MEDICAL-SURGICAL II

ASSESSMENT OF THE RENAL/URINARY SYSTEM

Organs:
 Kidneys (left kidney is higher than right due to placement of liver), contains nephrons
 Ureters - moves urine from kidney to the bladder
 Bladder - stores urine
 Urethra
 Males: prostate gland → produces semen

Physiology of Urinary System:

 Excretes urine and water
 Filters toxins, returns useful substances back into the bloodstream
 Produces hormone renin (elevates/regulates blood pressure) and erythropoietin (red blood cell formation)
 Regulates acid-base and electrolyte balance
 Vitamin D activation

Aging Effects on Renal System:

 Reduced blood flow to the kidneys - loss of nephrons and tissue
 Thickened glomerular and tubular basement membranes
 Decreased tubule length
 Decreased GFR
 Nocturnal polyuria
 Risk for dehydration → decreased sense of thirst

Physical Exam Findings:

 SKIN: dry and dark skin, severe itchiness, uremic frost, acne
 CV: high blood pressure, 
 GU: decreased urine intake/output
 GI: abdominal Pain
 MSK: back pain
 CNS: confusion
 PSYCH: depression, low self-esteem
 RESP: pulmonary edema, hardening of respiratory tract, higher incidence of TB, fluid overload
Laboratory Assessment:
  Increased creatinine - altered mental status
 Increased BUN
 Urinalysis → red or white blood cells, proteinuria, casts, pH, ketones present
 Bladder scan → urinary retention
 CT scan

CARE OF PATIENTS WITH URINARY PROBLEMS

Stress Incontinence: the inability to have control over when/when you pee; mostly associated with older adult patients. 

PATIENTS WITH RENAL DYSFUNCTION

Pyelonephritis: infection involving the kidneys (pelvis, calyces, medulla); and inflammation is linked with the infection. The most common
bacteria to cause this are: E. coli, Klebsiella, Enterobacter, Proteus, Pseudomonas, and Staphylococcus saprophyticus. This infection
usually begins in the lower urinary tract and ascends upward. Identification of the infectious organism is extremely important, so that
treatment can begin as soon as possible. Older patients and/or those who have comorbidities have a higher risk of complications from this,
and impaired renal function from repeat exposures of infection may complicate things even more. Septic shock may also occur. Infections
can be either acute or chronic. Higher risk for chronic kidney disease due to already damaged tissues. May be the result of Foley
catheterization or kidney stones. Most common in women who are 20-30 years old.
Acute is an active bacterial infection/urinary reflux that can cause interstitial inflammation, tubular cell necrosis, abscess
formation in the capsule, cortex, or medulla; or temporarily altered kidney function. 
Chronic is the result of repeated infections which cause scarring and progressive inflammation; can result in the thickening of
the calyces and post inflammatory fibrosis with permanent renal scarring, more common with obstructions, urinary anomaly, and
vesicoureteral urine reflux → reflux (backflow) occurs at junction where ureter and bladder meet.
Signs and Symptoms:
 Flank pain
 Fever
 Chills
 Urinary frequency, urgency, and dysuria
 Nausea
 Vomiting
 Diarrhea
 Increased heart rate
 Costovertebral angle pain
 Nocturia
 Hypertension
  Malaise
 Fatigue
 Flank/back pain
 Dysuria
 Confusion
 Abdominal Pain
Diagnosis:
 Urinalysis → shows leukocytes, bacteria, nitrites, and red blood cells
 Urine culture
 Antibiotic sensitivity test (like the lab we did in microbiology class)
 CBC shows leukocytosis (increase in total number of white blood cells)
 IV urography → contrast dye test
Treatment/Management:
 Administer antibiotics for infection:
 Nitrofurantoin
 Ciprofloxacin
 Levofloxacin
 Ofloxacin
 Trimethoprim-Sulfamethoxazole
 Ampicillin
 Amoxicillin
 Administer pyretics for fever
 Administer fluids to prevent dehydration and correct electrolyte imbalances from nausea and vomiting
 Administer phenazopyridine to help with dysuria symptoms
 Repeat urine culture after completing antibiotics treatment
Nursing Interventions:
 Monitor vital signs
 Monitor I&Os
 Assess for side effects of medications
 Teach patient that phenazopyridine will cause urine to turn orange
 Explain importance of sticking to antibiotics

Glomerulonephritis: Also known as nephritic syndrome. This is typically preceded by an ascending infection or occurs because of another
disorder. When this is caused by another disorder, it is known as secondary.
Infectious causes of this are: Group A beta-hemolytic Streptococcus, measles, mumps, cytomegalovirus, varicella, coxsackievirus,
pneumonia, chlamydia, malaria, syphilis, or pneumococcal infection. 
Systemic disorders that can cause this are: systemic lupus erythematosus, viral hepatitis B or C, thrombotic thrombocytopenic purpura,
or multiple myeloma. 
Depending on the cause, the acute episode may completely resolve. Patients should be monitored closely, and signs of renal failure must
be checked. Chronic glomerulonephritis develops over 20-30 years, and acute glomerulonephritis occurs after an infection. Exact
cause of this is unknown, but is associated with hypertension.
Signs and Symptoms:
 Hematuria
 Proteinuria
 Peripheral edema
 Elevated blood pressure (higher than the patient’s normal)
 Oliguria
 Nausea
 Vomiting
 Loss of appetite/anorexia (due to decreased renal function)
 Dysuria
 Fatigue
 Crackles
 S3 heart sound
 Weight gain
 Difficulty breathing
 Reddish-brown or Pepsi-colored urine
Diagnosis:
 Urinalysis → shows red blood cells and protein, first void of the day is preferred for testing
 Glomerular filtration rate (GFR) will be decreased
 24 hour urine collection
 Increased blood urea nitrogen (BUN)
 Serum albumin will be decreased
 Renal biopsy to determine cause
 Specific gravity of 1.010
Treatment/Management:
 Monitor renal function
 Monitor electrolyte levels
 Monitor vital signs
 Administer diuretics to remove extra fluid
 Monitor urinary output
 Restrict fluid intake
  Plasmapheresis if due to autoimmune cause
Nursing Interventions:
 Monitor vital signs
 Monitor I&Os
 Weigh daily
 Assess respiratory system for lung sounds, difficulty breathing, crackles in lungs (could mean fluid overload)
 Assess cardiovascular system for heart rate, heart sounds, and the presence of S3 could mean fluid overload
 Assess extremities for edema
 Provide medication education (it’s one of the rights of medication administration! Do it)
 Educate patient and family about disease

Acute Renal Injury/Failure: a decrease in renal function can occur in an acute (sudden) or chronic (progressive) manner. Acute renal
failure can be broken down into pre-renal, renal, or post-renal. In acute renal failure, the blood flow to the kidneys is compromised, but they
start working again following treatment and figuring out the underlying cause. 
There are 4 phases of acute kidney injury/failure:
1. Onset: begins with the onset of the event, ends when oliguria develops, and lasts for hours to days
2. Oliguria: begins with the kidney injury, urine output is 100-400mL/24 hours (normally 720mL in 24 hours) with or without diuretics,
and lasts 1-3 weeks.
3. Diuresis: begins when the kidneys start to recover, diuresis of a large amount of fluids occurs, and this can last 2-6 weeks.
4. Recovery: continues until kidney function is fully restored and can take up to 12 months (1 year) 
Pre-Renal Causes: diminished renal perfusion, severe burns, hypovolemia (fluid/blood loss), use of diuretics, third-spacing of fluids
(abnormal accumulation of fluid in the extracellular/interstitial space), reduced renal function due to NSAID use, congestive heart failure,
liver failure, decreased cardiac output, and peripheral vascular resistance
Intrarenal Causes: trauma, renal artery or vein stenosis, thrombosis, use of nephrotoxins (NSAIDs, antibiotics, blood transfusion reactions,
heavy metals, alcohol, cocaine, or contrast dyes), acute tubular necrosis, infection, vasculitis, pyelonephritis, poisoning, or acute
glomerulonephritis.
Post-Renal Failure: urinary tract obstruction, bladder obstruction/stone, bladder atrophy, prostate hypertrophy, kidney stones, kidney
cancer, compression of the ureter by prostate, spinal cord injury or disease
Signs and Symptoms: 
 Azotemia → elevated BUN and creatinine levels
 Hypovolemia → tachycardia, orthostatic hypotension, dry skin, and dry mucous membranes
 Peripheral edema (fluid overload)
 Decreased urinary output
 Dysuria
 Uremic pruritus → itching associated with kidney disease
 Dysrhythmias
 Crackles
  Shortness of Breath
 Decreased Oxygenation
 Very little to excessive urine output
 Possible hematuria
 Lethargy
 Muscle twitches and/or cramps in legs
 Seizures
 Dry skin and dry mucous membranes
 Confusion
 Metallic taste in mouth
 Anorexia
Diagnosis: 
 BUN and Creatinine levels are increased
 Biopsy
 BUN/Creatinine ratio is elevated
 Urinalysis → may show casts
 Ultrasound shows enlarged kidney
 Creatinine clearance decreases
 Decreased sodium level
 Metabolic acidosis
Treatment/Management:
 Fluid hydration replacements
 Depends on cause/severity
 Severe: dialysis or surgery
 Surgery to remove kidney stones
Patient Education:
 Low protein diet
 No new medications/vitamin supplements unless okay by doctor
 No tobacco or smoking
 Control blood pressure
 Healthy weight, exercise for 30 minutes a day for 5 days per week
 Seek medical care if: short of breath or excess swelling

Chronic Renal Disease/Failure: irreversible disease (but can be controlled) due to the damaging effects on the kidneys due to diabetes,
hypertension, glomerulonephritis, HIV infection, polycystic kidney disease, or ischemic nephropathy. In chronic renal failure, the patient can
die as a result of complications of the disease. Patients may be asymptomatic at first, but as time goes on their symptoms may start to
appear; especially during times of stress (fever, surgery, or infection). Older adults are at a greater risk for this because of the normal aging
process (decreased amount of functioning nephrons, decreased GFR). Make sure the elderlys get up and drink their water. Most common
causes are diabetes and hypertension. Repeat infections cause scarring. Most cases cannot be cured
Risk Factors:
 Diabetics
 Obesity
 Smokers
 Older than 60
 Family History
 Often takes nephrotoxic medications
 Hypertension
 Cardiovascular Disease
 Immunologic Diseases
 Polycystic Kidney Disease
There are 5 stages of this, and they are:
1. Stage 1: minimal kidney damage when GFR within expected range (greater than 90mL/min)
2. Stage 2: mild kidney damage with mildly decreased GFR (60-89 mL/min)
3. Stage 3: moderate kidney damage with moderate decrease in GFR (30-59 mL/min)
4. Stage 4: severe kidney damage with severe decrease in GFR (15-29 mL/min)
5. Stage 5: kidney failure and end-stage kidney disease, little to no GF (less than 15mL/min) - end-stage, risk of excessive weight
gain, fluid restriction is recommended
Signs and Symptoms: 
 CONSTI: Weight loss
 NEURO: lethargy, depression, decreased attention span, slurred speech, tremors, jerky movements, ataxia, seizures, or coma
 CV: fluid overload (jugular distention, severe edema), hypertension, dysrhythmias, heart failure, orthostatic hypotension, peaked T
waves on EKG
 RESP: halitosis with deep sighing, yawning, shortness of breath, tachypnea, hyperpnea, Kussmaul respirations, crackles, pleural
friction rub, frothy pink sputum
 HEME: anemia (pallor, weakness, dizziness), ecchymoses, petechiae, melena
 GI: mouth and throat ulcers, foul breath, blood in stool, vomiting
 MSK: thin and fragile bones
 RENAL: proteinuria, hematuria, casts in urine; change in urine amount, color, and concentration
 SKIN: decreased skin turgor, yellow cast to skin, dry, pruritus, uremic frost
 REPRO: erectile dysfunction
 MISC: hiccups (rare)
Diagnosis:
 Glomerular filtration rate (GFR) is decreased
  Ultrasound shows reduced size of kidneys
Treatment/Management: Treatment needs to address the underlying problem (if acute). However, correcting one problem may make a
different problem worse.
 Administer IV fluids to correct hypovolemia
 Administer inotropic agents for patients with congestive heart failure to enhance cardiac output
 Administer antibiotics for pyelonephritis
 Stent/catheter placement to drain fluid
 Dialysis (hemodialysis/peritoneal)
 Administer erythropoietin for anemia
 Restrict intake of potassium, phosphate, sodium, and protein
 Administer phosphate binders → calcium carbonate, sevelamer hydrochloride, lanthanum carbonate, sucroferric carbonate,
sucroferric oxyhydroxide, ferric citrate, and aluminum hydroxide
 Administer sodium polystyrene sulfonate to reduce potassium levels
 Monitor electrolyte levels
 Control blood pressure
 Control blood glucose levels
 No salty foods
 Avoid alcohol
 Hypertensive medications
 Electrolyte medications
 No OTC medications
 Healthy Weight
Nursing Interventions:
 Monitor vital signs for changes in heart rate or blood pressure
 Monitor I&Os
 Assess IV site for redness, swelling, or pain
 Check dialysis site for signs of infection
 Check AV shunt for palpable blood flow and listen with a stethoscope to hear the sound of blood flow through shunt
 No contrast dye tests
 No nephrotoxic medications → NSAIDs, ACE inhibitors, contrast agents
 Monitor patient closely

Polycystic Kidney Disease: Congenital disorder where clusters of fluid-filled cysts develop in the nephrons. Healthy kidney tissue is
replaced by severe non functioning cysts.  This is a hereditary condition caused by a genetic mutation, and is more common in
Caucasians. 
There are two types:
1. Autosomal dominant trait: most common form of PKD, cysts begin to multiply when the patient turns 30 years old
2. Autosomal recessive trait: multiple cysts are present at birth
Signs and Symptoms:
 Anxiety
 Guilt
 Abdominal pain
 Flank pain
 Headaches
 Hypertension caused by kidney ischemia
 Abdominal distention
 Constipation
 Bloody or cloudy urine
 Kidney stones
 Hyponatremia
 Nocturia
 Progressive kidney failure
Diagnosis:
 Urinalysis → hematuria, proteinuria, bacteria
 Gradual increase of creatinine, BUN, and creatinine clearance
 Ultrasound
 CT
 MRI
Treatment/Management:
 Control blood pressure with medications and/or diet
 Obtain daily weight
 Provide pain medication, implement nonpharmacological measures
 Do not use NSAIDs
 Apply heat to abdomen or flank areas
 Administer antibiotics, monitor closely for nephrotoxicity
 Monitor urine specific gravity
 Provide adequate fluid intake
 Increase fiber
 Encourage patient to ambulate
 Assess bowel sounds and movements
 Administer laxatives as prescribed
  Needle aspiration and drain cysts

Diabetic Nephropathy: Common in both type 1 and type 2; damage to the kidneys from elevated blood glucose levels and dehydration. 
Nursing Interventions:
 Monitor hydration and kidney function (I&Os, creatinine)
 Report an hourly output less than 30mL/hr
 Monitor blood pressure

Renal Cell Carcinoma: kidney cancer occurs when cancer cells create a tumor within the kidney. Exposure to chemicals, lead, and smoking
all increase the risk of developing kidney cancer. Identification of renal cancer is important for a favorable outcome. Patients often have
vague symptoms and may not seek medical care until later in the disease, when the cancer is more developed. Metastatic disease has the
worst prognosis.
Signs and Symptoms:
 Weight loss
 Anemia
 Hematuria
 Elevated blood pressure due to increased renin production
 Dull or aching flank pain (rare)
Diagnosis:
 CBC
 Urinalysis (shows red blood cells)
 ESR elevated
 Ultrasound reveals mass
 CT scan with contrast
 MRI
Treatment/Management:
 Surgical removal of tumor
 Radiation
 Chemotherapy
Nursing Interventions:
 Monitor vital signs
 Monitor I&Os for first 24-48 hours postop
 Monitor operative site for redness, swelling, or bleeding
 Monitor postoperative pain
 Monitor hemoglobin and hematocrit
 Monitor for postop infection
Kidney Stones/Renal Calculi: also known as nephrolithiasis. This occurs within the kidneys, and stones can also form other places within
the urinary tract. The patient may not have any symptoms from kidney stones until the stone attempts to move down the ureter towards the
bladder, and patients develop crystals within the urine. A slow flow of urine gives the crystals time to form a stone. Crystals may be formed
from calcium, uric acid, cystine, or struvite. Medications such as diuretics can increase the risk of developing kidney stones in some people.
A stone may lodge itself in the ureter and that will block the flow of urine. Hydronephrosis and swelling of the ureter may occur. Kidney
stones often happen again and again, especially in people with a family history. These stones can also be present in the urinary tract, and
the most common cause of this is dehydration.
Risk Factors: Exact cause is unknown
 Increased occurrence in males
 Urinary tract lining is damaged
 Urine flow that is decreased, concentrated, and contains particles of calcium
 Metabolic defects
 High alkalinity or acidity of urine
 Urinary stasis, retention, immobilization, and dehydration
 Decreased fluid intake 
 Increased incidence of dehydration among older adults
Signs and Symptoms:
 Hematuria
 Unilateral spasms of  pain in flank area
 Pain that may radiate to the lower abdomen, groin, scrotum, or labia
 Nausea, vomiting, and sweating associated with occurrence of pain
 Elevated blood pressure with pain
 Extreme flank pain that comes slowly or quickly
 Urinary frequency
 Dysuria
 Diaphoresis
 Pallor
 Nausea
 Vomiting
 Tachycardia
 Tachypnea
 Oliguria/anuria → medical intervention (surgery) needed right away; this is a medical emergency
Diagnosis:
 Urinalysis
o Altered odor
 o Turbidity
o Increased RBC, WBC, and bacteria
 Abnormal serum calcium, phosphate, and uric-acid levels
 Ultrasound shows stones
 X-ray of kidneys, ureters, and bladder
 Intravenous pyelogram
 CT
 MRI
Treatment/Management:
 Provide pain relief, morphine as a narcotic or a NSAID
 Administer antispasmodics
 Increase fluid intake
 Lithotripsy - shock waves break up stone
 Stent placement
 Surgical removal of stone
Nursing Interventions:
 Monitor I&O
 Monitor pain level and response to pain medications
 Strain urine to isolate stone for lab analysis
 Provide fluids
 Administer medications that lower recurrence
 Dietary modifications

Kidney Transplant: treatment for end-stage kidney disease besides dialysis. It can greatly improve one’s quality of life. The recipient’s
tissue must be matched with a donor’s in order for this to work. Donors can be living, dead, or from a cadaver. Tissue typing avolves ABO
compatibility and antigen compatibility. Patients receiving a donor kidney from a living, related donor with matching tissue type have the
greatest rate of survival. Kidneys used from cadavers or dead donors must be sufficiently perfused to maintain viability of the organ. The
donated kidney is surgically implanted into the recipient’s body. 
Risk Factors for Kidney Transplant Complications:
 Younger than 2 years old or older than 70 years old
 Advanced and/or untreatable heart disease
 Cancer
 Chemical dependency
 HIV, Hepatitis B, or Hepatitis C
 Certain immune disorders
 Morbidly obese
  Diabetes
 Chronic pulmonary disease
 Untreated GI conditions, such as peptic ulcer disease
Indications of End-Stage Kidney Disease:
 Anuria (no urine)
 Proteinuria
 Elevated BUN and creatinine
 Severe electrolyte imbalance → hyperkalemia, hypernatremia
 Fluid overload with heart failure or pulmonary edema
 Uremic lung
Signs and Symptoms of ESKD:
 Anorexia
 Fatigue
 Numbness and tingling of extremities
 Shortness of breath
 Dry and itchy skin
 Metallic taste in mouth
 Muscle cramping
 Decreased attention span
 Seizures
 Tremor
 Heart failure
 Edema of hands and feet
 Dyspnea
 Distended jugular veins
 Anemia
 Vomiting
 Pulmonary edema
 Hypertension
 Cardiac dysrhythmias
 Pallor
 Bruising
 Halitosis
 Diminished or dark colored urine
Diagnosis/Lab Results:
 Proteinuria
  Hematuria
 Elevated BUN levels
 Elevated serum creatinine
 Decreased GFR
 Decreased H&H
 Elevated potassium and phosphorus
 Sodium could be normal, low, or high
 Metabolic acidosis

CARE OF PATIENTS WITH URINARY PROBLEMS

Urinary Incontinence: involuntary leakage of urine, could be either due to either the normal aging process or an injury. Urinary incontinence
most affects older women, and it is less common in men. This can also occur in other parts of life, including: pregnancy, childbirth, and
menopause.
There are many types of this, including:
 Stress → 
 Urge → 
 Overflow → 
 Functional → 

Urinary Tract Infection/Cystitis: a UTI occurs when an organism (usually gram negative, such as E. coli) enters the urinary tract, and is the
most common in women and older adults. Inflammation of the local area occurs, followed up by infection as the organism reproduces.
Often the bacteria is present on the skin of the genital area and enters the urinary tract through the urethral opening. The organism can
also be introduced during sexual contact. The infection occurs as an uncomplicated, community-acquired in this setting. Patients who have
a urinary catheter in place may also develop a UTI due to the catheter letting bacteria easily enter the bladder. Other instruments
(cystoscopy) may also cause a UTI because this also allows bacteria to easily enter. Some equipment is also not completely sterilized
between patients. This equipment is usually cleaned thoroughly with a high-level disinfectant because it would not be able to handle high
temperatures needed for sterilization. UTIs that are identified are treated and resolved. Some bacteria have become resistant to certain
antibiotics (like MRSA), so it is very important to test the urine after the course of antibiotics is done. If left untreated, UTIs can spread
upward and either become a kidney problem or a systemic issue (sepsis), especially in elderly patients.
Signs and Symptoms:
 Urinary frequency
 Urinary urgency
 Dysuria
 Feeling of fullness in suprapubic area
 Lower back pain
Diagnosis:
  Urinalysis shows leukocytes, nitrites, and red blood cells
 Urine culture and sensitivity
Treatment/Management:
 Administer antibiotics → nitrofurantoin, ciprofloxacin, levofloxacin, ofloxacin, trimethoprim-sulfamethoxazole, ampicillin, or
amoxicillin
 Encourage fluids
 Administer phenazopyridine for dysuria
 Repeat urine testing after treatment
Nursing Interventions:
 Monitor I&Os
 Monitor vital signs (fever)
 Encourage fluid intake
 Encourage cranberry juice to make the urine more acidic
 Teach patient that phenazopyridine will turn urine orange

Urothelial Cancer: also known as bladder cancer. This is typically a non aggressive cancer type that occurs in the transitional cell layer of
the bladder, and often recurs. While it is uncommon for this to happen, it can invade deeper layers of the bladder tissue, and when this
happens, the cancer is more aggressive. Exposure to industrial chemicals such as paints and textiles, history of Cyclophosphamide use,
and smoking all increase the risk of developing bladder cancer. The more aggressive the cancer cell type, the greater risk of it
metastasizing to other parts of the body. Patients may have stage 3 or stage 4 at the time of diagnosis. The more advanced the disease is
at diagnosis time and the more aggressive the tumor is, the patient is at greater risk of dying.
Signs and Symptoms:
 Hematuria
 Peripheral edema 
 Elevated blood pressure
 Oliguria
 Nausea
 Vomiting
 Loss of appetite
Diagnosis:
 Urinalysis → red blood cells and red blood cell casts
 Decreased GFR
 24 hour urine collection for proteinuria
 BUN level will be increased
 Serum albumin will be decreased
 Renal biopsy
Treatment/Management:
 Monitor renal function
 Monitor electrolyte levels
 Monitor vital signs
 Administer diuretics
 Monitor urinary output
 Restrict intake
 Plasmapheresis (when plasma is separated from blood cells)
 Chemotherapy
 Immunotherapy (only 1% of people can do this though)
 Radiation
 Surgical tumor removal
Nursing Interventions:
 Monitor vital signs
 Monitor I&Os
 Weigh daily
 Assess respiratory system (lung sounds, difficulty breathing, and crackles)
 Assess cardiovascular status (heart rate, heart sounds, and listen for S3)
 Assess extremities for edema
 Provide medication education, and teach them about disease process

Bladder Trauma: 

ASSESSMENT AND CARE OF PATIENTS WITH ACID-BASE IMBALANCES

Metabolic Acidosis: The acid-base balance of the blood is thrown off, causing it to become more acidic. There is an arterial pH of less than
7.35. There may be an overproduction of hydrogen ions (lactic acidosis in fever and seizures, diabetic ketoacidosis, starvation, drinking
alcohol, or taking aspirin), deficient elimination of hydrogen ions (renal failure), deficient production of bicarbonate ions (renal failure,
pancreatic insufficiency), or excess elimination of bicarbonate ions (diarrhea). Correction or management of the underlying cause is
necessary to help restore the acid-base balance.
Common Causes of Metabolic Acidosis: overproduction of hydrogen ions
 Diabetic ketoacidosis
 Starvation
 Heavy exercise
 Seizure activity
 Fever
  Hypoxia
 Ischemia
 Alcohol intoxication
 Salicylates (NSAIDs)
 Kidney failure
 Pancreatitis
 Liver failure
 Dehydration
 Diarrhea
Signs and Symptoms: underproduction of hydrogen ions
 Lethargy
 Bilateral muscle weakness
 Hyporeflexia
 Tachycardia
 Hypotension
 Hyperventilation (rapid, deep breathing)
 Bradycardia to heart block
 Tall T waves
 Widened QRS complex
 Prolonged PR interval
 Thready peripheral pulses
 Depressed CNS activity
o Lethargy
o Confusion
o Stupor
o Coma
 Kussmaul respirations → diabetic ketoacidosis (involuntary rapid and deep breathing)
 Warm, flushed, and dry skin
Diagnosis:
 ABG showing a pH of <7.35 and HCO3- under 22, but PCO2 is within normal range (45-35)
 Possible ketones in urine
 Normal or elevated chloride level
Treatment/Management:
 Administer IV fluids for hydration
 Monitor ABG levels
 Administer oxygen therapy as necessary
  Administer bicarbonate
 Correct underlying condition causing imbalance
 Administer insulin and fluids (D5W) for diabetic ketoacidosis
 Intubate if needed
 Hemodialysis may be needed
Nursing Interventions:
 Monitor I&Os
 Monitor vital signs
 Monitor lab test results
 Monitor ABG results

Metabolic Alkalosis: The acid-base balance of the blood is basic because of either a decrease in acidity or an increase in bicarbonate.
Alkalosis is often associated with decreased levels of potassium or calcium. Metabolic alkalosis may be due to excess intake of antacids,
blood transfusions, long-term parenteral nutrition, prolonged vomiting, nasogastric suctioning, Cushing’s disease, thiazide diuretics, or
excess aldosterone.
Common Causes of Metabolic Alkalosis:
 Antacids
 Blood transfusions
 Sodium bicarbonate administration
 Total parenteral nutrition
 Prolonged vomiting
 Nasogastric suctioning
 Hypercortisolism
 Hyperaldosteronism
 Thiazide diuretics
Signs and Symptoms:
 Muscle weakness → decreased respiratory effort
 Muscle cramping/twitching
 Anxiety
 Irritability
 Tetany 
 Seizures
 Positive Chvostek’s sign
 Positive Trousseau’s sign
 Increased reflexes (hyperreflexia)
 Increased heart rate
  Increased CNS activity
 Paresthesias (pins and needles)
 Normal or low blood pressure
 Digitalis (digoxin) toxicity
 Increased rate and depth of breathing
Diagnosis:
 ABG showing pH >7.45, bicarbonate >26, and PCO2 >45.
 Potassium and chloride levels are low
Treatment/Management:
 Monitor ABG and electrolyte levels
 Administer fluids and electrolytes
 Administer supplemental oxygen as needed
 Administer electrolytes if needed
Nursing Interventions:
 Monitor vital signs
 Monitor cardiovascular changes in heart rate and rhythm
 Monitor I&Os
 Assess IV site for infiltration
 Check neurological status frequently

ARTERIAL BLOOD GAS VALUES AND THEIR CLINICAL SIGNIFICANCE

Respiratory Acidosis: Metabolic Acidosis: Name of Normal Metabolic Alkalosis: Respiratory Alkalosis:
underproduction of hydrogen underproduction of Normal Value overproduction of overproduction of
ions hydrogen ions Value: Range: hydrogen ions hydrogen ions

Signs and Symptoms:  Signs and Symptoms: Arterial pH 7.35- Signs and Symptoms: Signs and Symptoms:
7.45
VITALS: Tachycardia and VITALS: bradycardia, VITALS: tachycardia, VITALS: tachypnea
hypertension at first, but then weak peripheral hypotension NEURO: inability to
turns into bradycardia and pulses, hypotension, Below CARDIO: atrial concentrate,
hypotension tachypnea 7.35: tachycardia, ventricular numbness, tingling,
CARDIO: Dysrhythmias CARDIO: dysrhythmias acidic issues when pH tinnitus, and possible
(ventricular fibrillation) NEURO: headache, 7.40: increases loss of consciousness 
NEURO: anxiety, irritability, and drowsiness, confusion Normal NEURO: numbness, CARDIO: tachycardia,
confusion at first; possible RESP: rapid and deep (neutral) tingling, tetany, muscle ventricular/atrial
lethargy and coma as acidosis respirations Above weakness, dysrhythmias
becomes worse SKIN: warm, dry, and 7.45: hyperreflexia, RESP: rapid and deep
RESP: ineffective shallow and pink alkalotic confusion, convulsions respirations
rapid breathing RESP: depressed
SKIN: pale or cyanotic skeletal muscles →
ineffective breathing

Treatment: Treatment: PCO2 (Partial 45-35 Treatment: Treatment:

 Oxygen  If DKA, Pressure of  Varies with  Oxygen
therapy/maintain patent administer Carbon Above causes therapy
airway  insulin Dioxide) 45:  If GI related;  Anxiety
 Enhance gas exchange  If due to GI acidic administer reducing
by having the patient losses Below antiemetics, measures
change positions, deep (diarrhea), 35: fluids, and  Rebreathing
breathing/coughing, administer alkalotic electrolyte techniques
ventilation support (if antidiarrheals replacements
needed), and and provide  If related to
bronchodilators fluids potassium
 If serum depletion;
bicarbonate is discontinue
low, administer medication or
sodium whatever is
bicarbonate causing the
imbalance

HCO3 22-26
(Sodium
Bicarbonate) Below
22:
acidic
Above
26:
 alkalotic

DIALYSIS

In a nutshell, dialysis can sustain life for clients who have acute or chronic kidney failure. This does NOT replace the hormonal function of
the kidneys. There are two types of dialysis: peritoneal dialysis and hemodialysis.

Functions of Dialysis:
 Rids the body of excess fluid and electrolytes
 Achieves acid-base balance
 Eliminates waste products
 Restores internal homeostasis → osmosis, diffusion, and ultrafiltration

AV fistula vs. AV graft (dialysis):

 AV fistula: takes forever to mature and heal, can be used forever (or at least a very long time) - 4-6 weeks before able to
use, external ones are prone to infection and scarring.
 AV graft: fast maturation, but it cannot be used forever
 Two needles are inserted: one in the artery, the other one in vein

Hemodialysis: takes blood from the body, cleans/filters it through a machine (dialyzer), and then the filtered blood gets put back into
circulation. This requires vascular access from either an AV fistula or an AV graft. This type of dialysis is based on condition and symptoms,
not GFR. Patients will need this 3 days a week for 3-5 hours each treatment session.
Conditions that Require Dialysis:
 Renal insufficiency
 Acute kidney injury
 Chronic kidney disease
 Drug overdose
 Hyperkalemia for an extended period of time
 Hypervolemia that does not change with diuretics
Signs and Symptoms that Warrant Hemodialysis:
 Fluid volume changes → fluid overload
 Electrolyte and pH imbalances
 Changes in nitrogenous waste
 Neurological changes → cognitive impairment
  Bleeding
 Uremia
 Pruritus
 Nausea
 Vomiting
1. Preprocedure: Hemodialysis
 Check for informed consent form
 Use a temporary hemodialysis dual-lumen catheter (AV graft) or subcutaneous device until the doctor inserts a long-term
device (AV fistula)
 Assess long-term device’s patency (presence of bruit, palpable thrill, distal pulses, and circulation). Elevate the extremity
after the doctor surgically creates an AV fistula to reduce swelling
 Avoid doing this to the arm that has access device:
 Blood pressure
 Taking blood (venipuncture)
 Inserting IVs
 Assess vital signs, lab values (BUN, creatinine, electrolytes, hematocrit)
 Weigh patient before treatment session
 Withhold medications that lower blood pressure until after dialysis
2. Intraprocedure: Hemodialysis → Monitor for Complications
 Monitor machine for kinks in tubing, air bubbles, temperature (should be 100°F)
 Patient exhibiting hypotension, cramping, vomiting, bleeding (oozing) at the access site, and contamination of equipment
 Monitor vital signs and coagulation studies during treatment
o Administer anticoagulants, such as heparin → reversal is protamine sulfate
o Monitor aPTT to assess risk of hemorrhage
 Provide emotional support 
 Provide activities during treatment, such as: books, TV, music, magazines
 Advise patient to tell you if they feel dizzy, have a headache, or feel nauseous during treatment
 Advise patient not to eat during treatment
3. Postprocedure: Hemodialysis

Most common cause of renal failure: diabetes

Alcoholism: attacks kidneys first, and then the liver

INTEGUMENTARY SYSTEM DYSFUNCTION

Organs:
 Skin:
o Epidermis
 Prevents fluid loss from body
 Dermis
 Protects underlying tissues
 Subcutaneous Layer/Hypodermis

Burns: damage to skin and body tissues caused by flames, heat, extreme cold, friction, radiation (sunburn), chemicals, or electricity. Burns
are divided into three categories: first degree, second degree, and third degree, and they are also classified on how much they affect the
skin. When large portions of the face/head, chest, hands, genitalia, or joints get a second or third degree burn, prompt medical attention is
needed right away, and serious burns can lead to death. If the patient has inhaled smoke or nose hairs are singed, assess for breathing
and damage to the respiratory tract, and in that case CPR may be needed. Infants and old people with burns need medical attention
IMMEDIATELY. Lactated Ringers is the most commonly used IV solution for burns.
First-Degree: damage to the epidermis (outer layer) only. These burns are red, painful, and there is a bit of swelling.
Second-Degree: epidermis and dermis is damaged. These cause severe pain, white and red burn borders, swelling, blisters, and possible
drainage.
Third-Degree: goes through all three skin layers (epidermis, dermis, subcutaneous layer) and could involve underlying tissues. These are
often painless (dermis has nerves, and they get destroyed), and looks either black (eschar) or red.
 Types of Burns:
1. Dry heat burns → result from open flames and explosions
o Smother the flames
o Remove smoldering clothing and all metal objects
2. Moist heat burns → contact with hot liquid or steam; these injuries are the most common in older adults and young children
2. Contact burns → occur when hot metal, tar, or grease comes into contact with the skin
2. Electrical burns → when an electrical current passes through the body and can cause severe damage, including: severe tissue
damage, loss of organ function, tissue destruction so severe that an amputation needs to happen, cardiac arrest, or respiratory
arrest.
o Remove patient from source of burn
o Smother any present flames
o Initiate CPR
o Obtain an EKG
5. Chemical burns → when cleaning products (drain/oven cleaner, bleach) or agents in the industrial setting (caustic soda, sulfuric
acid) come into contact with the skin
o If dry chemicals are on skin or clothing, do not wet them
o Brush off any dry chemicals present on skin or clothing
 o Determine what kind of chemical is causing the burn
o Remove patient’s clothing
o Do not attempt to neutralize the chemical unless the appropriate solution is available
6. Thermal burns → when clothing catches on fire from heat or a spark that is caused by electrical sparks
6. Flash (arc) burns → contact with electrical current that travels through the air from one conductor to another
6. Conductive electrical injury → when a person touches electrical wiring or equipment
6. Radiation burns → results from therapeutic treatment for cancer or from getting sunburnt
o Remove patient from radiation source
o Remove patient’s clothing using tongs or lead gloves
o If the patient has radioactive particles on the skin, send him or her to the nearest designated radiation decontamination
center.
o Help the patient bathe or shower
10. PRIORITY - Inhalation burns → inhaling deadly fumes, smoke, steam, carbon monoxide, and heated air. Head and neck are most
affected. Patients who sustain this type of burn are usually intubated due to impaired gas exchange. 26.3
Factors Determining Inhalation Injury or Airway Obstruction:
 Patients who were injured within an enclosed space
 Charcoal on the teeth and gums
 Unconscious at the time of injury
 Patients with singed hair (nose, scalp, eyelashes, and eyebrows)
 Patients spitting up carbonaceous sputum
 Hoarseness or brassy cough
 Use of accessory muscles or stridor
 Poor oxygenation or ventilation
 Edema, erythema, and ulceration of upper airway
 Wheezing, bronchospasm
 Patients with extensive burns or burns directly on their face
 Difficulty swallowing
 Drool
 Adventitious lung sounds
Physiological Effects of Carbon Monoxide:
1%-10% (normal level) → increased threshold to visual stimuli, increased blood flow to vital organs
11%-20% (mild poisoning) → headache, decreased cerebral function, decreased visual acuity, slight breathlessness
21%-40% (moderate poisoning) → headache, tinnitus, nausea, drowsiness, vertigo, altered mental status, confusion, stupor, irritability,
decreased blood pressure, depressed ST segment on ECG, dysrhythmias, pale or purple-red skin
41%-60% (severe poisoning) → coma, convulsions, cardiopulmonary instability
61%-80% (fatal poisoning) → death
Many medications make skin more sensitive to sun exposure so it makes it extremely easy to get a sunburn. 
These include: 
 Amiodorone - antiarrhythmic 
 Carbamazepine - anticonvulsant, mood stabilizer
 Furosemide - diuretic
 Naproxen - NSAID
 oral contraceptives - birth control
 Piroxicam - NSAID
 Quinidine - antiarrhythmic
 Quinolones - antibiotic
 Sulfonamides - anticonvulsant
 Sulfonulureas - antidiabetics (type 2)
 Tetracyclines - antibiotic
 Thiazides - diuretic
Signs and Symptoms: First Degree
 Red
 Dry
 Painful
 No breaks in the skin
 Blanches → blood flow is constricted with compression, compressed skin turns pale/white
Signs and Symptoms: Second Degree (superficial partial thickness or deep partial thickness)
 Deep red
 Blisters filled with clear fluid
 Wet/weeping
 More painful than first degree burns
 Blanches
Deep Partial Thickness:
 Varies in color (yellow, white, or red)
 Has blisters
 Wet or dry
 May not blanch
 May only be pain due to pressure since nerve endings are damaged
Signs and Symptoms: Third Degree
 Charred black, leathery gray, or waxy white
 Dry
 No blanching
 Can be painless
  Stiff/inelastic
Signs and Symptoms: Fourth Degree
 Charred black
 Dry
 Pain only from deep pressure
 Patches of dead skin
Diagnosis:
 Appearance
 Amount and/or type of pain
 Lab results: hyperkalemia, hyponatremia, high BUN and high creatinine
 Tissue biopsies (sometimes)
 Pulse Oximetry → assesses amount of oxygen in blood
 Pulmonary function test → shows how well the lungs are working (inhalation burns can cause respiratory failure or airway edema,
bronchioles collapse. Could develop pneumonia.)
 Rule of nines → estimates the total body surface area (TBSA) burned:
 Anterior Head: 4.5%
 Posterior Head: 4.5%
 Anterior torso: 18%
 Posterior torso: 18%
 Anterior legs: 18%
 Posterior legs: 18%
 Anterior arm: 9%
 Posterior arm: 9%
 Perineum/Genitalia: 1%
 Palm of hand (including fingers): 1%
Treatment/Management: The purpose of burn treatment is to prevent infection, decrease inflammation and pain, and promote healing.
Treatment choices depend on the degree of the burn and where the burn is. Any second-degree burn greater than 5%-10% of body surface
and all third-degree burns belong in a hospital, preferably being treated in a burn unit. All electrical burns and burns to the ears, face,
hands, feet, and perineum/genitalia all require hospital care, as well as if an elderly or infant gets burned.
 Maintain patent airway
 Administer tetanus shot (prophylaxis)
 Perform head-to-toe assessment
 Administer oxygen as needed
 Keep the patient NPO
 Elevate the extremities (if no breaks or fractures)
 Obtain vital signs
 Check the area for any exposed electrical wires (if you are where the patient is)
  Use cold water to decrease the temperature of the area for a first-degree burn or a small second-degree burn and to stop the
burning
 For chemical burns, ensure that all of the chemical has been flushed away
 For electrical burns, look for entrance and exit wounds
 Cover the skin loosely with dry gauze
 If this is a second-degree burn, use a topical antibiotic ointment such as silvadene to prevent a secondary bacterial infection before
applying the gauze
 Administer analgesics as needed (Tylenol, ibuprofen)
 If this is a third-degree burn, the eschar needs to be debrided/cut away to allow new tissue to grow. Eschar blocks new cell growth
 These wounds are often covered in moist saline gauze, as new tissue grows best in this environment. When the gauze dries, it
adheres to the dead tissue. The area is mechanically debrided when the gauze is removed.
 Oral antibiotics may be necessary, such as silver sulfadiazine
 Administer analgesics (opioids such as morphine or oxycodone) as needed, especially before painful dressing changes → IV
ROUTE ONLY
 IM route is not ideal because it will take a long time for the medication to be absorbed through the tissues since they are now
damaged
 Prevent heat loss due to large areas of tissue exposed from lack of skin coverage. Cover patient with a blanket
 Maintain fluid levels since fluid loss is common due to evaporation and wound drainage, urine should be clear. Administer Lactated
Ringers
 Leave blisters alone to prevent infection
 Surgical procedures, such as skin grafting or amputation may be needed → 3rd to 4th degree burns. Grafting is from own skin or
artificial skin. Biggest concern is rejection of new skin.
Nursing Interventions:
 Anticipate pain medication needs to make the patient more comfortable
 Assist in range of motion to avoid contracture development due to pain with movement
 Encourage family to visit
 Assist with activities of daily living (ADLs)
 Isolation may be needed to protect the patient from bacteria, especially if a large amount of skin is not intact
 Teach patient to look and report signs of infection: fever, increased redness, increase in drainage, or change in drainage color
 Monitor electrolyte levels → hyperkalemia and hyponatremia (cells release potassium into the whole body; low sodium due to
water/fluid loss)
Three Phases of Burn Care: 26.1
1. Emergent/Resuscitative Phase: begins with the injury and continues for 24-48 hours greater than 25% of TBSA, priorities would
be to secure the airway, support circulation and organ perfusion, manage pain, prevent infection through adequate wound care,
maintaining body core temperature, and providing emotional support and comfort. This is when hypovolemic shock most commonly
happens, and this is a common cause of death in burn patients. Intubation is often needed. Watch for hypovolemic shock in
patients who have serious burns.
 2. Acute Phase: begins 36-48 hours after burn occurs (when the fluid shift resolves), assess the cardiovascular, respiratory, and
gastrointestinal systems. Also provide wound care and psychosocial interventions; this phase ends with the closure of the wound.
Pain control is still very important, as well as hypovolemic shock and respiratory distress.
3. Rehabilitative Phase: begins when most of the burn area has healed, priority actions would include psychosocial support (low self-
esteem, disturbed body image, coping, able to function), prevention of scars and contractures (from the mesh), and resumption of
ADLs (work, family, social roles). This phase ends when the client is able to function similarly to the way they were able to pre-burn,
and this phase can last for many years. Follow-up appointments, make sure the skin is covered up. Resources as group therapy
First Aid: Burns
 Cool the burn under clean and cool running water for at least 10 minutes. If this is not available, you can apply a cold/cool (NOT
freezing) compress instead, or use any cold and running liquid. Cooling the burn will reduce pain, swelling, and the risk of scarring.
The faster and longer a burn is cooled, there is less of an impact.
 If the burn requires further medical care, loosely cover it with a clean dressing. Keeping the area clean helps prevent infection
 If necessary, call 911. Always call 911 if a child or elderly has been burned, the burn blisters, affects more than one area of the
body, covers the feet, joints, or face; or if underlying tissues (ex. bone) are visible. 
 If clothes/jewelry are on the burn, do NOT remove it
 Do NOT apply an ice cube or butter to the burn (oil retains heat, and if you put it on and they need to remove it at the hospital it may
cause more pain/damage. Ice also may cause further damage to the skin.)
Infection Control: Table 26
 Signs of infection: red, drainage, odor
 Need for debridement
 Crucial for beginning to end, important to do it right
 Sterile techniques
Interprofessional Care:
 Cardiologist
 Psychiatrist
 Nutritionist/Dietician

Depth of Burns

Superficial Thickness Superficial partial Deep partial Full thickness Deep full thickness
thickness thickness

 Damage to  Damage to  Damage to  Damage to to  Damage to all

epidermis entire entire the entire skin layers
epidermis and epidermis epidermis and  Extends into
Area(s) some parts of and deep dermis muscles,
 Involved the dermis into the  Can extend tendons, and
dermis into the bones
subcutaneous  Muscles
tissue release
 Nerve damage myoglobin
 No cell
regrowth

 Pink to red  Pink to red  Red to  Red, black,  Black

 No blisters  Blisters white brown, yellow,  No blisters
 Mild edema  Moderate  No blisters or white  No edema
Appearance  No eschar edema  Severe  No blisters  Eschar hard
(blackening)  No eschar edema  Severe edema and inelastic
(blackening)  Eschar soft  Eschar hard
and dry and inelastic

 Painful/tender  Painful  Painful and  Sensation  Heals within

 Sensitive to  Heals within 3 sensitive to minimal or weeks to
heat weeks touch absent months
Sensation  Heals within  No scarring,  Heals in 2-  Heals within  Scarring
and Healing 3-6 days but minor 6 weeks weeks to  Grafting
 No scarring pigment  Scarring is months
 Peeling changes likely  Scarring
occurs after 2-  Possible  Grafting
3 days grafting

 Sunburn   Flash flames  Scalds  Scalds  Electrical

 Flash burn and scalds  Contact  Contact burns burns
 Less than  Short contact burns  Chemical burns  Flames
10% TBSA with hot  Chemical  Electrical burns
burned objects burns  Long exposure
 25% TBSA  Electrical to hot objects
Examples
burned burns  Misc: monitor for
 Long hypovolemic shock,
exposure to because this is a
hot objects common cause of
  Greater death in severely
than 25% burned patients
TBSA
 Burns to
sensitive
areas
 Age (older
than 60),
thinner skin

ALTERATIONS IN IMMUNITY

Systemic Lupus Erythematosus: chronic inflammatory disorder affecting the skin and other organ systems. Antibodies against DNA and
RNA cause an autoimmune inflammatory response, resulting in swelling (edema) and pain. It is very common in young women and is
genetic. The cause is currently unknown. People who have this have a good prognosis, but are prone to attacks (exacerbations). Most
patients do well on medications, but some people do not respond well, so their organs fail and they eventually die. There is currently no
cure.
Signs and Symptoms:
 Butterfly rash on face
 Fatigue
 Fever
 Malaise
 Joint pain
Diagnosis:
 Positive antibody test
 Positive rheumatoid factor
Treatment/Management: Supportive Care
 Administer NSAIDs (ibuprofen, indomethacin, acetaminophen, etc.)
 Administer antimalarials
 Administer immunosuppressants
 Administer analgesics
 Advise patient to avoid sunlight
 Allow patient to cover up butterfly rash with foundation (makeup)
  Help them reduce stress
 Monitor them for signs of infection

LAB VALUES AND THEIR CLINICAL SIGNIFICANCE

Name of Tested Value Normal Reference Significance of Abnormal Findings/Values

Range

Hemoglobin ♀: 12-16 g/dL High: chronic hypoxia, polycythemia vera

♂: 14-18 g/dL Low: anemia, hemorrhage

Hematocrit ♀: 37%-47% g/dL High: chronic hypoxia, polycythemia vera

♂: 42%-52% g/dL Low: anemia, hemorrhage

RBC count ♀: 4.2-5.4 g/dL High: chronic hypoxia, polycythemia vera

♂: 4.7-6.1 g/dL Low: anemia, hemorrhage

WBC count 5,000-10,000 g/dL High: infection, inflammation, autoimmune disorders, leukemia
Low: prolonged infection, bone marrow suppression 

Neutrophils 55-70% Function: ingests and phagocytosis of microorganisms and foreign substances

Lymphocytes 20-40% Function: produces antibodies, important in immunity

MCH 27-31 pg High: macrocytic cells, possible anemia

Low: microcytic cells, possible iron deficiency anemia

MCV 80-95 fL High: macrocytic cells, possible anemia

Low: microcytic cells, possible iron deficiency anemia

Prothrombin Time (PT) 11-12.5 seconds High: possible deficiency of clotting factors V and VII
Clotting V Factor: needed to convert 
prothrombin → thrombin
Clotting VII Factor: converting 
 prothrombin → thrombin, dependent on vitamin K
Low: excessive vitamin K

Partial thromboplastin 60-70 seconds  High: bleeding disorder, liver disease

time (PTT) Low: excessive bleeding, persistent nosebleeds, easy bruising

Platelets 150,000-400,000/mm3 High: polycythemia vera, malignancy

Low: bone marrow suppression, autoimmune disease, hypersplenism

Blood Urea Nitrogen 10-20 High: urinary tract obstruction, congestive heart failure, recent heart attack,
decreased kidney function, dehydration
Low: low protein diet, malnutrition, severe liver damage, drinking a lot of fluids
(overhydration), being female, or being a child

Creatinine ♀: 0.5-1.1 High: kidney impairment

♂: 0.6-1.2 Low: decreased muscle mass

BUN/Creatinine Ratio 6-25 High: fluid volume deficit, obstructive uropathy, catabolic state, high-protein diet
Low: fluid volume excess

Specific Gravity (urine) 1.005-1.030 High: decreased kidney perfusion, inappropriate ADH secretion, heart failure
Possible range: 1.000- Low: chronic kidney disease, diabetes insipidus, malignant hypertension, taking
1.040 diuretics, lithium toxicity

ELECTROLYTE LEVELS AND THEIR CLINICAL SIGNIFICANCE

Name of Normal Reference International Clinical Significance of Abnormal Values

Electrolyte Range Recommended Units
(IU)

Sodium  136-145 136-145 High: hypernatremia, dehydration, kidney disease,

(Na+) hypercortisolism
   Low: hyponatremia, fluid overload, liver disease, adrenal
Older than 90 years IU Older than 90: 132- insufficiency
 old: 132-146 146

Potassium  3.5-5.0 3.5-5.0 High: hyperkalemia, dehydration, kidney disease, acidosis,

(K+) adrenal insufficiency, crush injuries (bleeding, bruising)
Low: hypokalemia, fluid overload, diuretic therapy, alkalosis,
insulin administration, hyperaldosteronism

Older than 90 years IU Older than 90: 3.5-5.0

old: 3.5-5.0

Calcium  9.0-10.5 2.25-2.62 High: hypercalcemia, hyperthyroidism, hyperparathyroidism

(Ca+) Low: hypocalcemia, vitamin D deficiency, hypothyroidism,
hypoparathyroidism, kidney disease, excessive intake of
phosphorus

Older than 90 years IU Older than 90: 2.05-

old: 8.2-9.6 2.40

Chloride  98-106 98-106 High: hyperchloremia, metabolic acidosis, respiratory alkalosis,

(Cl-) hypercortisolism
Low: hypochloremia, fluid overload, excessive vomiting or
diarrhea, adrenal insufficiency, diuretic therapy, chronic kidney
disease

Older than 90 years IU Older than 90: 98-111

old: 98-111

Magnesium 1.3-2.1 0.65-1.05 High: hypermagnesemia, kidney disease, hypothyroidism, adrenal

 (Mg+) insufficiency
Low: hypomagnesemia, malnutrition, alcoholism, ketoacidosis
 Older than 90 years IU Older than 90: 0.65-
old: 1.3-2.1 1.05

Phosphorus and 3.0-4.5 0.97-1.45 High: hyperphosphatemia, kidney disease, hypoparathyroidism,

Phosphate  acidosis, hypocalcemia
(P or PO4-) Low: hypophosphatemia, chronic antacid use,
hyperparathyroidism, hypercalcemia, vitamin D deficiency,
alcoholism, malnutrition

Older than 90 years IU Older than 90: 0.97-

old: 3.0-4.5 1.45