WEEK_6_N2112_Module_SIX_Acid_Base_Renal__1_

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May 16, 2024

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1 Week 6: Nursing 2112 – Module 6 Part 1: Acid Base, Alterations to Fluid and Electrolytes Part 2: Alterations to Renal Function ACID BASE OBJECTIVES: Students should be able to:  Describe how hydrogen and bicarbonate play a role in maintaining homeostasis.  Explain the causes and characteristics of each of the acid-base disturbances.  Identify how the renal and respiratory systems work to compensate for each other.  Interpret Arterial Blood Gases. ALTERATIONS IN FLUIDS AND ELECTROLYTES OBJECTIVES: Students should be able to:  Distinguish between hypovolemia and hypervolemia.  Interpret and apply theoretical knowledge of the pathophysiology of conditions that cause fluid and electrolyte imbalance.  Describe the risk factors, pathophysiology, clinical manifestations, assessments, diagnostics and management for: Sodium, Potassium, Calcium, Magnesium and Phosphate  Explain the pharmacological and non-pharmacological interventions to prevent, manage, and alleviate manifestations arising from the alterations to fluid and electrolyte balance and alterations in renal and urinary function.  Describe the nursing process regarding a patient at risk of fluid/electrolyte imbalance. ALTERATIONS IN URINARY AND RENAL FUNCTION OBJECTIVES: Students should be able to:  Differentiate between lower and upper UTI’s.  Discuss the management of urinary incontinence and urinary retention.  Identify the difference between acute kidney injury (AKI) and chronic kidney disease (CKD).  Assess patients at risk for both of these conditions using case scenarios and chart data. Week Six N2112 Developed by the Teaching Team Concept Content Acid-Base Balance  Causes of the four disturbances/imbalances  S/S of imbalance  Management of acid-base imbalance  Related Lab values Fluid Balance  Hyper/hypovolemia  Iso, hyper, hypotonic solutions  Nursing process of Fluid imbalance  Related Lab values Electrolyte Balance  Sodium, Potassium, Calcium, Mg and Phos.  Manifestations and Management  Related Lab values Urinary and Renal Alterations  Upper and lower infections  Incontinence and retention  AKI  CKD  Intro to Dialysis  Nursing process for Renal patients

2  Determine appropriate nursing interventions for the prevention and treatment of these conditions  Interpret and apply theoretical knowledge of the pathophysiology of conditions that cause alterations in the renal and urinary system using critical thinking and clinical judgment for nursing practice.  Develop a nursing care plan for a client experiencing renal disease or injury.  Describe why a patient would have dialysis, the similarities and differences between hemodialysis and peritoneal dialysis, and potential complications of each. PREPARATION Terminology for Review: The following terms will be utilized within this module and throughout the course. Please familiarize yourself with these terms and be able to define them. Acid-Base Acid -anything that donates a H+ Base -anything that donates OH- Acidosis Acidosis - A condition of acidity or low pH (below 7.35) of the blood - high hydrogen ion concentration. ANP Atrial natriuretic peptide (ANP) - a hormone secreted by the heart when blood pressure rises - fine-tunes blood pressure and sodium-water balance of the body What does ANP do - inhibit the renin-angiotensin- aldosterone mechanism - It blocks renin and aldosterone secre-tion -inhibits other angiotensin-induced mechanisms that enhance water and Na+ reabsorption -Consequently, ANP’s overall influence is to decrease blood pressure by allowing Na+ (and Baroreceptors When are baroreceptors activated -When arterial blood pressure rises, it activates baroreceptors Where are baroreceptors -These stretch receptors are located in the carotid sinuses (dila-tions in the internal carotid arteries, which provide the major blood supply to the brain) - in the aortic arch - in the walls of nearly every large artery of the neck and thorax What happens when baroreceptors are stretched -When stretched, baroreceptors send a rapid stream of impulses to the cardiovascular center, inhibiting the vasomotor and cardio-acceleratory centers and stimulating the cardioinhibitory center. The result is a decrease in blood pressure Two mechanisms bring this about: ●Vasodilation. Decreased output from the vasomotor center allows arterioles and veins to dilate. Arteriolar vasodilation reduces total peripheral resistance, so MAP falls. Venodila-tion Metabolic alkalosis -When excessive loss of metabolic acids occurs, bicarbonate concentration increases, causing metabolic alkalosis Oliguria -decreased urine output -30mL/hr or less Osmoreceptor -Structure sensitive to osmotic pressure or concentration of a solution. Renin-angiotensin-aldosterone- system The renin-angiotensin-aldosterone mechanism influences both blood volume and blood pressure by regulating the release of aldosterone and therefore Na+ and water reabsorption by the kidneys. 1. When blood pressure (or blood vol-ume) falls, specialized cells of the juxtaglomerular complex in the kid-neys are excited. 2. These cells respond by releasing renin into the blood. 3. Renin splits off part of the plasma protein angiotensinogen (an0je-o-ten9sin-o-jen), triggering an enzy-matic cascade that forms Week Six N2112 Developed by the Teaching Team

3 water) to flow out of the body in urine (natriuretic 5 pro-ducing salty urine). Anuria Anuria -Abnormally low urinary output (less than 50 ml/day) ADH ADH -ADH causes the kidneys to retain water. Alkalosis Alkalosis -A condition of basicity or high pH (above 7.45) of the blood - low hydrogen ion concentration Arterial blood gas Azotemia Azotemia -(increased nitrogen levels in the blood) -abnormal concentration of nitrogenous wastes in the blood shifts blood to the venous reservoirs, which decreases venous return and cardiac output. ●Decreased cardiac output. Impulses to the cardiac centers inhibit sympathetic activity and stimulate parasympathetic activity, reducing heart rate and contractile force. As CO falls, so does MAP Dialysis Dialysis -DIffusion of solute(s) through a semipermeable membrane. Diffusion -movement of particles from a higher concentration to a lower concentration Diuresis Urine production Electrolytes Electrolytes are solutes in body fluids Filtration Hypovolemia Hypervolemia Metabolic acidosis - Metabolic acidosis occurs as the body's cells switch to anaerobic metabolism -In response to metabolic acidosis, heart rate and stroke volume increase in an attempt to improve tissue angiotensin II, which stimulates the glomerulosa cells to release aldosterone. Aldosterone -released in response to low Na+ or high K+ blood levels Its pri-mary target is the kidney tubules, where it ●Stimulates Na+ reabsorption (causing increased blood volume and blood pressure because water follows Na+) ●Causes K+ secretion into the tubules for elimination from the body Respiratory acidosis - when a person breathes shallowly -when gas exchange is hampered by diseases such as pneumonia, cystic fibrosis, or emphysema -CO2 accumulates in the blood -Thus, respiratory acidosis is characterized by falling blood pH and rising PCO2 -While respiratory acidosis is frequently associated with respiratory system pathology Respiratory alkalosis -results when carbon dioxide is eliminated from the body faster than it is produced -This is called hyperventilation (deeper and faster breathing than needed to remove CO2; p. 855) - results in the blood becoming more alkaline -respiratory alkalosis is often due to stress or pain Week Six N2112 Developed by the Teaching Team

4 perfusion. Sodium Potassium Pump Uremia uremia -clinical syndrome associ-ated with renal failure is called uremia (literally “urine in the blood”) -fatigue -anorexia, nausea -mental changes, and muscle cramps -While uremia was once attributed to accumulation of nitro-genous wastes (particularly urea), we now know that urea is not especially toxi multiorgan failure from uremia is caused by the interplay of multiple factors. These include - ionic and hormo-nal imbalances (including anemia due to lack of erythropoietin; p. 648) - as well as metabolic abnormalities and accumulation of various toxic molecules that interfere with normal metabolism Recall Previous Concepts from Biology  Normal fluid and electrolyte balance and distribution.  Osmosis and osmolality.  Normal homeostatic mechanisms for regulation of fluids.  Determine which patient populations are at an increased risk for fluid and electrolyte imbalances. Required Readings: Adams, M.P., Urban, C.Q., Sutter, R.E., El-Hussein, M. and J. Osuji, J. (2021), Pharmacology for nurses: A pathophysiological approach, Third Canadian Edition . North York, ON: Pearson Canada Inc. For all pharmacology also review the Nursing Considerations section for each class of medication.  Chapters 52, 53 Week Six N2112 Developed by the Teaching Team

5 Power-Kean, K., Zettel, S., El-Hussein, M.T., ,Huether, S.E., McCance, K.L., Brashers, V.L. & Rote, N.S. (2022). Understanding pathophysiology (2nd Canadian edition) . Milton, ON, Canada: Elsevier.  Chapter 5 (Fluid and Electrolytes, Acids and Bases)  Chapter 29 (Structure and Function of the Renal and Urological Systems) – This should be a review.  Chapter 30 (Alterations of Renal and Urinary Tract Function) EL Hussein, M. & Osuji,J. (2020). Brunner & Suddarth’s Canadian Textbook of Medical-Surgical Nursing (4 rd Ed.). Wolters Kluwer. Philadelphia.  Chapters 44, 45, 46 Content Study Guide : All of this material is testable, whether covered in class or not. The following content questions are meant to augment your learning objectives. These questions should direct your readings and help you sort out the required content, as well as integrate the content from your required readings. Use the required readings to prepare for class and help you to participate in the discussion and application of this information. Often, the lecture slides/materials will help to answer some of these questions for you. Print off your lecture materials and use them alongside this content study guide. Acid Base 1. What is the role of the Hydrogen ion (H+) in maintaining homeostasis? The concentration of hydrogen ions in body fluids -approximately 0.000 000 1 mg/L -This number, which may be expressed as 10−7mg/L, is indicated as pH 7.0 pH facts -- acidity or alkalinity of a solution -As the pH changes 1 unit (e.g., from pH 7.0 to pH 6.0), the [H+] ([H+] = hydrogen ion concentration) changes tenfold -The greater the [H+], the more acidic the solution and the lower the pH. The lower the [H+], the more alkaline or basic the solution and the higher the pH. In biological fluids -a pH of less than 7.4 is defined as acidic and a pH greater than 7.4 is defined as alkaline, or basic Hydrogen ion is needed to maintain -membrane integrity - the speed of metabolic enzyme reactions 2. What are the common causes of acid-base disturbance? 3. What is the pathophysiology and management of each acid-base disturbance? Week Six N2112 Developed by the Teaching Team

6 UP Pg 128-129 Acid-Base Imbalances Pathophysiological changes in the concentration of hydrogen ion in the blood lead to acid-base imbalances. acidemia -pH of arterial blood is less than 7.4 acidosis -A systemic increase in hydrogen ion concentration or a loss of base is termed acidosis alkalemia -the pH of arterial blood is greater than 7.4 alkalosis -A systemic decrease in hydrogen ion concentration or an excess of base is termed alkalosis Acidosis and alkalosis may be caused by -may be caused by metabolic or respiratory processes arterial blood gases -Acid-base imbalances are assessed using measurement of arterial blood gases - which includes the reporting of pH, PaCO2, and HCO Figure 5-13 Metabolic Acidosis In metabolic acidosis - concentrations of non–carbonic acids increase - bicarbonate lost from ECF - cannot be regenerated by the kidney (Table 5-10). Metabolic acidosis can occur either quickly, as in -lactic acidosis caused by poor perfusion - hypoxemia Metabolic acidosis can occur s slowly over an extended time, as in -renal failure -diabetic ketoacidosis -starvation (anion gap acidosis). Week Six N2112 Developed by the Teaching Team

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