Exam 1: MedSurg

Importance of Fluid & Electrolyte Balance

  • Foundation for understanding later content (renal, cardiac, endocrine).

  • Many later pathologies either CAUSE or are AFFECTED BY fluid/electrolyte shifts.

  • Some values must be memorized (lab normals).

Syllabus / Unit-1 Guidance

  • Locate Unit-1 in syllabus ➜ lists USLOs (Unit-Specific Learning Outcomes).

  • Recommended strategy: highlight text & lecture notes according to USLO wording.

  • Core electrolytes to master now:
    • Potassium (K⁺)
    • Sodium (Na⁺)
    • Calcium (Ca²⁺)
    • Magnesium (Mg²⁺)

  • Additional content: age-related changes, prevention strategies, diagnostics, treatments.

Functions of Water in the Human Body

  • Transportation medium: moves nutrients (glucose, O₂) & ions (Na⁺/K⁺) via blood.

  • Temperature regulation: dehydration ⟶ impaired heat dissipation ⟶ fever spikes (esp. children).

  • Acid-base (H⁺) balance: acts as solvent for buffering systems.

  • Medium for enzymatic digestion: saliva ≈ water + enzymes (amylase) starts carb breakdown in mouth.

Age-Related Sensitivities

Infants / Young Children

  • Dependent on caregivers for fluids.

  • High metabolic rate & surface-area-to-volume ➜ rapid fluid loss.

  • Immature kidneys can’t concentrate urine well.

Older Adults

  • Lose ≈ 40\% of functional cells with age (kidney, gastric, neural, cardiac).

  • ↓ Thirst & hunger sensations.

  • Decreased renal & cardiac reserve ➜ sensitive to both overload & deficit.

  • Polypharmacy: diuretics, antihypertensives, etc.

Electrolyte Refresher (Chemistry Quick-Look)

  • Electrolytes = molecules that carry charge after gaining/losing e⁻.

  • Charge allows movement across membranes & electrical activity (nerves, muscle).

  • Mnemonic tip: condense dense textbook sentences to ≤6 words for clarity.

Key Terms & Mechanisms of Fluid Movement

Semipermeable Membrane

  • Allows selective passage; found in cell membranes, capillaries, alveoli.

Solute vs. Solvent

  • Solute = “floaters” (Na⁺, glucose).

  • Solvent = liquid carrier (H₂O).

Osmosis

  • Water (solvent) moves low ➜ high solute concentration to equalize.

  • Prefix “osmo-” always implies water (e.g., serum osmolality = concentration test).

Diffusion

  • Solute particles move across membrane until evenly distributed; water level stays constant.

Filtration

  • Physical pushing of fluid/solids across membrane (e.g., glomerulus).

  • Driven by hydrostatic & oncotic pressures.

Active Transport

  • Energy-requiring movement (e.g., Na⁺/K⁺-ATPase) against gradient.

Homeostasis Concept

  • Body maintains narrow “lane” for variables (temp, pH, fluids).

  • Therapies aim to return patient to that lane.

IV Fluid Tonicity

Category

Relative Concentration vs. Cell

Water Movement

Common Examples

Isotonic

Equal

No major shift

0.9% NaCl (Normal Saline), D5W, Lactated Ringers

Hypertonic

Higher solute than cell

Water exits cell (cell shrinks)

3% NaCl, D10W

Hypotonic

Lower solute than cell

Water enters cell (cell swells)

0.45% NaCl

Physiologic Regulators of Volume & Electrolytes

Kidneys

  • Sense ↓ perfusion ➜ release renin.

  • Renin–Angiotensin–Aldosterone System (RAAS):
    • Renin ➜ \rightarrow Angiotensin II ➜ vasoconstriction.
    • Angiotensin II ➜ Aldosterone (adrenal cortex) ➜ retains Na⁺ & H₂O.
    • Net: ↑ BP & volume.

Hypothalamus (Osmoreceptors)

  • Detect ↑ osmolality (concentrated blood) ➜ thirst + release ADH.

ADH (Antidiuretic Hormone)

  • Posterior pituitary.

  • “Anti-peeing” hormone: inserts aquaporins in renal collecting duct ➜ H₂O reabsorption.

  • Deficiency (e.g., post-neurosurgery) → Diabetes Insipidus ➜ polyuria (≥ 8\text{ L/day}).

Baroreceptors

  • Located in carotid sinus & aortic arch.

  • Sense stretch/pressure:
    • Low BP ➜ sympathetic activation (↑ HR, vasoconstrict).
    • High BP ➜ parasympathetic (vagal) tone.

Atrial / Brain Natriuretic Peptides (ANP/BNP)

  • Atria/ventricles secrete when stretched (high volume).

  • Promote natriuresis (Na⁺ excretion) & diuresis ➜ ↓ volume, ↓ BP.

  • BNP clinically monitored in CHF; elevated values (e.g., >500\,\text{pg/mL}) indicate fluid overload.

Populations at Risk Summary

  • Elderly: ↓ total body water, meds (furosemide), comorbid CHF/CKD.

  • Infants: high turnover, immature organs.

  • Patients with endocrine disorders (SIADH, Addison’s, Cushing’s).

  • Surgical / neuro patients (risk of DI/ADH issues).

Fluid Imbalances

Terminology

  • Euvolemia: normal volume.

  • Hypovolemia: deficit.

  • Hypervolemia (Fluid Volume Excess): surplus.

Hypervolemia

Etiologies

  • Congestive Heart Failure (pump failure).

  • Renal insufficiency/CKD (poor excretion).

  • Excess/rapid IV fluids (bolus).

  • Endocrine/metabolic (SIADH, Cushing’s).

  • Liver disease ➜ hypoalbuminemia & third-spacing.

Clinical Manifestations

  • General edema:
    • Peripheral / dependent (feet, hands).
    • Ascites (abdominal).
    • Anasarca = whole-body massive edema.

  • Pulmonary edema: crackles, dyspnea, cough, frothy sputum, ↓ \text{SpO}_2, tachypnea.

  • Cardiovascular: bounding pulses, jugular venous distension, ↑ BP (may see reflex bradycardia).

  • Rapid weight gain (> 1\text{ kg} / 24\text{ h}).

  • Possible weeping of fluid through skin in severe cases.

Laboratory Findings

  • Dilutional hyponatremia (↓ Na⁺).

  • ↓ Serum osmolality & ↓ urine specific gravity.

  • ↓ Hematocrit (diluted RBCs).

  • ↑ BNP/ANP.

Diagnostics

  • History & S/S context (e.g., CHF + salty diet).

  • CXR for pulmonary edema.

  • Echocardiography to assess ejection fraction.

  • Serum labs above.

Management

Medical Orders:

  • Fluid restriction (calculate allowance; subtract Jell-O/ice-cream volumes).

  • Diuretics (loop: furosemide).

  • Low-sodium diet (Na⁺ attracts H₂O).

  • Compression stockings (need order).

  • Possible dialysis/ultrafiltration if kidneys fail.

Nursing Interventions (may initiate/monitor):

  • Strict I&O recording (fluids in/out; include IV, oral, enteral).

  • Daily weights (same scale, gown, time).

  • Elevate edematous limbs; semi-Fowler/high-Fowler for pulmonary congestion.

  • Skin care: protect from breakdown, manage “weeping”.

  • Patient/family education: sodium sources, fluid limits, reading labels.

  • Monitor vitals, lung sounds, lab trends; alert provider for worsening (gain >2\text{ lb} overnight).

Quick Comparison Table

Parameter

Hypervolemia

Hypovolemia (preview)

BP

↑

↓

HR

variable (often bounding)

↑ (tachy)

Weight

↑

↓

Skin turgor

taut/edematous

tenting/dry

Na⁺

↓ (dilute)

↑ (concentrated)

Hct

↓

↑

Urine SG

↓

↑

(Details of hypovolemia will follow in subsequent lecture.)

Ethical / Practical Considerations

  • Over-rapid IV bolus in elderly CHF pts ➜ iatrogenic pulmonary edema—avoid by verifying baseline EF & titrate pump rates.

  • Cognitive impairment: need caregivers to enforce fluid restrictions or encourage intake.

  • Psych eval before bariatric surgery to prevent malnutrition-related anasarca.

Study Tips & Connections

  • Revisit high-school chemistry of ions; link charge ➜ physiologic movement.

  • Use prefix clues: “osmo-” (water), “baro-” (pressure).

  • Relate RAAS/ADH/ANP interplay to pharmacology (ACE-I, ARBs, diuretics).

  • Daily weight change rule of thumb: 1\text{ kg} \approx 1\text{ L} water.

  • Connect lab interpretations (osmolality, BNP) to physical exam findings for clinical reasoning.

    Importance of Fluid & Electrolyte Balance

    • Foundation for understanding later content (renal, cardiac, endocrine).

    • Many later pathologies either CAUSE or are AFFECTED BY fluid/electrolyte shifts.

    • Some values must be memorized (lab normals).

    Syllabus / Unit-1 Guidance

    • Locate Unit-1 in syllabus ➜ lists USLOs (Unit-Specific Learning Outcomes).

    • Recommended strategy: highlight text & lecture notes according to USLO wording.

    • Core electrolytes to master now:
      • Potassium (K⁺)
      • Sodium (Na⁺)
      • Calcium (Ca²⁺)
      • Magnesium (Mg²⁺)

    • Additional content: age-related changes, prevention strategies, diagnostics, treatments.

    Functions of Water in the Human Body

    • Transportation medium: moves nutrients (glucose, O₂) & ions (Na⁺/K⁺) via blood.

    • Temperature regulation: dehydration ⟶ impaired heat dissipation ⟶ fever spikes (esp. children).

    • Acid-base (H⁺) balance: acts as solvent for buffering systems.

    • Medium for enzymatic digestion: saliva ≈ water + enzymes (amylase) starts carb breakdown in mouth.

    Age-Related Sensitivities

    Infants / Young Children

    • Dependent on caregivers for fluids.

    • High metabolic rate & surface-area-to-volume ➜ rapid fluid loss.

    • Immature kidneys can’t concentrate urine well.

    Older Adults

    • Lose ≈ 40\% of functional cells with age (kidney, gastric, neural, cardiac).

    • ↓ Thirst & hunger sensations.

    • Decreased renal & cardiac reserve ➜ sensitive to both overload & deficit.

    • Polypharmacy: diuretics, antihypertensives, etc.

    Electrolyte Refresher (Chemistry Quick-Look)

    • Electrolytes = molecules that carry charge after gaining/losing e⁻.

    • Charge allows movement across membranes & electrical activity (nerves, muscle).

    • Mnemonic tip: condense dense textbook sentences to ≤6 words for clarity.

    Key Terms & Mechanisms of Fluid Movement

    Semipermeable Membrane

    • Allows selective passage; found in cell membranes, capillaries, alveoli.

    Solute vs. Solvent

    • Solute = “floaters” (Na⁺, glucose).

    • Solvent = liquid carrier (H₂O).

    Osmosis

    • Water (solvent) moves low ➜ high solute concentration to equalize.

    • Prefix “osmo-” always implies water (e.g., serum osmolality = concentration test).

    Diffusion

    • Solute particles move across membrane until evenly distributed; water level stays constant.

    Filtration

    • Physical pushing of fluid/solids across membrane (e.g., glomerulus).

    • Driven by hydrostatic & oncotic pressures.

    Active Transport

    • Energy-requiring movement (e.g., Na⁺/K⁺-ATPase) against gradient.

    Homeostasis Concept

    • Body maintains narrow “lane” for variables (temp, pH, fluids).

    • Therapies aim to return patient to that lane.

    IV Fluid Tonicity

    Category

    Relative Concentration vs. Cell

    Water Movement

    Common Examples

    Isotonic

    Equal

    No major shift

    0.9% NaCl (Normal Saline), D5W, Lactated Ringers

    Hypertonic

    Higher solute than cell

    Water exits cell (cell shrinks)

    3% NaCl, D10W

    Hypotonic

    Lower solute than cell

    Water enters cell (cell swells)

    0.45% NaCl

    Physiologic Regulators of Volume & Electrolytes

    Kidneys

    • Sense ↓ perfusion ➜ release renin.

    • Renin–Angiotensin–Aldosterone System (RAAS):
      • Renin ➜ \rightarrow Angiotensin II ➜ vasoconstriction.
      • Angiotensin II ➜ Aldosterone (adrenal cortex) ➜ retains Na⁺ & H₂O.
      • Net: ↑ BP & volume.

    Hypothalamus (Osmoreceptors)

    • Detect ↑ osmolality (concentrated blood) ➜ thirst + release ADH.

    ADH (Antidiuretic Hormone)

    • Posterior pituitary.

    • “Anti-peeing” hormone: inserts aquaporins in renal collecting duct ➜ H₂O reabsorption.

    • Deficiency (e.g., post-neurosurgery) → Diabetes Insipidus ➜ polyuria (≥ 8\text{ L/day}).

    Baroreceptors

    • Located in carotid sinus & aortic arch.

    • Sense stretch/pressure:
      • Low BP ➜ sympathetic activation (↑ HR, vasoconstrict).
      • High BP ➜ parasympathetic (vagal) tone.

    Atrial / Brain Natriuretic Peptides (ANP/BNP)

    • Atria/ventricles secrete when stretched (high volume).

    • Promote natriuresis (Na⁺ excretion) & diuresis ➜ ↓ volume, ↓ BP.

    • BNP clinically monitored in CHF; elevated values (e.g., >500\,\text{pg/mL}) indicate fluid overload.

    Populations at Risk Summary

    • Elderly: ↓ total body water, meds (furosemide), comorbid CHF/CKD.

    • Infants: high turnover, immature organs.

    • Patients with endocrine disorders (SIADH, Addison’s, Cushing’s).

    • Surgical / neuro patients (risk of DI/ADH issues).

    Fluid Imbalances

    Terminology

    • Euvolemia: normal volume.

    • Hypovolemia: deficit.

    • Hypervolemia (Fluid Volume Excess): surplus.

    Hypervolemia

    Etiologies

    • Congestive Heart Failure (pump failure).

    • Renal insufficiency/CKD (poor excretion).

    • Excess/rapid IV fluids (bolus).

    • Endocrine/metabolic (SIADH, Cushing’s).

    • Liver disease ➜ hypoalbuminemia & third-spacing.

    Clinical Manifestations

    • General edema:
      • Peripheral / dependent (feet, hands).
      • Ascites (abdominal).
      • Anasarca = whole-body massive edema.

    • Pulmonary edema: crackles, dyspnea, cough, frothy sputum, ↓ \text{SpO}_2, tachypnea.

    • Cardiovascular: bounding pulses, jugular venous distension, ↑ BP (may see reflex bradycardia).

    • Rapid weight gain (> 1\text{ kg} / 24\text{ h}).

    • Possible weeping of fluid through skin in severe cases.

    Laboratory Findings

    • Dilutional hyponatremia (↓ Na⁺).

    • ↓ Serum osmolality & ↓ urine specific gravity.

    • ↓ Hematocrit (diluted RBCs).

    • ↑ BNP/ANP.

    Diagnostics

    • History & S/S context (e.g., CHF + salty diet).

    • CXR for pulmonary edema.

    • Echocardiography to assess ejection fraction.

    • Serum labs above.

    Management

    Medical Orders:

    • Fluid restriction (calculate allowance; subtract Jell-O/ice-cream volumes).

    • Diuretics (loop: furosemide).

    • Low-sodium diet (Na⁺ attracts H₂O).

    • Compression stockings (need order).

    • Possible dialysis/ultrafiltration if kidneys fail.

    Nursing Interventions (may initiate/monitor):

    • Strict I&O recording (fluids in/out; include IV, oral, enteral).

    • Daily weights (same scale, gown, time).

    • Elevate edematous limbs; semi-Fowler/high-Fowler for pulmonary congestion.

    • Skin care: protect from breakdown, manage “weeping”.

    • Patient/family education: sodium sources, fluid limits, reading labels.

    • Monitor vitals, lung sounds, lab trends; alert provider for worsening (gain >2\text{ lb} overnight).

    Quick Comparison Table

    Parameter

    Hypervolemia

    Hypovolemia (preview)

    BP

    ↑

    ↓

    HR

    variable (often bounding)

    ↑ (tachy)

    Weight

    ↑

    ↓

    Skin turgor

    taut/edematous

    tenting/dry

    Na⁺

    ↓ (dilute)

    ↑ (concentrated)

    Hct

    ↓

    ↑

    Urine SG

    ↓

    ↑

    (Details of hypovolemia will follow in subsequent lecture.)

    Ethical / Practical Considerations

    • Over-rapid IV bolus in elderly CHF pts ➜ iatrogenic pulmonary edema—avoid by verifying baseline EF & titrate pump rates.

    • Cognitive impairment: need caregivers to enforce fluid restrictions or encourage intake.

    • Psych eval before bariatric surgery to prevent malnutrition-related anasarca.

    Study Tips & Connections

    • Revisit high-school chemistry of ions; link charge ➜ physiologic movement.

    • Use prefix clues: “osmo-” (water), “baro-” (pressure).

    • Relate RAAS/ADH/ANP interplay to pharmacology (ACE-I, ARBs, diuretics).

    • Daily weight change rule of thumb: 1\text{ kg} \approx 1\text{ L} water.

    • Connect lab interpretations (osmolality, BNP) to physical exam findings for clinical reasoning.

Anatomy & Physiology (review reminder)

  • Re-read first-term anatomy texts & course quizzes for kidney, ureter, bladder, urethra location/structure.

Factors Influencing Urinary Elimination

  • Developmental stage

    • Infants, preschoolers, school-age children, older adults

  • Psychosocial influences (privacy, anxiety, cultural beliefs)

  • Fluid & food intake (type, amount, timing)

  • Medication effects (diuretics, anticholinergics, etc.)

  • Muscle tone of pelvic floor & detrusor

  • Pathologic conditions (DM, HTN, stones, infections, neurologic disease)

  • Surgical procedures (anesthesia ↓ tone, instrumentation ↑ infection risk)

Key Quantitative Targets (normal & minimum)

  • Minimum daily fluid intake: (2\text{–}3\,\text{L})

  • Minimum urine output: (30\,\text{mL/hr}) or (0.5\,\text{mL/kg/hr})

  • Usual adult average output: \approx 60\,\text{mL/hr}

Nephrotoxic Substances (memorize!)

  • Anti-infectives (e.g., aminoglycosides)

  • ACE inhibitor – captopril

  • Antineoplastics – cisplatin

  • Immunosuppressants – cyclosporine

  • NSAIDs – salicylates, ibuprofen, indomethacin

  • Other common drugs – acetaminophen, furosemide, phenazopyridine HCl

  • Contrast media dye – Gastrografin

  • Anesthetics – halothane

  • Heavy metals – lithium, gold salts, lead

  • Industrial chemicals – carbon tetrachloride (cleaning solvent)

  • Environmental toxins – pesticides, snake venom

Age-Related Changes

  • \downarrow GFR & overall kidney function

  • Prostatic enlargement obstructs male urine flow

  • \downarrow renal hormone secretion (renin, erythropoietin, calcitriol)

  • \downarrow bladder tone & capacity

  • Nocturia frequency \uparrow

  • Post-menopausal \downarrow estrogen leads to urethral/pelvic floor laxity → infections & stress incontinence

Assessment Overview

  • History: chief complaint, onset, duration, quantity/quality changes, pain, precipitating factors

  • Focused questions: HTN? DM? stones? recurrent UTIs? urgency/frequency/incontinence? usual fluid intake?

  • Physical exam: inspect abdomen, palpate bladder, CVA tenderness, skin turgor/edema, VS

  • Urine inspection: color, clarity, odor, volume

  • Ongoing: strict I&O, residual measurement, pain monitoring

Diagnostic Tests & Normal Ranges to Recall

  • Urinalysis & C&S (sterility, pH 4.5\text{–}7.8, SG 1.010\text{–}1.030, no glucose/ketone/blood)

  • CBC (infection, anemia)

  • BUN \rightarrow 7\text{–}20\,\text{mg/dL}

  • Serum creatinine \rightarrow 0.6\text{–}1.3\,\text{mg/dL}

  • BUN:Creatinine ratio \approx 10\text{:}1\text{–}20\text{:}1

  • Creatinine clearance (via 24-hr urine) estimates GFR

  • Imaging: KUB X-ray, ultrasound, CT, angiography

  • Urodynamic studies: post-void residual (PVR), cystometry, uroflowmetry

Urinary Incontinence

Types & Definitions (memorize pathophysiology → intervention)

  • Stress: leak with ↑ abdominal pressure (laugh, cough). Teach Kegels, weight loss, avoid bladder irritants, schedule voids.

  • Urge: hyperactive detrusor → sudden urge. Bladder training, anticholinergics, limit caffeine.

  • Mixed: stress + urge combo → combine above strategies.

  • Overflow: over-distended bladder, poor contractility/outlet obstruction. Timed voiding, double-void, intermittent cath, treat BPH.

  • Functional: cognitive/physical barrier (e.g., arthritis). Toileting assistance, bedside commode, clear pathways, clothing mods.

  • Neurologic (reflex/total): spinal or brain lesion; intermittent/indwelling cath, skin care, possible diversion.

Primary Nursing Diagnoses

  • Functional/Reflex/Stress/Overflow/Urge/Total Urinary Incontinence

  • Urinary Retention; Impaired Urinary Elimination
    Related Dx: Risk for Infection, Impaired Skin Integrity, Low Self-esteem, Deficient Knowledge, Social Isolation, Caregiver Strain, Fluid-volume imbalance, Disturbed Body Image

Goals

  • Restore normal pattern/output; prevent infection, skin breakdown, F&E imbalance; promote independence/toileting; use appropriate containment devices

Interventions Summary

  • Promote fluid intake \ge 2\,\text{L/day} unless contraindicated

  • Maintain voiding schedule & privacy; bedside aids

  • Prevent UTIs: peri-care, wipe front→back, void q4h, before/after sex, cotton underwear

  • Bladder/continence training, habit/prompted voiding

  • Pelvic floor (Kegel) exercises (30-50 contractions/day)

  • Assess/adjust meds (diuretics timing, anticholinergics for urge)

  • Maintain skin integrity: barrier creams, frequent changes

  • Catheterization: sterile technique; minimize indwelling time

  • Dietary tweaks: limit caffeine, spicy foods, citrus if irritative

  • Community resources: PT, continence clinics, support groups

  • “Trigger” techniques to stimulate stream (running water, warm water over perineum, Crede)

Cystitis (Lower UTI)

Etiology

  • Mostly bacterial (E. coli); also stones, catheters, urinary diversion, immobility
    Clinical Manifestations

  • Urgency, frequency, dysuria, nocturia, incontinence, bladder spasms

  • Hematuria; urine dark/tea/cloudy; low-grade fever; pelvic discomfort; fatigue
    Diagnostics

  • UA (>10^5 CFU/mL), positive nitrites/leukocyte esterase

  • C&S; maybe KUB/CT if recurrent
    Treatment

  • Antibiotics (SMX-TMP, nitrofurantoin, fluoroquinolone per C&S)

  • Analgesic: phenazopyridine (turns urine orange)

  • ↑ Fluids \ge 3\,\text{L}; avoid bladder irritants

  • Education: complete full Rx; preventive measures (see above)

Urethritis

Causes

  • Infection (bacterial, chlamydia, gonorrhea)

  • Trauma (catheter, intercourse)

  • Hypersensitivity (spermicides, bubble bath)
    Manifestations

  • Dysuria, frequency, urgency, bladder spasm, urethral discharge
    Management parallels cystitis: targeted antibiotic, analgesic, remove irritant, hydration

Pyelonephritis

Acute

  • Usually ascending bacterial infection; F > M (20-30 y)

  • S/S: fever, chills, ↑WBC, flank pain/CVA tenderness, N/V, dysuria, nocturia, bacteriuria/pyuria, edema/overload
    Chronic

  • Scar tissue from repeated episodes; can be silent → polyuria, fatigue, weight loss, N/V
    Assessment

  • Hx recurrent UTIs, renal surgeries

  • Labs: UA, C-reactive protein, ESR, BUN/Cr, GFR, blood cultures, WBC

  • Imaging: KUB, CT; kidney biopsy if needed
    Treatment

  • Broad then C&S-directed antibiotics (usually 10\text{–}14 days)

  • Analgesics, antipyretics, hydration \ge 2\,\text{L} unless contraindicated

  • Sodium restriction if edematous; avoid high-sodium processed foods

  • Hospitalize if septic/shock

Glomerulonephritis

Acute (post-infectious)

  • Post \beta-hemolytic strep throat, mono, STI, viral illness

  • Global renal tissue inflammation → fluid overload complications (HTN encephalopathy, HF, pulmonary edema)
    S/S

  • Hematuria (cola urine), proteinuria, edema, SOB, HTN, tachycardia, flank pain, headache, malaise, ↑BUN/Cr, hyperkalemia, hypoalbuminemia
    Chronic

  • Develops over years; mild proteinuria/hematuria, HTN, fatigue, edema
    Assessment & Diagnostics

  • Recent infection? surgery? systemic disease?

  • UA, 24-hr protein, BUN/Cr, GFR, kidney biopsy
    Interventions

  • VS & weight daily, strict I&O

  • Treat cause (antibiotic for strep)

  • Dietary ⟶ limit K^+, Na^+, protein if azotemic

  • Potential dialysis when GFR very low

Urolithiasis (Renal Calculi)

Risk Factors

  • Dehydration, urinary stasis/obstruction, infection, genetics, high Ca/Vit D or Vit C, immobility (bone Ca release)
    Types (calcium oxalate most common, also uric acid, struvite, cystine)
    S/S

  • Sudden flank/CVA pain (renal colic), hematuria, bladder distension, N/V, pallor, infection symptoms
    Diagnostics

  • UA, SG, 24-hr urine chemistry, CT (non-contrast), KUB, IVP
    Treatment

  • Pain: ketorolac IV, opioids

  • Strain urine for stone analysis

  • Meds: thiazide diuretic (↓Ca excretion), allopurinol (uric acid), alpha-blocker to aid passage

  • Encourage ambulation & fluids (\ge 3\,\text{L/day})

  • Lithotripsy, ureteral stent, or surgical removal if obstructive
    Teaching

  • ↑ fluids, ↑ activity

  • Dietary modifications per stone type (e.g., ↓oxalate foods, ↓purines)

Acute Kidney Injury (AKI / Acute Renal Failure)

Definition & Patho

  • Abrupt loss of function; ↓GFR within hours–days; ↑Cr & BUN; F&E & acid-base imbalance
    Etiology

  1. Pre-renal: perfusion drop (hypovolemia, HF, hypotension)

  2. Intra-renal: direct nephron damage (ATN from toxins, ischemia, infection, nephrotoxic drugs)

  3. Post-renal: obstruction (stones, BPH, tumors, strictures)
    Five Key Kidney Functions & Clinical Correlates

  • Waste/fluid excretion ⇢ azotemia, edema; monitor I&O, weight; diuretics/fluid restriction

  • Acid-base (bicarbonate production) ⇢ metabolic acidosis; ABGs; may need sodium bicarb

  • BP regulation (renin) ⇢ HTN or hypotension; monitor VS; antihypertensives

  • Vitamin D activation ⇢ hypocalcemia; Ca supplementation, fall precautions

  • Erythropoietin ⇢ anemia; monitor H&H; epoetin alfa
    Phases

  1. Onset: precipitating insult → oliguria start

  2. Oliguric 1\text{–}3 wks (UO < (400\,\text{mL/day})). Worse prognosis if prolonged; dialysis often needed.

  3. Diuretic phase: sudden high UO (1000\text{–}2000\,\text{mL/day}) yet tubules still impaired → monitor hypovolemia/lytes

  4. Recovery: 3\text{–}12 mo; labs trend to baseline
    Diagnostics

  • I&O trends, rising BUN/Cr, ↑K^+/Phos, ↓Ca^{2+}, metabolic acidosis (ABG)

  • Imaging: renal US (rule out obstruction), CT no contrast, KUB, cystoscopy, retrograde pyelogram, biopsy (control BP to ↓bleed risk)
    Medical Management

  • Prevent: hydrate high-risk pts (contrast load, surgery)

  • Maintain F&E: fluid challenges (500\text{–}1000\,\text{mL}) or restriction, dialysis PRN

  • Avoid nephrotoxins, limit proteins, K, Na

  • Infection prevention: minimize catheters, asepsis
    Nursing Diagnoses

  • Ineffective tissue perfusion, Fluid volume excess, Risk for infection, etc.
    Nursing Management (Pre/Intra/Post-renal framework)

  • Pre: replace volume (NS, LR) if hypovolemic; if third-spacing, maybe albumin

  • Intra: identify nephrotoxic meds, obtain cultures, administer antibiotics, monitor drug troughs

  • Post: monitor for obstruction; prep for stent/lithotripsy; ensure consent, labs
    Older Adult Considerations

  • ↓CO, impaired thirst → higher AKI risk; limited Na conservation; poor urine concentrating ability; chronic comorbid renal damage
    Complications

  • Pericarditis (friction rub, pleuritic pain, tachycardia, fever)

  • Neurologic seizures from ↑BUN

  • Anemia (↓EPO & trauma bleeding)
    Goals Summary

  • VS within target (MAP >65\,\text{mmHg}, O$_2$ sat \ge 94\%)

  • Avoid contrast & nephrotoxins where possible

  • Control fluid overload; protect skin; detect infection early
    Patient Teaching

  • Diet: controlled protein, restricted Na^+, K^+, phosphorus; adequate calories

  • Medication review: OTC NSAIDs caution, contrast alerts

  • Monitor weight daily; report >2\,\text{lb}/day gain