax
 3. Surgical treatment
a. TURP = gold standard
c. TURP: surgical procedure to remove prostate tissue using a resectoscope
inserted through the urethra (gold standard for BPH)
i. CBI vs manual irrigation and nursing management
1. CBI: large triple lumen indwelling catheter inserted into the
bladder for bladder irrigation for 24 hours post-op
a. NS infused and drained from the bladder continuously
b. Titrate to pink
i. not titrating enough  clots
c. always assess the catheter for kinks of the patient
complains of acute pain
d. always record the amount of irrigating solution instilled
minus the amount of collected urine = urinary output
2. Manual: do if the catheter becomes obstructed (likely due to a
blood clot)
a. Patient complains of acute bladder spasms
b. Decreased irrigation of outflow (inflow>outflow)
c. Large clots are noted in the urine and patient complains
of pain
d. During irrigation, painful bladder spasms can occur
e. Call provider if patency is not re-established post-manual
irrigation
ii. Post-op expected findings
1. Bleeding for 24-36 hours (moderate/small blood, small clots) –
x7-10 days
2. With bladder spasms, check for clots and kinks in the catheter
3. Urinary incontinence is expected after catheter removal for
several week – teach Kegels
iii. Discharge education and when to notify the provider
1. Discharge
a. Avoid NSAIDs (increases risk of bleeding)
b. Avoid activities that increase abdominal pressure
c. Possibility of erectile dysfunction and retrograde
ejaculation
d. Urinary incontinence – Kegels
e. Assess the amount of urine and the color of the output
2. Notify provider
a. Hemorrhage, bright red bleeding, big clots = not expected
(ketchup like)
b. Chills, fever
c. Inability to urinate >4 hours
d. Severe pain not relieved by pain medications
e. Feeling of bladder fullness unresolved post-void
29. CAUTI
a. Prevention care
i. Handwashing
ii. Sterile insertion
iii. Bag below bladder
iv. Routine perineal care (BID)
v. Avoiding unnecessary catheterization
b. Nursing management
i. Clinical manifestations of suspected CAUTI
1. Acute delirium especially with older adults
2. Flank pain/CVA tenderness
3. Hematuria
4. Malodorous urine
5. Cloudy urine
6. Increased urinary frequency and tenderness, especially after foley
removal
ii. What to do if CAUTI suspected
1. Urine culture
2. Remove foley
a. After the catheter is removed, the patient remains at risk
for bacteriuria for at least 24 hours
3. Monitor I/Os and vitals
iii. Treatment (recognize medications)
1. Antibiotics
a. Cephalexin PO
b. Cefpodoxime PO
c. Ceftriaxone IV
d. Cefepime IV
iv. Education
1. Complete the antibiotic regimen even if symptoms improve
2. Fluid intake goal ~3L/day
3. Shower, not bath
4. No vaginal hygiene
30. Distinguish urinary incontinence types and associated managements/patient education
a. Focus on incontinence types and associated patient education
i. Stress incontinence: due to increased abdominal pressure
1. Ex: sneezing, coughing, laughing, pregnancy, picking up heavy
objects
2. More common in females
3. Management: Kegels
ii. Urge incontinence: immediately preceded by urgency, lose urine on the
way to the bathroom
1. “Overactive bladder”
2. More common in females
 3. Management: Kegels
iii. Mixed: associated with urgency and increased abdominal pressure
iv. Overflow: overdistended bladder due to chronic retention  leakage of
small amounts of urine
1. More common in males due to BPH and prostate cancer
2. Management: Crede maneuver  push on belly/bladder
v. Neurogenic/reflex: no warning precedes involuntary urination due to
disturbed function of the nervous system
1. Ex: spinal injury
2. Management: treat underlying cause, straight cath every 2-3
hours
vi. Functional: untimely urination due to physical or cognitive impairments
1. Usually, older adults that cannot move fast enough/things are in
the way
2. Management: environmental modifications (bedside commode,
move obstacles from path, timed bathroom trips)