ROBAINA N. ACOB 3B 2.

Hypertension *The fluid that enters the capsule

3. Pneumonia is glomerular filtrate.
TOPIC 1 4. Acute Watery Diarrhea
5. Influenza Tubular reabsorption- it is the
CARE OF CLIENTS WITH movement of substance from the
PROBLEMS IN FLUID AND 6. Acute Hemorrhage Fever
7. Urinary Tract Infection filtrate in the kidney tubules into
ELECTROLYTES, ACUTE the blood in the peritubular
AND CHRONIC 8. Dengue Fever
9. Typhoid Fever capillaries.
Estimated of the global burden of 10. Disease of the heart *insert picture
disease indicate that diseases of
the kidney and urinary tract Organs of the urinary system: Only 1% of the filtrate remains in
account for approximately 1. Kidneys the tubules and become urine.
830,000 deaths and 18,467,000 2. Ureters
disability-adjusted life years Water and other substances that
3. Urinary Bladder are useful to the body are
annually, ranking them 12th 4. Urethra
among causes of death (1.4% of reabsorbed.
all deaths) and 17th among causes Nephron- is composed of Water is reabsorbed by osmosis,
of disability (1.0% of all glomerulus and renal tubules while most solutes are reabsorbed
disability-adjusted life years). by active transport.
This ranking is similar across -primary function is formation of
world bank regions. urine TUBULAR SECREATION

Generally, Renal disease progress Glomerulus- is a tuft of semi- It is the transport of substances
to a final stage as End-Stage permeable capillaries, surrounded from the blood into the renal
Renal Disease (ESRD) and by the Bowman’s capsule. tubules.
function is substituted by Renal Renal Tubules *insert picture
Replacement Therapy (RRT),
Hemodialysis, Peritoneal Three regions of the Renal MICTURITION
Dialysis, or transplantation. Data Tubules:
It is the act of expelling urine
combined from different source 1. Proximal Convoluted from the bladder also urination or
show that more than 1.5 million Tubules voiding.
people worldwide are on RRT, 2. Loop of Henle
80% of whom live in Japan, 3. Distal Convoluted Tubules FUNCTIONS OF URINARY
Europe, and North America. SYSTEM
About 1,200 ml of blood flows to
Kidney disease, especially End the kidneys per minute, which is 1. Urine formation
Stage Renal Disease (ESRD), are 20-25% of the cardiac output. 2. Excretion of waste
already the 7th leading cause of products
death among the filipinos. One The Glomerular Filtration Rate 3. Regulation of electrolytes
filipino develops chronic renal (GFR) is 125ml/min 4. Regulation of acid base
failure every hour or about 120 balance
-from this, the kidneys form 0.5 to
filipinos per million population 5. Control of water balance
1ml of urine per minute, thereby
per year. More than 5,000 filipino
30 to 60ml per hour or FUNCTIONS OF URINARY
patients are presently undergoing
approximately 1,500 ml per day. SYSTEM
dialysis and approximately 1.1
million people worldwide are on 250-450ml of urine in the bladder 6. Control of blood pressure
renal replacement therapy. triggers micturition reflex. (renin)
In the past, Chronic Urine formation: 7. Regulation of red blood
Glomerulonephritis (CGN) was cell production
the most common cause of The three steps of formation of (erythropoietin)
chronic renal failure. Today urine by the kidneys are: 8. Synthesis of vitamin D to
diabetes mellitus and active form
1. Glomerular Filtration
hypertension have taken center 2. Tubular Reabsorption ERYTHROPOIETIN (EPO) is
stage in the causation of ESRD 3. Tubular Secretion a hormone produced by the
which together account for almost formation of red blood cells by
60% of dialysis patients. *insert picture the bone marrow.
Regional Morbidity: Ten (10) *insert picture *insert picture
Leading causes number and Glomerular filtration-
rate/100,000 Population TOPIC 2
movement of water and solutes
1. Acute Respiratory from the blood to the glomerular Brief review of the blood
Infection capsule circulation
Blood circulation- deoxygenated and inferior vena cava and THE DISTRIBUTION OF BODY
blood from systemic veins > CYCLE GOES ON AND ON. FLUIDS AND
superior and inferior vena cava > ELECTROLYTES
right atrium > tricuspid valve > USUAL PATHWAY OF THE
right ventricle > pulmonic valve > BLOOD Major fluid compartments:
pulmonary artery > pulmonary Artery > arteriole > capillary > 1. INTARCELLULAR
arteriole > pulmonary capillary venule > vein FLUID (ICF)- found
(where gas exchange occurs within the cells
between the blood in the Venous return- the going back or
pulmonary capillary and the return of blood to the heart 2. EXTRACELLULAR
alveoli) FLUID (ECF)- found
BODY FLUIDS AND outside the cells and
Alveoli- is rich in oxygen while ELECTROLYTES transport system within
pulmonary capillary blood is rich Approximately 60% of the the
in carbon dioxide. Through the average adult’s weight is FLUID
process of diffusion , oxygen will COMPARTMENTS OF ECF
(water and electrolytes)
go to the blood in the pulmonary 1. INTRAVASCULAR
capillary making the blood Infants – 70-80% of their body FLUID OR PLASMA-
oxygenated blood then carbon weight within the vascular system
dioxide will go to the alveoli then
Premature infants- 90% 2. INTERSTITIAL FLUID-
to be exhaled from the lungs.
Older than 60 years old- 50% surrounds cells
Oxygenated blood in the
pulmonary capillary in the lungs > Age, sex and body fat affects total 3. TRANSCELLULAR
pulmonary venule > pulmonary body water. FLUID- cerebrospinal,
vein > left atrium > bicuspid pericardial, pancreatic,
valve > left ventricle > aortic Infants: high daily fluid pleural, intraocular,
valve > aorta ? systemic artery requirements with little fluid biliary, peritoneal and
reserve; this makes the infant synovial fluids
Coronary artery supplies vulnerable to dehydration
oxygenated blood to the heart. 4. LYMPH
For infants those less than 2 years
Cerebral artery supplies of age, have greater daily fluid Intravascular fluid- the fluid
oxygenated blood to the brain. loss than older child and within the blood vessels which
respiratory and metabolic rates contains plasma.
Hepatic artery supplies
are higher therefore, dehydrate Approximately 3 L of the average
oxygenated blood to the liver.
more rapidly. 6 L of blood volume in adults is
Renal artery supplies oxygenated made up of plasma or the fluid
In general, younger people have a
blood to the kidneys. portion of the blood.
higher percentage of body fluid
Systematic artery > systemic than older people, and men have The remaining 3 L is made up of
arteriole > systemic capillary proportionately more body fluid formed elements namely
(where gas exchange occurs than women. erythrocytes (red blood cells),
between the blood in the systemic leukocytes (white blood cells),
People who are obese have less
capillary and the cells. The blood and thrombocytes (platelets).
fluid than those who are thin,
is rich in carbon dioxide as end
because fat cells contain little MOVEMENT OF BODY
metabolism.
water. FLUIDS AND
Through the process again of ELECTROLYTES
Function of water:
diffusion, oxygen in the blood
will go to the cells because the 1. Medium for metabolic Osmosis- movement of water
cells need oxygen in order to reactions within the cells across cell membranes from the
function well. The brain cells less concentrated solution to the
really need oxygen. Five to ten 2. Transporter of nutrients, more concentrated solution.
minutes without oxygen to the waste products
Osmotic pressure- power of a
brain cells will result to 3. Lubricant solution to draw water across a
irreversible brain damage. The
4. An insulator and shock semipermeable membrane.
carbon dioxide from the cells will
go to the ___ the systemic absorber -pulling power of a solution
capillary making the blood 5. One means of regulating
deoxygenated blood. Osmolality- total solute
and maintain body concentration within a fluid
Systemic capillary > systemic temperature compartments and is measured as
vanule > systemic vein > superior a part of solute per kilogram of
water
-expressed in milliosmols per - pulling force exerted by the -Used to prevent or treat cellular
kilogram (mOsm/kg). colloids in a solution dehydration by providing free
water to the cells.
THE HIGHER THE -Is the osmotic pressure exerted
OSMOLALITY (the by proteins (e.g. albumin) -Contraindicated in acute brain
concentration) A SOLUTION, injuries because cerebral cells are
THE GREATER IS ITS Active transport- passage of ions very sensitive to free water,
PULLING POWER FOR or molecules across the cell absorbing it rapidly and leading to
WATER. membrane from a less cellular edema.
concentrated solution to a more
Milliosmols- measure osmotic -Hypotonic solution makes the
concentrated with the expense of
activity as a total of the number of cells swell
metabolic energy
particles present.
Example of Hypotonic solution:
275-295 mOsm/L- NORMAL Sodium-Potassium Pump- the
SERUM OSMOLALITY sodium concentration is greater in 1. 0.45% NaCI (Half Normal
the ECF than in the ICF, because Saline)
Solutes- substance dissolved in a of this, sodium tend to enter the
liquid 2. 0.33% NaCI (One Third
cell by diffusion. This tendency is Normal Saline)
-Can be CRYSTALLOIDS (salts offset by the sodium-potassium
that dissolve readily into true pump that is maintained by the 3. 5% Dextrose in Water
solutions) or COLLOIDS (D5W)
cell membrane and actively
(substances such as large protein moves sodium from the cell into D5W is isotonic on initial
molecules that do not readily the ECF administration but provides free
dissolve into true solutions) water when dextrose is
TOPIC 3 metabolized, expanding
Osmolarity- concentration of the
solute per liter of a solution Parental Fluid and Electrolyte intracellular and extracellular
Replacement fluid volumes. D5W is avoided in
Tonicity- refers to the osmolality clients at risk for increased
of a solution Intravenous (IV) fluid therapy is intracranial pressure (IICP)
essentials when clients are unable because it can increase cerebral
Sodium- is the greatest to take food and fluids orally. edema.
determinant of serum osmolality,
with glucose and urea also Intravenous fluids enter the HYPERTONIC SOLUTION
contributing systemic vein of the clients.
-Have higher osmolality than
Potassium, Glucose, and Urea are Classification of IV Solutions: body fluids causing water to be
primary contributors to the pulled from the cells into the
1. Isotonic
intracellular fluid osmolality vessels, resulting to increased
2. Hypotonic vascular volume and decreased
Diffusion- molecules move from cell water.
a solution of higher concentration 3. Hypertonic
to lower concentration HYPERTONIC SOLUTION
*insert picture
Filtration- is the process whereby -Also used to pull excess fluid
fluid and solutes move together ISOTONIC SOLUTION from cells and promote osmotic
across a membrane from one - Same osmolality as diuresis causes RBC to shrink.
compartment to another normal plasma -Salt attracts water
Filtration pressure - Used to replace ECF -Hypertonic Solution makes the
- difference between the losses and to expand cell shrink
hydrostatic pressure and osmotic vascular volume quickly
pressure Hypertonic Solution
Example of Isotonic Solution:
Hydrostatic pressure - 5% dextrose in normal saline
1. Normal Saline (NSS; 0.9 (D5NS)
- pushing pressure of a fluid NaCI)
against the wall it occupies - 5% dextrose in 0.45% NaCI
2. Lactated ringer’s Solution (D5 ½ NS)
Hydrostatic pressure in the (Plain LR)
capillaries tends to filter fluid out - 5% dextrose in lactated ringer’s
HYPOTONIC SOLUTION (D5LR)
of the intravascular compartment
into the interstitial fluid -Have lower osmolality than REGULATION OF BODY
normal plasma FLUIDS
Oncotic pressure
 In a healthy person, the volumes -Other factors affecting ADH: In order to prevent osmolarity
and chemical composition of the blood volume, temperature, pain, from decreasing below normal >
fluid compartments stay within and some drugs such as opiates, increased aldosterone > increased
narrow safe limits. Illness can barbiturates, and nicotine. reabsorption of Na in distal
upset this balance so that body tubule.
has little or too much fluid. It is LUNG FUNCTION
also influenced by the person’s PARATHYROID FUNCTIONS
-Through inhalation, lungs
activity and temperature. remove approximately 300ml of - embedded in the thyroid gland,
FLUID INTAKE water daily in the normal adult. regulate calcium and phosphate
balance by means of parathyroid
Water in food - 1,000ml -Hyperpnea (abnormally deep hormone (PTH)
respiration) or coughing increase
Water from oxidation – 300ml this loss, mechanical ventilation PTH influences bone resorption
with excessive moisture also calcium absorption from the
Water as liquid – 1,200ml decrease it. intestines and calcium
TOTAL = 2,500ml reabsorption from the renal
If the blood flow (perfusion) or tubules.
FLUID OUTPUT pressure to the kidney decreases,
renin is released which causes RENIN-ANGIOTENSIN-
Urine (kidney) conversion of angiotensinogen to ALDOSTERONE SYSTEM
Insensible losses angiotensin I, which is then (RAAS)
converted to angiotensin II by
- Skin (sweat-100ml) angiotensin converting enzyme - specialized receptors in the
500ml (ACE) from the lungs. juxtaglomerular cells of the
kidney nephrons respond to
- Lungs 400 ml Angiotensin II acts directly on the changes in renal perfusion.
nephrons to promote sodium and
- Feces 100ml water retention and it also ATRIAL NATRIURETIC
stimulates the release of FACTOR (ANF)
TOTAL = 2,500ml
Aldosterone thereby reducing - is released from the cells in the
Insensible fluid losses- is usually urine output and increased blood atrium of the heart in response to
not noticeable and measured. It volume. excess blood volume and
occurs in the skin through stretching of the atrial walls.
diffusion and perspiration. PITUITARY FUNCTIONS
- hypothalamus manufactures ANF promotes sodium wasting
Obligatory losses- certain fluid and act as a potent diuretic, thus
losses that are required to ADH, which is stored in the
posterior pituitary and released as regulating vascular volume and
maintain normal body function inhibits thirst, thus reducing fluid
through respiration, kidneys, skin needed.
intake.
and feces (approximately ADH is a water conserving
1,300ml) hormone because it causes body BARORECEPTORS
MAINTAINING to retain water. - small nerve receptors that detect
HOMEOSTASIS ALDOSTERONE changes in pressure within blood
vessels and transmit this
Kidneys- primary regulator of - mineralocorticoid secreted by information to the CNS.
body fluids and electrolytes the zona glomerulosa (outer zone)
balance. of the adrenal cortex- increase - responsible for monitoring and
secretion causes sodium retention circulating volume, sympathetic
135-180 liters of plasma per day and parasympathetic neural
are normally filtered in an adult (and thus water retention) and
potassium loss. activity as well as endocrine
but only 1.5 liters of urine is activities.
excreted. If osmolarity increases >
decreased secretion of Aldosterone, decreases
ANTIDIURETIC HORMONE glomerular filtration and increases
(ADH)- regulates water excretion Aldosterone > decreased
reabsorption of Na in distal sodium and water reabsorption.
from the kidney
tubule. FUNCTIONS AND
-When serum osmolality rises, REGULATION OF
ADH is produced, causing the And at the same time
ELECTROLYTES
collecting ducts to become more Increased ADH secretion >
permeable to water conserve water Electrolytes- are changed ions
capable of conducting electricity.
-When serum osmolality EFFECT: decreased urine
decreases, ADH is suppressed. excretion increased urine
osmolarity
Anion (negatively charged) and Tissue damage and acidosis shift - normal serum levels of
cation (positively charged) potassium out of cells into ECF. phosphate in adults range from
balance always exist. 1.8 to 2.6 mEq/L
Calcium
Cations: sodium (Na), potassium Bicarbonate
(K), calcium (Ca), and - majority of this in the body is
magnesium (Mg) stored in the skeletal system, with - is present both ICF and ECF. Its
a relatively small amount in ECF. primary function is regulating
Anion: chloride (CI), bicarbonate acid-base balance as an essential
(HCO3), phosphate (HPO4), and - normal total serum calcium level component of the body’s
sulfate (SO4). is 4.5 to 5.5 mEq/L. buffering system.
Most electrolytes enter the body When calcium levels in the ECF Acid-base balance
through dietary intake and are fall, parathyroid hormone and
excreted in the urine. calcitriol cause calcium to be - an important part of regulating
released from bones into ECF and homeostasis of body fluids is
increase the absorption of calcium regulating their acidity and
in the intestines, thus raising alkalinity.
FUNCTIONS OF serum calcium levels.
ELECTROLYTES: Acid- is a substance that releases
Conversely, calcitonin stimulates hydrogen ions in solution.
1. Maintaining fluid balance the deposition of calcium in bone,
reducing the concentration of Bases or alkalis
2. Contributing to acid-base
regulation calcium ions in the blood. - have a low hydrogen ion
With increasing age, the intestines concentration and can accept
3. Facilitating enzyme reaction hydrogen ions in solution.
absorb calcium less effectively,
4. Transmitting neuromuscular and more calcium is excreted by The relative acidity or alkalinity
reaction the kidneys. Calcium shifts out of of a solution is measured by its
TOPIC 4 the bone to replace these ECF pH, which is an inverse reflection
losses, increasing the risk of of the hydrogen ion concentration
FLUIDS AND osteoporosis and fractures of the of the solution.
ELECTROLYTES wrists, vertebrae, and hips. Lack
of weight-bearing exercise (which - the normal pH of arterial blood
Regulation of electrolytes between 7.35 and 7.45.
helps keep calcium in the bones)
Sodium and a vitamin D deficiency Buffers- prevent excessive
contribute to this risk, as do changes in pH by binding with or
- is the most abundant cation in genetics and lifestyle factors.
ECF and a major contributor to releasing hydrogen ions.
serum osmolality. Magnesium The major buffer in ECF is the
- normal serum sodium levels are - is found primarily in the bicarbonate and carbonic acid
135 to 145 mEq/L skeleton and ICF, where it is the system.
second most abundant FACTORS AFFECTING
Aldosterone- increases sodium intracellular cation.
reabsorption in collecting duct of BODY FLUID,
nephrons. - normal serum magnesium level ELECTROLYTES, AND
is 1.5 to 2.5 mEq/L ACID-BASE BALANCE:
Potassium
Chloride 1. Age
- is the major cation in ICF, with
only a small amount found in the - is the major anion of ECF, and 2. Sex and body size
ECF. normal serum levels are 95 to 108 3. Environment temperature
mEq/L.
- normal serum potassium levels 4. Lifestyle- diet, exercise, stress
are 3.5 to 5.0 mEq/L When sodium is reabsorbed in the and alcohol consumption
kidney, chloride usually follows.
Potassium is a vital electrolyte for Chloride is a major component of Stress can increase cellular
skeletal, cardiac, and smooth gastric juice such as hydrochloric metabolism, blood glucose
muscle activity. It must be acid and is involved in regulating concentration, and catecholomine
ingested daily because the body acid-base balance. levels. In addition, stress can
cannot conserve it. increase production of ADH and
Phosphate stimulate the RAAS, both of
Aldosterone increases potassium
excretion. - is the major anion of ICF. And it which decrease urine output. The
also found in ECF, bone, skeletal overall response of the body to
Insulin helps move potassium into muscle and nerve tissue. stress is to increase blood volume.
cells.
DISTURBANCES IN FLUID essentially unavailable for use. * dry mouth, tongue, and mucous
VOLUME, ELECTROLYTE Fluid may be sequestered in the membrane
AND ACID-BASE BALANCES bowel, in the interstitial space as
edema. * warm, flushed, dry skin
FLUID IMBALANCES
(VOLUME IMPAIRMENT) Common locations: * soft, sunken eyeballs

Two basic types: Tissue spaces (edema) * tachycardia

1. Isotonic imbalances- occur Abdomen (ascites) * low BP- decreased vein filling
when water and electrolytes are * tachypnea
lost or gained in equal Pleural spaces (pleural effusion)
proportions, so that osmolality of Pericardial spaces (pericardial * altered LOC
the body fluid remains constant. effusion) * oliguria, highly colored urine
2. Osmolar imbalances- involve Causes: SIGNS AND SYMPTOMS OF
the loss or gain of only water, so DEHYDRATION:
that the osmolality of the serum is Injury or inflammation,
altered. malnutrition or liver dysfunction, *insert picture
high vascular hydrostatic
FOUR CATEGORIES OF pressure. DIAGNOSTICS:
FLUID IMBALANCES:
HYPERTONIC/HYPEROSMO Normal or increased Hct and
* Isotonic loss of water and LAR DEHYDRATION BUN (blood uria nitrogen),
electrolytes increase urine specific gravity,
- more water is lost than solutes, increase serum osmolality
* Isotonic gain of water and Na or solute excess and serum (higher than 300 mOsm/kg)
electrolytes osmolality is elevated. Water is
lost without electrolyte lost. Normal hematocrit in men is 40-
* Hyperosmolar loss of water- 54 and 37-47 in women.
water deficit ( in relation to Na Causes:
or other solution) and Na/solute Normal BUN- 7 to 20 mg/dL
excess ( in relation to water) * inadequate fluid intake (2.5-7.1 mmol/L)
* Hypoosmolar gain of water- * excess loss of water without Normal urine specific gravity is
water excess and Na deficit proportional loss of solutes 1.010-1.025
(hyperventilation)
FLUID VOLUME DEFICIT Normal serum osmolality- 280-
* increased solute intake without 300 mOsm/kg.
Types of Fluid Volume Deficit sufficient water (high CHON tube
feeding) COLLABORATIVE
* ISOTONIC FLUID MANAGEMENT:
VOLUME DEFICIT (FVD) * excess accumulation of solutes
secondary to disease condition * Fluid replacement (1kg BW- 1L
- occurs when the body losses fluid)
both water and electrolytes from (RF,DM)
the ECF in similar proportion. ASSESSMENT/MANIFESTATI * Oral (safest route)- initial
(HYPOVOLEMIA) ON: rehydration, avoid sodas, fruit
juice and sports drink
Hypovolemia occurs as a result * thirst
of: * Intravenous- initial expand ECF
* weight loss- 1 kg= 1L with isotonic IV until adequate
1. Abnormal losses through the circulating volume and renal
skin, gastrointestinal tract, or * mild DHN- 2% body wt. Loss
or 1-2 L fluid loss perfusion are achieved.
kidneys (diuretics)
* moderate DHN- 5% body wt. * Measure intake and output
2. Decrease intake of water
Loss or 3-5L fluid loss (with S/ * Monitor
3. Bleeding Sx)
* Monitor the weight daily
4. Burns * severe DHN- 8% body wt. Loss
or 5-10L fluid loss (frank * Safety measures such as side
5. Movement of fluid in a third rails
shift hypotension and delirium)
15% body wt. Loss can be fatal * Treat underlying cause
THIRD SHIFT SYNDROME
(anuria,coma; > 10L fluid loss in EVALUATION: the client
- fluid shifts a vascular space into adult) exhibits: mental alertness; moist
an area where it is nor readily mucous membrane; urine output
accessible as extracellular fluid. * elevated temperature
is approximately equal to fluid
Fluid remains in the body but is intake
HYPOOSMOLAR 1. Increased capillary hydrostatic - Lymph returns to the
INTOXIFICATION- more fluid pressure (e.g. hypertension) bloodstream most of the small
is gain than the solutes. proteins that the blood capillaries
2. Decreased colloid osmotic filtered.
Causes: pressure
* Excess fluid intake Pathogenesis of edema:
Causes: injury or inflammation
* Increased secretion of ADH and malnutrition or liver 1. Increased hydrostatic pressure
(SIADH) dysfunction
*inreased capillary permeability 2. Increased permeability of the
* Decreased/inadequate urine vessel wall
output (RF, heart failure) *causes: damage to the blood
vessels and C. Alteration in osmolality
* High corticosteroid level (osmotic/electrolyte imbalances)
(therapy, stress, disease results in *vasodilation due to
Na and water retention) inflammation, release of - ELECTROLYTE
histamine IMBALANCES:
* Repeated plain water enemas
*lymphatic obstruction - HYPONATREMIA (Na
* Psychologenic polydipsia deficit)
Causes: surgical removal of group
ASSESSMENT/MANIFESTAT of lymph nodes and vessels to - Na loss or water excess
ION: prevent spread of Ca - Serum Na level is less than 135
* Peripheral edema Trauma, radiation therapy, mEq/L
* Tense or bulging fontanels in malignant metastasis DILUTIONAL
children under 18 mos. *Filariasis HYPONATREMIA- water
intoxification- serum Na level is
*Changes in mental status- brain *Retention of excess fluid and diluted by an increase in the ratio
cells affected (confusion, plasma proteins in ISC--more of water to Na. This causes water
incoordination, convulsion) water moves into the area-- to move into the cell, so that the
* Hyperventilation LOCALIZED EDEMA patient develops an ECF volume
excess.
* Sudden weight gain *Na and water excess
Causes: include SIADH-
* Warm moist skin TOPIC 5 Syndrome of Inappropriate
* Increased ICP (bradycardia, MOVEMENT OF FLUID Antidiuretic Hormone,
increased systolic, decreasd BETWEEN hyperglycemia, and excess
diastolic pressure) COMPARTMENTS electrolyte- poor parenteral
infusions, use of tap water enemas
* Pulmonary edema Fluid leaves plasma at anteriolar and irrigation of NGT with tap
end of capillaries because water instead of normal saline.
DIAGNOSTICS: outward force of hydrostatic
pressure predominates. Diabetes SIADH
Decrease Hct, BUN, serum
Insipidus
osmolality (<275 mOsm/kg), Fluid returns to the plasma at
decreased serum Na, Chest X-ray High urinary Low urinary
venular ends of capillaries output output
may show pleural effusion and because inward force of colloid
ABG shows low pO2 and pCO2, Low levels of High levels of
osmotic pressure predominates. ADH ADH
as pulmonary edema progresses to
hyperventilation and respiratory Starling’s Law Hypernatremia Hyponatremia
failure, pH drops. Dehydrated Over hydrated
Homeostatis is maintained by the Lose too much Retain too
COLLABORATIVE opposing effects of: fluid much fluid
MANAGEMENT *Vascular Hydrostatic Pressure *BOTH WILL PRESENT WITH
1. Fluid restriction EXCESSIVE THIRST
*Plasma Colloid Osmotic
2. Administration of diuretics Pressure Etiology:

3. MIO and weigh daily - Whatever comes out of the *Treatment with diuretics
arteriolar end should go back at *Restricted Na intake
4. Monitor serum Na level the venular end to prevent edema.
5. Promote safety *Loss from GI or billiary drainage
- The net inward force of the and draining fistulas
6. Assess neurologic status colloid osmotic pressure is due to
the plasma proteins. *Decreased aldosterone secretions
MECHANISM FOR THE (Addison’s disease)
FORMATION OF EDEMA
* ‘’Trapping’’ of water and Na M-Medications, meals (too much lympg fluid compartments than in
sodium intake) blood.
*Edema, ascites, burns or small
bowel obstruction O-Osmotic diuretics -is also contained in gastric and
pancreatic juices, sweat, bile, and
*Diaphoresis- warm climate, D-Diabetes insipidus saliva.
exercise, fever, ‘’salt-wasting
nephritis’’ E-Excessive H2O loss -Aldosterone secretion increases
L-Low H2O intake sodium reabsorption, thereby
ASSESSMENT increasing chloride absorption
( decreased ECF, increased Etiology:
-Bicarbonate has an inverse
ICF ) -more water than Na is lost from relationship with cloride. As
*Headache the body chloride moves from plasma into
(hyperventilation,diarrhea) the RBCs (called the chloride
*Muscle weakness shift), bicarbonate moves back
-high Na intake
*Fatigue and apathy into the plasma.
-salt tablets
*Postural hypotension -Hydrogen ions are formed, which
-rapid infusion of saline then help release oxygen from
*Anorexia, nausea and vomitting hemoglobin.
-water deprivation
*Abdominal cramps -Chloride is primarily obtained
Assessment:
from the diet as table salt.
*Weight loss
-extreme thirst
-Chloride is produced in the
*Feeling of apprehension
-dry, sticky mucous membrane stomach, where it combines with
*Seizure and coma hydrogen to form hydrochloric
-oliguria acid.
*Specific gravity is low (1.002-
1.004) -firm, rubbery tissue turgor, -As chloride decreases (usually
excitement, agitation because of volume depletion)
COLLABORATIVE sodium and bicarbonate ions are
MANAGEMENT: -red, dry swollen tongue
retained by the kidney to balance
*Detecting and controlling -tachycardia the loss. Bicarbonate accumulates
hyponatremia -fatigue in the ECF, which raises the pH
and leads to hypochloremic
*Treatment of shock (0.9% NaCI -restlessness metabolic alkalosis.
IV, plasma expanders)
-disorientation HYPOCHLOREMIA
*Sodium replacement and other (CHLORIDE DEFICIT)
electrolytes deplected (K, Ca, -hallucination
HCO3) -increased in serum bicarbonate
-serum osmolality exceed than
level increases chloride excretion
*Salt, salty foods in diet 295 mOsm/L
-serum chloride level falls below
*Water restriction -specific gravity is increased
95 mEq/L
*Safety precautions e.g. use of COLLABORATIVE
COLLABORATIVE
side rails, supervision of MANAGEMENT:
MANAGEMENT:
ambulation -preventing and correcting
-replacement therapies- oral or IV
HYPERNATREMIA (NA hypernatremia
infusion
EXCESS, EDEMA) -monitor I and O
-monitor serum and urinary
Na and water excess -- edema, -restrict Na in diet chloride level- client should be
excess in Na in relation to water NPO prior to blood extraction and
in ECF -- Hypernatremia -monitor behavioral changes do not draw from site with
Serum Na level is higher than 145 -increase oral fluid or D5W hemodialysis access, no
mEq/L infusion tourniquet and prevent client from
pumping the first and site without
Increase Na -- increase ECF -diuretics saline infusion.
osmolality -- ICF moves into ECF
-dialysis HYPOCHLOREMIA
-- ICF dehydration
(CHLORIDE EXCESS)
CHLORIDE
‘’The Model’’
-serum chloride level higher than
-the major anion of the ECF, is
(Causes of increased sodium) 108 mEq/L
found more in the interstitial and
-chloride increases with 8. Metabolic alkalosis 3. Elevated U wave is specific to
imbalances of sodium, potassium, hypokalemia
water and carbon dioxide levels in 9. Hyperaldosteronism
the body MANAGEMENT
10. Insulin hypersecretion
-cellular chloride shifts are seen in -dietary intake- 50 to 100 mEq/L
11. Unwilling to eat normal diet
the response to acid-base changes -fruits like BANANA, vegetables,
and volume disturbances in the 12. Magnesium depletion legumes, whole grains, milk and
body 13. Some medications meat
COLLABORATIVE HYPOKALEMIA can cause -administering IV potassium
MANAGEMENT: alkalosis, and in turn alkalosis can -there should be adequate urine
-chloride restriction cause hypokalemia flow during administration of
-promote chloride excretion by Hydrogen ions move out of the potassium IV
administering diuretics cells in alkalotic states to help -shake the IV bottle after injecting
correct the high Ph, and the K to avoid hyperkalemia
-monitor acis-base, respiratory potassium ions move in to
and cardiac status maintain an electrically neutral COLLABORATIVE
-restoration of balance- state. MANAGEMENT:
appropriate IV, correct - Hyperaldosteronism increases -preventing hypokalemia through
dehydration renal potassium wasting and can early detection of patients at risk
-client education lead to severe potassium
depletion. -correcting hypokalemias
HYPOKALEMIA (K -K - rich foods - banana, dried
DEFICIT) - Potassium losing diuretics can
induce hypokalemia fruits (raisin, prunes), orange, raw
-serum K level is lower than 3.5 carrots, raw tomato, baked potato,
mEq/L - Other medications that can lead melon (cantaloupe), watermelon
to hypokalemia include
-hypokalemia -- alkalosis corticosteroids, sodium penicillin, -K supplements- slow IV drip
carbenicillin and amphotericin (KCI)
-during anabolism or
glycogenesis, K enters the cell - Insulin promotes the entry of -K sparing diuretics-
potassium into the skeletal muscle spironolactone
POTASSIUM (K) and hepatic cells, patients with Note: potassium supplement can
-major intracellular electrolytes persistent insulin hypersecretion cause small bowel lesion so
may experience hypokalemia patient must be assessed for and
-influences both skeletal and caution about abdominal
cardiac muscle activity CLINICAL
MANIFESTATIONS: distention, pain and GI bleeding
-to maintain K balance, the renal HYPERKALEMIA (K
system must function, because 1. Fatigue
EXCESS)
80% of the K excreted daily 2. Anorexia
leaves the body by way of the -serum K level higher than 5.0
kidneys, the other 20% is lost 3. Nausea mEQ/L
through the bowel and in sweat.
4. Vomitting -K excess causes acidosis
ALDOSTERONE also increases
the excretion of potassium by the 5. Muscle weakness -during catabolism, K leaves the
kidney. cells
6. Leg cramps
HYPOKALEMIA COLLABORATIVE
7. Decreased bowel motility MANAGEMENT:
Causes: 8. Paresthesias -preventing hyperkalemia through
1. Use of diuretics 9. Dysrhythmias early detection of patients at risk
2. Vomitting 10. Increased sensitivity to -correcting hyperkalemia
3. Gastric suction digitalis -avoid potassium rich-foods
4. Diarrhea ECG CHANGES INCLUDE: -10% glucose with regular insulin
1. Flat or inverted T waves or IV
5. Prolonged intestinal suctioning
both -dialysis
6. Recent ileostomy
2. Depressed ST segments
7. Villous adenoma
-calcium IV (antagonizes effect of 1. Peaked, narrow T waves
potassium)
H ions shift into ICF 2. ST- segment depression
-promote b
3. Shortened QT interval
K moves out from ICF going to If the serum potassium level
TOPIC 6 the blood continues to increase,
*ADDITIONAL INPUTS IN 1. The PR interval becomes
HYPERKALEMIA* prolonged;
HYPERKALEMIA
CAUSES OF 2. Disappearance of the P waves;
HYPERKALEMIA: PSEUDOHYPERKALEMIA- a and
false hyperkalemia
1.Oliguric renal failure 3. Widening of the QRS complex
CAUSES OF
-If there is less urine output less PSEUDOHYPEKALEMIA: CALCIUM
K will be excreted thereby more K
will be congested in the blood 1. Improper collection or transport -99% is located in the skeletal
of a blood sample system
1. Use of potassium conserving
diuretics in patients 2. Traumatic venipuncture -A major component of bones and
teeth
2. Metabolic acidosis 3. Use of tight tourniquet around
an exercising extremity while -About 1% of skeletal calcium is
3. Addison’s disease drawing a blood sample, rapidly exchangeable with blood
producing hemolysis of the calcium
4. Crush injury sample before analysis
-The small amount of calcium
-In trauma cases K inside the OTHER CAUSES OF located outside the bone circulates
cells go out and go to the blood in PSEUDOHYPERKALEMIA: in the serum, partly bound to
the blood circulation which protein and partly ionized
causes hyperkalemia 1. Marked leucocytosis (increased
WBC) and thrombocytosis -Plays a major role in transmitting
1.Burns (increased platelet count) nerve impulses and helps regulate
2.Stored bank blood transfusion muscle contraction and relaxation,
2. Drawing blood above a site including cardiac muscle
-Administration should only last where potassium is infusing
for 4-6 hours or there will be -Is essential in activating enzymes
3. Familial pseudokyperkalemia, that stimulate many essential
hemolysis(destruction of RBC); in which K leaks out of the RBCs
when RBC is destroyed K will go chemical reactions in the body,
while the blood is awaiting and it also plays a role in blood
out and mix with the blood analysis
causing hyperkalemia coagulation
CLINICAL -Exists in plasma in 3 forms:
1 .Rapid IV administration of MANEFISTATIONS:
potassium 1. IONIZED
1. Muscle weakness
2. Certain medications like ACE -50% for neuromuscular activity
inhibitors, NSAIDs 2. Tachycardia at first followed and blood coagulation
by bradycardia
3. Pseudohyperkalemia 2. BOUND
3. Dysrhythmia
- In acidosis, potassium moves -to serum proteins, primarily
out of the cells and into the ECF. 4. Flaccid paralysis albumin
This occurs as hydrogen ions
enter the cells to buffer the pH of 5. Paresthesias (numbness) 3. COMPLEXED
the ECF 6, Intestinal colic -Combined with nonprotein
“The H ions will go to the cells to 7. Cramps anions: phosphate, citrate, and
neutralize the acidosis as a carbonate
compensatory mechanism of the 8. Abdominal distention
body and then in exchange to the -Calcium is absorbed from foods
9. Irritability in the presence of normal gastric
H ions, the cells will give out the
K to the blood causing the blood 10. Anxiety acidity and vitamin D
to have increase in K” -Excreted primarily in the feces
ECG CHANGES IN
H ions in the blood HYPERKALEMIA: -the serum calcium level is
(Metabolic Acidosis) controlled by
Earliest changes:
PARATHYROID HORMONE 10. Alkalosis 2. Do NOT put anything in
(PTH) and CALCITONIN mouth
11. Alcohol abuse
-as ionized serum decreases 3. Call 911 if seizure lasts
(HYPOCALCEMIA), the 12. Medications like aluminum- longer than 5 mins.
parathyroid glands secrete containing antacids,
PARATHYROID HORMONE aminoglycosides, caffeine,
(PTH) cisplatin, corticosteroids,
mithramycin, phosphates, 1. MENTAL CHANGES
-this, in turn, increases calcium isoniazid and loop diuretics -Such as depression, impaired
absorption from the GI tract, memory, confusion, delirium, and
increases calcium reabsorption CLINICAL
MANIFESTATIONS: even hallucinations
from the renal tubule, and releases
calcium from the bones 1. TETANY 2. ECG CHANGE:

-the increase in calcium ion -Refers to the entire symptom -Prolonged QT interval: due to
concentration suppresses PTH complex induced by increased prolongation of the ST segment,
secretion neural excitability and a form of ventricular
tachycardia called TORSADES
-when calcium increases -Sensations of tingling may occur DE POINTES may occur
(HYPERCALCEMIA) in the tips of the fingers, around
excessively, the thyroid gland the mouth and in the feet and 3. RESPIRATORY EFFECTS:
secretes CALCITONIN spasms of muscles -Dyspnea and laryngospasm
-it inhibits Ca reabsorption from 4. CHRONIC
the bone and decreases the serum HYPOCALCEMIA:
Ca concentration 2. TROUSSEAU’S SIGN
-Can be elicited by inflating a BP Hyperactive bowel sound, dry and
-a pt. may have a total body Ca brittle hair and nails, and
deficit (as in osteoporosis) but cuff on the upper arm to about 20
mmHg above systolic pressure; abnormal clotting
normal serum Ca level
within 2 to 5 minutes, carpal 5. OSTEOPOROSIS
HYPOCALECEMIA (Ca spasm (an adducted thumb, flexed
DEFICIT) wrist and metacarpophalangeal -Associated with prolonged low
joints, extended interphalangeal intake of Ca and represents a total
-serum Ca level lower than 8.5 body Ca deficit, even though
mg/dl joint fingers together) will occur
as ischemia of the ulnar nerve serum Ca levels are usually
-manifestations of low Ca are not develops normal
apparent until ionized Ca level is -Common in postmenopausal
< 4.0 mg/dl 3. CHVOSTEK’S SIGN
women
-increased in phosphate level -Consists of twitching of muscles
supplied by the facial nerve when ASSESSMENT AND
causes in Ca DIAGNOSTIC FINDINGS:
the nerve is tapped about 2 cm
CAUSES OF anterior to the earlobe, just below 1. Evaluate serum Ca levels,
HYPOCALCEMIA: the zygomatic arch serum albumin level and the
1. Primary hypoparathyroidism 4. SEIZURES arterial pH

2. Surgical hypoparathyroidism -May occur because -When the arterial pH increases

hypocalcemia increases irritability (alkalosis), more Ca becomes
3. After radical neck dissection: of the CNS and peripheral nerves bound to protein. As a result, the
first 24- 48 hours after surgery ionized portion decreases.
*FIRST AID FOR SEIZURE: SYMTOMPS OF
4. Massive administration of place the client in side lying
citrated blood HYPOCALCEMIA MAY
position to prevent aspiration OCCUR WIH ALKALOSIS
5. Inflammation of the pancreas SEIZURE FIRST AID: Acidosis has the opposite effect;
6. Renal failure who frequently 1. Do not panic that is, less Ca is bound to protein
have elevated phosphate levels and therefore exists in the ionized
2. Turn on their side and start form
7. Inadequate vitamin D timing the seizure
consumption 1. PTH levels are decreased in
3. Stay with child, do not retrain hypoparathyroidism
8. Magnesium deficiency
1. Place something soft 2. Magnesium and phosphorus
9. Medullary thyroid carcinoma, under head levels need to be assessed to
low serum albumin levels
identify possible causes of treating hypocal in pt with occur after severe of multiple
decreased Ca Chronic Renal Failure (CRF) fractures or spinal cord injurY
3. Increasing the dietary intake of COLLABORATIVE
Ca to at least 1,000 to 1,500 MANAGEMENT:
MEDICAL MANAGEMENT: md/day in the adult is
recommended; Ca- containing -Increase fluid intake (3- 4 L/day)
1. Parenteral Ca salts include: – to reduce risk of stone
foods include milk products,
-Calcium Gluconate (usually green leafy vegetables, canned formation in kidneys and relieve
given to pts; has less Ca than salmon, sardines and fresh oysters thirst due to polyuria
Clacium Chloride) -Acid: ash fruit juices (prune
4. Hypomagnesemia can also
-Calcium Chloride (more Ca) cause tetany; if the tetany juice, cranberry juice) ascorbic
responds to IV calcium, then a acid
-Calcium Gluceptate
low magnesium level is -Acidic urine inhibits stone
-Calcium gluconate (administer considered as a possible cause in formation in the kidney
w/ D5W or NS but do not add chronic renal failure
with solution containing TOPIC 7
bicarbonate because rapid NURSING MANAGEMENT:
FLUIDS AND
precipitation may occur) 1. Seizure precautions ELECTROLYTES
-Usually calcium gluconate is 2. Teach pts at risk for HYPOMAGNESEMIA
being placed when having osteoporosis about Ca rich foods
THYROIDECTOMYIN in cases and supplements if needed. -Magnesium deficit
of hypocalcemia Emphasize regular weight- -Serum magnesium less than 1.3
-If hypomagnesia present, correct bearing exercises mEq/L and is frequently
with 50% Mg sulfate 2-4 ml over 3. Discussion of medications such associated with hypokalemia and
15 mins as alendronate (Fosamax), hypocalcemia.
-Too rapid IV administration of risedronate (Actonel), raloxifene Causes:
Ca can cause CARDIAC (Evista), calcitonin, and
ARREST, preceded by ibandronate (Boniva), a once-a- 1. Chronic alcoholism
bradycardia month bisphosphonate to reduce
2. Hyperparathyroidism
the rate of bone loss
-IV administrationof CA is 3. Hyperaldosteronism
dangerous in pts receiving 4. Teaching also includes
digitalis- derived medications as strategies to reduce the risk of 4. Diuretic phase of renal failure
it may cause digitalis toxicity falls
5. Malabsorptive disorder
-Ca should be diluted in D5W and 5. Caution pt to avoid overuse of
laxatives and antacids that contain 6. Diabetic ketoacidosis
administered as a slow IV bolus
or a slow IV infusion using a phosphorus, because their use 7. Refeeding after starvation
volumetric infusion pump decreases Ca absorption
8. Parenteral nutrition
-The IV site must be observed for HYPERCALCEMIA (Ca
excess) 9. Chronic laxative use
any evidence of infiltration
-Dangerous imbalance when 10. Diarrhea
-0.9% sodium chloride or PNSS
should not be used with calcium severe, hypercalcemic crisis has
because it increases renal Ca loss moratality rate as high as 50% if
not treated promptly  Chronic Alcohol Abuse- is a
-Solutions containing phosphates major cause of symptomatic
or bicarbonate should not be used -symptomatic hypercalcemia from hypomagnesemia in the US
with Ca because they cause immobilization is rare and when it (Crawford & Harris, 2011)
precipitation when Ca is added does occur, it is virtually limited
to people with high Ca turnover
-Ca can cause postural rates (e.g. adolescent during
hypotension  Magnesium deficiency occurs
growth spurt) and most cases
in diabetic ketoacidosis
1. Vitamin D therapy may be (DKA) secondary to
instituted to increase Ca increase a renal
absorption from the GI tract excretion during osmtic
diuresis and shifting of
2. Aliminum hydroxide, calcium
magnesium into the
acetate, or Ca carbonate antacids
cells with insulin
may be prescribed to decrease
therapy.
elevated phosphorus levels before
Clinical manifestations of produce alterations in cardiac Clinical Manifestations:
Hypomagnesemia: conduction leading to heart block
or asystole ( absence of electrical 1. Decreased BP
1. Neuromuscular irritability and mechanical activity in the 2. Thirst, nausea and vomiting
2. Positive trausseau’s sign and heart manifested by apnea and
Chvotek’s sign lack of pulse. 3. Drowiness

3. Insomnia Note: VS should be assessed 4. Loss of deep tendon reflexes

frequently during magnesium (DTRs)
4. Mood changes administration to detect changes Collaborative Management:
5. Anorexia in cardiac rate or rhythm,
hypotension, and respiratory 1. Calcium gluconate- antagonist
6. Vomiting distress (RR should not be less of magnesium
that 12 br/min. Check patellar
7. Increased tendon reflexes 2. Dialysis- if with renal failure
reflex also.
8. Increased BP 3. Correction of underlying cause.
Monitoring urine output is
*Hypomagnesemia may be essential before, during and after Phosphorus
accompanied by marked alteration magnesium administration;the
in psychological status. physician is notified if urine - is a critical constituent of all
volume decreases to less over 4 body tissues
Apathy,depressed mood, than 100ml over 4 hours.
apprehension and extreme -is essential to the function of
(25ml/hr) muscle and RBC
agitation have been noted as well
as ataxia [(impaired ability to Monitor urine output accurately. -provide structural support to
coordinate movement (e.g. bone and teeth
Calcium gluconate must be
staggering gait)] dizziness,
readily availableto treat HYPOPHOSPHATEMIA
insomnia and confusion.
hypocalcemic tetany or
At times, delirium, auditory or hypermagnesemia. -Phosphorus deficit
visual hallucinations and frank -serum phosphorus <2.5 mEq/L
QUALITY AND SAFETY
psychoses may occur.
NURSING ALERT Causes:
Collaborative Management:
-Iv magnesium sulfate must be 1. Refeeding after starvation
1. Dietary supplement-fruits, administered by an infusion pump
green vegetables whole grain and at a rate not to exceed 150 2. Alcohol withdrawal
cereals, milk,meat, nuts, seafoods. mg/min or 67mEq over 8hours.
3. DKA
2. Magnesium salts- -Magnesium sulfate still remains
4. Respiratory and metabolic
oral/parenteral the drug of choice to prevent
alkalosis
eclampsia.
3. Promotion of safety, protect
5. Hypomagnesemia
from injury -It has a CNS depressant action
which lessens the possibility of 6. Hypokalemia
4. Monitor for laryngeal stridor seizures.
7. Hyperparathyroidism
5. Correct underlying cause HYPERMAGNESEMIA
8. Hyperventilation
-Stridor: harsh sound produced by -magnesium excess
turbulent airflow through a partial -Hypophosphatemia may occur
destruction. -serum magnesium higher than during the administration of
2.7 mEq/L calories to patients ith severe
Milld hypomagnesemia can be
protein-calorie malnutrition (e.g.
corrected by diet alone. Principal Causes:
patient with anorexia nervosa or
dietary sources of magnesium
1. Oliguric phase renal failure alcoholism, older debilitated pts
incluse green leafy vegetables,
particularly when magnesium who are unable to eat.
nuts, seeds, legumes, whole
containing medication are
grains, seafoods and peanut butter -Marked hyppophosphatemia may
administered).
and cocoa. develop in malnourished pts who
2. Adrenal insufficiency received parenteral nutrition if the
Overt symptoms of
phosphorus loss is not corrected.
hypomagnesemia are treated with 3. Excessive IV Magnesium
parenteral administration of administration Clinical Manifestation:
magnesium.
4. DKA 1. Paresthesia
A bolus dose of magnesium
sulfate given too rapidly can 5. Hypothyroidism 2. Muscle weakness
3. Bone pain and tenderness impending hypocalcemia and  Femoral artery
monitoring for changes in urine
4. Chest pain output.  Radial is the most preferable
site used because:
5. Confusion 4. Administer vit. D preparations
such as Calcitriol as prescribed. 1. It is easy to access
Nursing Intervention:
ACID- BASE IMBALANCES 2. Not a deep artery w/c
1. gradual introduction of facilitate palpation
parenteral nutrition solution to
avoid rapid shifts of phosphorus 3. The artery has a collateral
into the cells.  Hydrogen ions are vital to life clood circulation
and health.
2. High phosphorus diet
 Hydrogen Ion concentration
3. With moderate is expressed as pH. pH below 7.35- ACIDOSIS
hypophosphatemia, supplements
such as Neutra-phos capsules, K-  Buffer is a substance that at Ph above 7.45- ALKALOSIS
Phos, and Fleet’s Phosphate Soda as a chemical sponge. If pH is 7 and below or 7.8 and
may be given as prescribed. above, death occurs.
- it soaks up or releases H ions to
HYPERPHOSPHATEMIA maintain stable pH. pCO2 below 35- ALKALOSIS
-Phosphorus excess CARBONIC ACID- PCO2 above 45- ACIDOSIS
BICARBONATE BUFFER
-serum phosphate level >5 mEq/L SYSTEM HCO3 below 22- ACIDOSIS
Causes: -present in ECF HCO3 above 26- alkalosis
1. Acute and chronic renal failure -carbonic acid is formed by the
2. Excessive intake of phosphorus combination of C02 & water  If pH and pCO2 are primarily
3. Vitamin D excess ( CO2 + H20= H2CO3) affected , respiratory acid-
base imbalances will result.
4. Respiratory and metabolic -20 parts bicarbonate: 1 part
acidosis carbonic acid  If ph and HCO3

5. Hypoparathyroidism -maintained by lungs & kidneys  Are primarily affected,

metabolic acid-base
*Renal Failure Phosphate Buffer System imbalances
-most common cause of -present in cells and ECF  will be experienced
hyperphosphatemia -active in thekidneys  The kidneys and lungs
Clinical Manifestations Protein Buffer System attempt to compensate one
another in maintaining acid-
1. Tetany -present in plasma and in cells base imbalance.
2. Tachycardia -Hgb is one of the proteins  In acid-base imbalances, the
3. Anorexia involved normal bicarbonate-carbonic
acid ration of 20:1 is lost
4. Nausea and vomiting -most plentiful buffer system
 The body attempts to
5. Muscle weakness compensate in an effort to
6. Signd and symptoms of  ABG ANALYSIS maintain the normal 20:1
hypocalcemia ratio
Normal values:
7. Hyperactive reflexes  In compensation, the kidneys
Blood PH- 7.35-7.45 attempt to compensate for
Nursing Interventions: pCO2- 35-45mmHg changes in blood CO2 by
making a corresponding
1. Instruct on low phosphorus diet HCO3- 22-26mEq/L adjustment in blood
if prescribed.
bicarbonate.
pO2- 80-100 mmHg
2. When appropriatem the nurse
 Normally, almost all the
instructs the patient to avoid
bicarbonate formed by the
phosphate-containing laxatives
Sites for obtaining ABG kidneys are retained.
and enemas.
 Radial artery  On the other hand, the lungs
3. Educate the pt about
attempt to compensate for
recognizing the signs of  Brachial artery abnormal changes in blood
 bicarbonate by making 2. Vomiting 4. Mental confusion
corresponding adjustment in
blood CO2 3. Gastric suctioning (gastric 5. Feeling of fullness in the head
lavage)
 Another compensatory 6. A decrease in the level of
mechanism for acid-base 4. Intestinal fistulas consciousness
imbalances is shifting of A common cause of metabolic 7. Hyperkalemia
hydrogen ions from ECF to alkalosis is vomiting or gastric
the ICF or vice versa. suction with loss of hydrogen and Nursing Interventions:

 METABOLIC ACIDOSIS chloride ions. 1. bronchodilators- reduces

(bicarbonate deficit) Clinical manifestations: bronchial spasms

-can be produced by a gain of 1. depressed breathing ( to 2. Adequate hydration0 2 to

hydrogen ions or a loss of conserve CO2) 3L/day
bicarbonate. 3. Place in semi-fowler’s position
2. Mental confusion
Causes: facilitates expansion of the chest
3. Dizziness wall
1. Diarrhea- direct loss of
bicarbonate 4. Numbness and tingling of 4. Na bicarbonate for ventricular
fingers or toes fibrillation or hperkalemia
2. Use of diuretics
5. Hypertonic muscles QUALITY AND SAFETY
3. Excessive administration of NURSING ALERT
chloride 6. Late: tetany, convulsions
-if the PACO2 is chronically
4. Early renal insufficiency 7. Hypokalemia gretaer than 50 mmHg (in COPD
5. Adminisrtation of parenteral Nursing Interventions: clients, the respiratory center
nutrition w/out bicarbonate becomes relatively insensitive to
1. PNSS IV CO2 as a respiratory stimulant,
Clinical Manifestations: 2. Carbonic Anhydrase Inhibitor leaving hypoxema as the major
(Diamax) to increase excretion of drive for respiration. Oxygen
1. Headache administration (more than 3L/min
bicarbonate by the kidneys
2. Confusion may remove the stimulus of
3. In hypokalemia, KCl as ordered hypoxemia and the patient
3. Hyperventilation - to decrease develops “cabon dioxide
the CO2 level as a compensatory 4. Protect from injury
narcosis” unless the situation is
action RESPIRATORY ACIDOSIS quickly reversed. Therefore
4. Hyperkalemia- result of the (carbonic acid excess) oxygen is administered only with
shift of potassium out of the cells. extreme caution.
-is always owing to inadequate
Nursing Interventions: excretion of C02 with inadequate TWO STIMULUS TO
ventilation (air flow) resulting in BREATHE:
1. treatment of underlying cause elevated plasma CO2
and restoration of electrolyte 1. Increased Carbon Dioxide
concentrations and consequently
balance increased levels of carbonic acid. 2. Decreased Oxygen
2. Sodium bicarbonate IV Causes: RESPIRATORY ALKALOSIS
3. Maintain good respiratory 1. Acute pulmonary edema (carbonic acid deficit)
function
2. Aspiration of a foreign object -is always caused by
4. Fulid replacement measure I hyperventilation, wich causes
and O 3. Atelectasis (lung collapse)
excessive “blowinf off” of CO2.
5. Protect from injury 4. Pneumothorax
Causes:
METABOLIC ALKALOSIS 5. Overdose of sedatives
1. extreme anxiety
(bicarbonate excess) 6. Sleep apnea
2. Hypoxemia
-can be produced by gain of 7. Morbid obesity
bicarbonate or a loss of hydrogen. 3. Early phase of salicylate
Clinical Manifestations: intoxication
Causes:
1. Tachycardia 4. Inappropriate ventilator settings
1. Excessive ingection of NaCO3
(soi=dium carbonate) or baking 2. Tachypnea Clinical manifestations:
soda
3. Hypertension
1. Lightheadedness- due to 1. Identify if it is acidosis or HCO3- 30 (alkalosis)
vasoconstrictiond snd decreased alkalosis (pH)
cerebral blood flow. -the client has METABOLIC
2. Identify if it is respiratory or ALKALOSIS
2. Inability to concentrate metabolic (CO2/HCO3)
3. Numbness and tingling- from 3. Identify if it compensated or
decreased calcium ionization uncompensated  IDENTIFY IF IT IS
COMPENSATED OR
4. Tinnitus -IDENTIFY IF IT IS ACIDOSIS UNCOMPENSATED
OR ALKALOSIS
5. Sometimes loss of -Our examples #1-4 are examples
consciousness Ex: 7.25- Acidosis (below 7.35) of UNCOMPENSATED ABGs.
Nursing Interventions: 7.55- Alkalosis (higher than -Uncompensated because even if
7.45) the client has respiratory problem,
1. Treat underlying cause the kidneys donot compensateby
2. If the cause is anxiety, the staying normal and even if the
patient is instructed to breathe  IDENTIFY IF IT IS client has metabolic problem, the
more slowly to allow CO2 to RESPIRATORY OR lungs do not compensate by
accumulate or to breathe into a METABOLIC ACIDOSIS staying normal.
closed system (such as paper bag) OR ALKALOSIS BY EXAMPLE #5:
USING CONCEPT
3. Anti- anxiety agent in very METHOD pH- 7.30 (acidosis)
anxious patients.
CONCEPT METHOD: PaCO2- 50 (acidosis)
-If PaCO2 is normal, HCO3 is HCO3- 32 (alkalosis)
 Anxiolytic- for short-term abnormal, the client has metabolic
relief of symptoms of anxiety problem. - the client has RESPIRATORY
ACIDOSIS, PARTIAL-
-Valium -If HCO3 is normal, PaCO2 is COMPENSATION since the pH
-Diazepam abnormal, the client has is abnormal.
respiratory problem
TOPIC 8 -partial because even though the
EXAMPLE #1: kidneys are compensating, it is
ARTERIAL BLOOD GASES not enough to bring the pH back
(ABG) pH- 7.30 (acidosis) to normal.
-measurements of acidity or PaCO2- 50 (acidosis) EXAMPLE #6:
alkalinity of the arterial blood HCO3- 24 (normal)
circulation. pH- 7.50 (alkalosis)
-the client has RESPIRATORY PaCO2- 52 (acidosis)
pH-acidity or alkalinity -7.35-7.45 ACIDOSIS
PaCO2-carbon dioxide-relate this HCO3- 34 (alkalosis)
EXAMPLE #2:
with “acid”- 35-45 -the client has METABOLIC
pH-7.52 (alkalosis) ALKALOSIS, PARTIAL
HC03-bicarbonate-relate with
“base”-22-26 PaCO2-28 (alkalosis) COMPENSATION since the pH
is abnormal.
PaO2- oxygen to check if patient HCO3-22 (normal)
has hypoxemia 80-100 EXAMPLE #7:
-the client has RESPIRATORY
beac ALKALOSIS pH- 7.35 (normal)

Note: EXAMPLE #3: PaCO2- 49 (acidosis)

-The amount of carbon dioxide is pH- 7.30 (acidosis) HCO3 - 30 (alkalosis)

directly proprtional to the number How would we know if the client
of hydrogen (H+) ions being PaCO2- 37 (normal)
has respiratory or metabolic
produced which is related to acid. HCO3-20 (acidosis) problem?
-the more CO2 in your blood, the -the client has METABOLIC TWO WAYS TO INTERPRET:
more acidic your blood is. ACIDOSIS
1. Know your patient’s diagnosis.
-the more HCO3 in your blood, EXAMPLE #4:
the more alkaline or basic your -If client came in respiratory
blood is. pH- 7.51 (alkalosis) problem like COPD for
PaCO2- 40 (normal) example, the client has
3-STEP ABG interpretation
RESPIRATORY ACIDOSIS, -NANDA includes diagnostic Cc/hr= TIV
FULL COMPENSATION. labels that relate to fluid and acid-
base imbalances. TTI
-If the client came with vomiting
or diarrhea meaning he/she is  Deficient Fluid Volume: BLOOD TRANSFUSION
losing acid therefore the client has Decreased intravascular, -is the introduction of whole
METABOLIC interstitial and /or ICF. This blood or blood components into
ALKALOSIS, FULL refers to dehydration and the venous circulation.
COMPENSATION water loss alone without
change in sodium. CULTURALLY COMPETENT
CARE
 Excess fluid volume:
EXAMPLE #7: Increased isotonic fluid -Jehovah’s Witnesses do not
pH- 7.35 (normal) retention receive blood or blood products.
Blood volume expanders are
PaCO2- 49 (acidosis)  Risk for Imbalance Fluid acceptable if they are not
Volume derivatives.
HCO3- 30 (alkalosis)
 Risk for Deficient Fluid -Christian Scientists donot
How would we know if the client Volume ordinarily use blood or blood
has resppiratory or metabolic products.
problem?  Impaired Gas Exchange:
Excess or deficit in NOTE:
oxygenation and/or carbon
dioxide elimination at the Once blood or a blood products is
-Full compensation because the removed from the refrigerator,
body compensate enough to bring alveolar-capillary membrane.
there is limited amount of time to
the pH back to normal.  Fluid, electrolyte and acid- administer it (e.g. packed RBCs
base imbalancs affect many should not hang more than 4
other body areas and as a hours after being removedfrom
 If no diagnosis, use consequence may be the the refrigerator).
alkalotic/acidic side. etiology of other nursing
diagnosis, such as: CLINICAL ALERT
 7.35-7.39- acidic (N)
 Impaired skin integrity -Normal saline should always be
 7.41-7.45- alkalotic (N) used when giving a blood
related to dehydration and/or
edema. transfusion. No other IV solutions
should be administered wih blood
 If no diagnosis, use  Ineffective Tissue Perfusion they may cause the blood cells to
alkalotic/acidic side related to decreased cardiac clump or cause clotting.
output secomdary to fluid
 7.35- 7.39- acidic (n) volume deficit or edema. -If the client has an infusion of
dextrose, stop that infusion and
 7.41- 7.45 - alkalotic (n)  Decreased Cardiac Output flush the line with saline prior to
pH-7.35 (normal) related to hypovolemia and/or initiating the transfusion.
cardiac dysrhythmias
PaCO2 - 49 (acidosis) secondary to electrolyte Blood is usually administered
imbalance through a #18 to #20-gauge IV
HCO3- 30 (alkalosis) needle or catheter.
-the client has Respiratory (N) (K or Mg).
TRANSFUSION REACTIONS:
Acidosis, Full Compensation EXAMPLE OF A NURSING
DIAGNOSIS 1. Hemolytic reaction:
EXAMPLE #8 incompability b/w client’s blood
pH- 7.44 (normal)  Deficient Fluid Volume and donor’s blood
related to nausea, vomiting
PaCO2- 48 (acidosis) and diarrhea as evidenced by Clinical Signs:
decreased urine output,  Chills, fever, headache,
HCO3- 32 (alkalosis)
increased urine backache, dyspnea, cyanosis,
-the client has METABOLIC (N) concentration,weaknessm chest pain, cyanosis, chest
ALKALOSIS, fever, decreased skin turgor, pain, tachycardia &
dry mucous membranes, hypotension
Full Compensation increased pulse rate and
DIAGNOSING: decreased BP. Nursing Interventions:
Ggts.min= TIV x DF 1. Discontiinue the tranfusion
immediately
TTI x 60 MINS.
2. Maintain vascular access with 4. Monitor VS. Administer FLUID AND ELECTROLYTE
normal saline cardiopulmonary resuscitation if IMBALANCES IN KIDNEY
needed. DISORDERS
3. Notify the physician
immediately. 5. Administer medication and/or -Patients with kidney disorders
oxygen as ordered. commonly experience fluid and
4. Monitor VS electrolyte imbalances and require
6.bCirculatory Overload: blood careful assessment and close
5. Monitor fluid intake and output administered faster than the monitoring for signs of potential
6. Send the remaining blood bag, circulation can accommodate. problems.
filter tubing, a sample of client’s Clinical signs:
blood and a urine sample to th QUALITY AND SAFETY
laboratory.  Cough, dyspnea, crackles NURSING ALERT
(rales), distended neck vein, -the most accurate indicator of
2. Febrile reaction: sensitivity of
the client’s blood to WBCs, tachycardia, hypertension fluid loss or gain in an acutely ill
platelets or plasma proteins. patient is WEIGHT.
NURSING INTERVENTIONS:
Clinical Signs: -A 1-kg weight gain is equal to 1
1. Place the client upright liter of 1000ml of retained fluid.
 Fever, chills, warm, flushed (MHBR), withfeet dependent to
skin, headache, anxiety, decrease venous return. CHRONIC KIDNEY DISEASE
muscle pain (CKD)
2. Stop or slow the transfusion.
NURSING INTERVENTIONS: -an umbrella term that describes
3. Notify the physician kidney damage or a decrease in
1. Discontinue the tranfusion the glomerular filtration rate
immediately 4. Administer diuretics and
oxygen as ordered. (GFR) lasting for 3 or more
2. Give antipyretics as ordered months.
5. . Sepsis: contaminated blood
3. Notify the physician administered RISK FACTORS OF CKD:

4. Keep the vein open with a Clinical Signs: 1. Cardiovascular disease

normal saline infusion. 2. Diabetes
 High fever, chills, vomiting,
5.Allergic reaction (mild): diarrhea, hypotension 3. Hypertension
sensitivity to infused plasma
protein NURSING INTERVENTIONS: 4. Obesity
Clinical Signs: 1. Stop the transfusion DIABETES is the primary cause
2. Keep the vein open with a of CKD
 Flushing, itching, urticaria,
bronchial wheezing normal saline infusion -more than 35% of the US
3. Notify the physician population aged 20 years and
NURSING INTERVENTIONS: older with diabetes have CKD
1. Stop or slow the transfusion, 4. Administer IV fluids, (Centers for Disease Control,
depending on agency protocol antibiotics as ordered 2014)

2. Notify the physician 5. Obtain a blood specimen from -is the leading cause of Renal
the client for culture. Failure (RF) in patients starting
3. Administer medication renal replacement therapy (RRT)
(antihistamine) as ordered. 6. Send th remaning blood and
tubing to the laboratory. -the second leading cause is
4. Allergic Reaction (severe)- HYPERTENSION, followed by
antibody-antigen reaction CONCEPT MAP OF FLUID
GLUMERULONEPHRITIS and
VOLUME DEFICIT
PYELONEPHRITIS:
Clinical Signs:
*insert image* POLYCYSTIC, HEREDITARY
 Dyspnea, chest pain, OR CONGENITAL
circulatory collapse, cardiac CONCEPT MAP OF FLUID DISORDERS AND RENAL
arrest. VOLUME EXCESS CANCERS
NURSING INTERVENTIONS: *insert image* -more than 20% of the US
CONCEPT MAP OF population aged 20years and older
1. Stop the transfusions with hypertension have CKD
HYPERKALEMIA
2. Keep the vein open with PATHOPHYSIOLOGY OF CKS
normal saline *insert image*
-In early stages of CKD, there can
3. Notify the physician be significant damage to the
kidneys without signs or Clinical Manifestations: completion of fluid balance charts
symptoms on different wards, found the
1. Elevated serum creatinine major reasons fluid balance charts
-the pathophysiology of CKD is levels indicate underlying kidney were not completed appropriately
not yet clearly understood but the disease as the creatinine level were staff shortage, lack of
damage to the kidneys is thought increases, symptoms of CKD training, and lack of time.
to be caused by PROLONGED begin.
ACUTE INFLAMMATION that
is not organ specific (serum creatinine - best indicator
of kidney/renal function) Accroding to the nursing and
STAGES OF CKD midwifery council (2007), record
2. Anemia due to decreased keeping is an integral part of
-stages are based on GFR. The erythropioetin production by the
normal GFR is 125mL/min kidney nursing care, not something to be
“fitted in” where circumstances
Stage 1 3. Metabolic acidosis allow. It is the responsibility of
GFR ≥ 90mL/mi 4. Abnormalities in calcium and the nurse caring for a patient to
phosphorus ensure observations and fluid
Kidney damage with normal or
increased GFR 5. Fluid retention evidenced by balance are recorded in a timely
both edema and congestive heart manner, with any abnormal
Stage 2 failure. findings documented and reported
GFR= 60-89 mL/min to the nurse in charge. The use of
Mild decrease in GFR Anasarca- generalized edema fluid balance charts the show
Stage 3 cumulative input and output is
ASSESMENT AND now being debated in the
GFR= 30-59mL/min DIAGNOSTIC FINDINGS: literature
Moderate decrease in GFR GFR is the amount of plasma (Bennet, 2010). A recent study bu
filtered through the glomeruli per Perren et al (2011) suggested that
Stage 4 unit of time. for a large proportion of
GFR=15-29mL/min MEDICAL MANAGEMENT: patients, especially those in
Severe decrease in GFR 1. Treat underlying causes critical care, cumulative fluid
balance charts are not accurate
Stage 5 2. Keep the BP below and their
GFR < 15mL/min 130/80mmHg
use should be questioned.
End-stage kidney disease or CKD 3. Early referral for initiation of
RRT - METHODOLOgy
CREATININE- is an endogenous - a survey approach was used for
waste product of skeletal muscle 4. Treat hyperglycemia
the study. The structured
that is filtered at the glomerulus. 5. Manage anemia (w/ Ferrous knowledge questionnaire was
-creatinine clearance is a good Sulfate supplement) adopted to
measure of the GFR TOPIC 9 collect the data to assess the
-to calculate creatinine clearance, knowledge of staff nurses in fluid
Evidence-base practice (EBP) on
a 24hr urine specimen is collected and electrolyte administration.
fluid and electrolytes sharing.
The
-midway through the collection, A study to assess the knowledge
the serum creatinince level is sample size was forty. The
and practices of staff nurses
measured. structured knowledge
regarding fluid and electrolytes
questionnaire consisted of 15
Creatinince Clearance= administration in post op cardiac
questions and the
surgical ICU and Cardiac surgical
Volume of urine (mL/min)Urine ward. time taken for the completion was
creatinine (mL/dL) about 10minutes.
Serum creatine Cellular Abberation
Monitoring a patient’s fluid
-is the best approximation of renal balance to prevent dehydration or CANCER
function. overdehydration is relatively
simple task, but fluid balance - is a large group of disease
-the typical reference range for characterized by uncontrolled
recording is notorious for being
serum creatinine is 60 to 100 growth and spread of abnormal
inadequate or inaccurate
micromoles per liter completed, which audited the cells.
- ONCOLOGY NURSING is also 2. Breast and differ in shape and
known CANCER NURSING. organization with respect to their
3. Colorectal cancer- due to food cells of origin) is associated with
EPIDEMIOLOGY we eat- most cancer occur in older
adults; according to the American increased malignant potential.
- in 2015, nearly 700,00 new Cancer Society(ACS), 78% of all
cancer cases were diagnosed. CARCINOGENESIS
cancer diagnoses are in people 55
- in the same year, nearly years of age or older (2015). > molecular process
600,000Americans died as a result
pf cancer. - OVERALL, the incidence of > Malignant transformation, or
cancer is higher in men than in carcinogenesis, is thought to be at
- despite significant advances in women. least a three-step cellular process,
science and technology, cancer is
the second leading cause of PATHOPHYSIOLOGY OF THE involving INITIATION.,
MALIGNANT PROCESS PROMOTION, and
death in the united States In 2015. PROGRESSION.
- Cancer is a disease process that
- the global cancer burden is begins when a cell is transformed CARCINOGENS
estimated to have risen to 18.1 bu genetic mutations of the
million new cases and 9.6 million > an agents that initiate or
CELLULAR promote malignant
deaths in 2018, according to new DEOXYRIBONUCLEIC ACID transformation.
report released by the (DNA).
International Agency For > substances that can cause
Research on - Genetic mutations may be cancer.
inherited and/or acquired, leading * During INITIATION,
Cancer (IARCH). to abnormal cell behavior. carcinogens such as
- the report said 1 in 5 men and 1 *THE INITIAL GENETICALLY CHEMICALS, PHYSICAL
in 6 women worldwide develop ALTERED CELL FORMS A FACTORS, or
cancer during their lifetime, and 1 CLONE AND BEGINS TO BIOLOGICAL AGENTS, cause
in 8 men and 1 in 11 women die PROLIFERATE mutations in the cellular DNA.
from the disease. Worldwide, the
total number of people who are ABNORMALLY, * Normally, these alterations are
reversed by DNA repair
alive within 5 years of a cancer EVADING mechanism or the changes initiate
prevalence, is estimated to be
43.8million. NORMAL programmed cellular death
(Apoptosis) or cell senescence.
- Cancers of the kung and female INTRACELLULAR
breast are the leading types * Cells can escape these
AND protective mechanisms with
worldwide in terms of the number
of EXTRACELLULAR GROWTH- permanent cellular mutations
REGULATING PROCESSES occurring, but
new cases. “For each of these OR SIGNALS AS WELL AS
types, approximately 2.1 million these mutations usually are not
diagnoses are estimated in 2018, THE IMMUNE SYSTEM signiicant to cells until the second
DEFENSE MECHANISMS OF step of carcinogenesis.* during
contributing about 11.6 percent of THE BODY. PROMOTION, repeated exposure
the total cancer incidence to promoting agents (co-
burden.” * GENETIC MUTATIONS MAY carcinogens) causes
LEAD TO ABNORMALITIES
THE LEADING CAUSES OF IN CELL SIGNALING proliferation and expansion of
CANCER DEATH IN THE U.S initiated cells with increased
IN ORDER OF FREQUENCY TRANSDUCTION expression or manifestations of
PROCESSES( signals from
AND LOCATION IN MEN outside and within cells that turn abnormal genetic information,
ARE: cell activities even after long latency periods.
1. Lung either on or off) that can in turn > Promoting agents are not
lead to cancer development. mutagenic and do not need to
2. Prostate interact with the DNA.
3. Colorectal * THE DEGREE OF
ANAPLASIA (a pattern of > latency periods for the
IN WOMEN: growth in which cells lack normal promotion of cellular mutations
characteristics vary with the type of agent, the
1. Lung dosage pf
the promoter, and the innate Examples of these viruses that are deaths.
characteristics and genetic known to cause cancer include:
stability of the target cell. 2. SMOKING
• HUMAN
> the promotion phase generally PAPILLOMAVIRUS(HPV) - is strongly associated with
leads to the formation of cervical and head and nexk cancers of the lungs, head and
PRENEOPLASTIC or benign cancers. neck, esophagus, stomach,
pancreas,
(noncancerous) lesion. • HEPATITIS B VIRUS (HBV)
liver cancer cervix, kidney, and bladder and
* During PROGRESSION, the with acute myeloblastic leukemia.
altered cells exhibit increasingly • EIPATEIN-BARR VIRUS
malignant behavior. These cells (EBV) burkitt lymphoma and - passive smoke or secondhand
nasopharyngeal cancer. smoke has been linked to lung
acquire the ability to stimulate cancer; nonsmoker who kive woth
ANGIOGENESIS (growth of new *There is a little evidence to a
blood vessels that allow cancer support the link of most bacteria
to cancer, although smoker have about a 20-30%
cells to grow), to invade adjacent chronicinflammatory reactions to greater risk of developing lung
tissues, and to metastasize. bacteria and the production of camcer.
PATHOGENESIS PF CANCER carcinogenic metabolites are - there is evidence that passive
possible smoke may be linked with
1. Cellular Transformation and childhood leukemia and cancers
Derangement theory mechanism that continue to be
investigated. of the
- conceptualizes that normal cells larynx, pharynx, brain, bladder,
may be transformed into cancer *HELICOBACTER PYLORI is
one bacterium identified as rectum, stomach and breast.
cells due to exposure to some
significant cause of gastric cancer. - the extensive list of suspected
etiologic agents. chemical substances continues to
2. Physical agents
2. FAILURE OF THE IMMUNE grow and include:
RESPONSE THEORY 3. Chemicals
1. AROMATIC AMINES AND
- advocates that all individuals 4. Genetic of familial factors ANILINE DYES
possess cancer cells. However, 5. Lifestyle factors 2. PESTICIDES AND
the cancer cells are recognized FORMALDEHYDES
6. Hormones
by the immune response system. 3. ARSENIC, SOOT, AND
So, the cancer cell undergo PHYSICAL AGENTS TARS
destruction. Failure of the
immune physical factors associated with 4. ASBESTOS
carcinogenesis include:
response system leads to inability 5. BENZENE
to destroy the cancer cells. • exposure to sunlight
6. CADMIUM
ETIOLOGY • radiation
7. CHROMIUM COMPOUNDS
- factors known to induce • Chronic irritation of
carcinogenesis include: could inflammation 8. NICKEL AND ZINC ORES
possible cause cancer • tobacco carcinogens 9. WOOD DUST
1. Viruses and bacteria • industrial chemicals and 10. BERYLLIUM
> it is estimated that about 11% of asbestos COMPOUNDS
all cancers worldwide are kinked Chemical Agents 11. POLYVINYL CHLORIDE
to viral infections ( schiller and
> many cancers are thought to be - Betel nut and lime, which are
lowy, 2014). related to environmental factors. chewed as stimulants in some
> after infecting individuals, DNA Most hazardous chemicals cultures, are also included.
viruses insert a part of their own produce their toxic effects by GENETICS AND FAMILIAL
DNA near the infected cell altering DNA structure. FACTORS> approximately 5-
genes causing cell division. 10% of cancers in adults display a
1. TOBACCO SMOKE pattern of cancers suggestive of a
> the newly formed cells that now - thought to be the single most familial
carrying viral DNA lack normal lethal chemical carcinogen,
controls on growth. predispositions.
accounts for about pne third of
cancer
> Examples include hereditary * Multiple studies have long - studies have linked obesity to
breast and ovarian cancer linked sedentary lifestyle and lack breast and colorectal cancer.
syndrome and multiple endcrine of regular exercise to cancel
neoplasia *Continuous UNMANAGED
development. STRESS that keeps hormones
syndrome (MEN1 and MEN2). such as EPINEPHRINE AND
* SITTING DISEASE - the
- other cancers associated woth negative effects of an over- CORTISOL at high levels can
familial inheritance syndromws sedentary lifestyle result in SYSTEMIC
include: “FATIGUE” and IMPAIRED
> increased risk of chronic
1. NEPHROBLASTOMAS diseases, organ damage, spine IMMUNOLOGIC
damage, muscle degeneration, leg SURVEILLANCE.
2. PHEOCHROMOCYTOMAS
disorders. 5. HEREDITY
3. COLORECTAL CANCER
>3 hours. > greater risk with positive family
4. STOMACH CANCER history
*HORMONAL AGENTS*
5. THYROID CANCER 6. OCCUPATION
> hormonal changes related to the
6. RENAL CANCER female reproductive cycle are also > e.g Chemical factory workers,
7. PROSTATE CANCER associated with cancer farmers (too much sun exposure),
radiology/dept. personnel
8. LUNG CANCER incidence. Early onset of menses
before age 12 and delayed onset 7. URBAN vs. RURAL
LIFESTYLE FACTORS of menopause after age 55, NULL RESIDENCE
> approximately one quarter to PARITY (never giving birth), and > cancer is most common among
one third of all cancers in the U.S delayed childbirth after age 30 are urban dwellers that rural residents
have been linked to lifestyle all associated with an BECAUSE OF GREATER
factors, such as: increased risk of breast cancer. EXPOSURE TO
1. DIET Increased numbers of pregnancies CARCINOGENS).
ate associated with a decreased
2. OBESITY is also associated 8. PRECANCEROUS LESIONS
with an increased risk for cancers incidence of breast, endometrial,
and ovarian > may undergo transformation
of the pancreas, galbladder, into cancer lesions and tumors.
cancers.PREDISPOSING
thyroid, ovary, and cervix, and for FACTORS > E.g Pigmented moles, burn
multiple myeloma, hodgkin scars, senile keratosis,
lymphoma, and and aggressive 1. AGE
leukoplakia, benign
form > older individuals are more polyps/adenoma of the
of prosttate cancer. prone to cancer. They have more
exposure to carcinogens. colon or stomach, fibrocystic
3. INSUFFICIENT PHYSICAL disease of the breast.
ACTIVITY 2. SEX
9. GEOGRAPHIC
*these factors are second only to > women- more probe to breast DISTRIBUTION
tobacco use as major risk factors cancer, uterus and cervix cancer.
> E.g cancer of the stomach in
associated with cancer > Men- more prone to prostate japan, cancer of the breast in U. S.
development. and lungs cancer.
> due to influence of
> dietary substances that appear to 3. STRESS environmental factors as national
increase the risk of cancer diet, ethnic customs and type of
- DEPRESSION, grief, anger, pollutions.
include: aggression, despair pr life stresses
1. FATS decrease immunocompetence 10. RACE

2. ALCOHOL (affects hypothalamus and > cancer can effect any pollution.
pituitary gland).
3. SALT-cured or smoked meats > However, African-Americans
- immunodeficiency may spur the experience a higher rate of cancer
4. NITRATE- and nitrite growth and proliferation of cancer than any other racial or ethnic
containing foods. cells.
group.AMERICAN CANCER
5. RED AND PROCESSED 4. OBESITY SOCIETY’s WARNING SIGNS
MEATS. OF CANCER
C- change in bowel or bladder While increasing stress may be Defined as an abnormal mass of
habits inevitable, traditional support tissues that serve no useful
structures within the family and purpose & may harm the host
A- a sore that does not heal community ought to be organism
U- unusual bleeding or discharge strengthened and new institutional
mechanism established to help Tumors are named according to
U- unexplained sudden weight individuals and families cope with tissue from which they arise
loss day to day stress. Almost all tumors end in –OMA
U- unexplained anemia Cancer promoting agents Classification of Neoplasms
T- thickening or lump in the should be avoided
1. Benign
breast or elsewhere Cigarette smoke is the most
pervasive cancer causing 2. Malignant
I- indigestion or difficulty in
swallowing substances. Benign
O- obvious change in wart or The numerous carcinogenic -A condition capable of disturbing
mole agents found in cigarette smoke the function of an organ: without
cause cancers of the lung, mouth, endangering the life of an
N- nagging cough or hoarseness pharynx, larynx, esophagus other individual
of voice. cancers and other acute and
chronic disease. -comes from the lating word
Normal range hemoglobin BENE meaning GOOD
-The damage is not inflicted on
women- 12-16 grams per Dc/L -GENUS meaning SORT thus
the smoker alone but on everyone
men- 13-18 grams dc/L who inhales cigarette smoke benign tumor is good sort of
(second hand smoke (SHS) or tumor
TOPIC 10 passive smoking).
Malignant
At least 1/3 all caners can be -High alohol consumption also
prevented. -Resistant to treatment & of fatal
increase the risk of many cancers.
nature, having the property of
Cancer protecting mechanism -Betel-quid chewing causes uncontrollable growth &
prevent cancer. cancer of the mouth and this habit dissemination capable of
-A healthy lifestyle that is started should be avoided. metastasizing.
in childhood, particularly eating a -Hepatitis B virus (HBV) is the Characteristics of Benign and
HEALTHY DIET, maintaining most common cause of liver Malignant tumor
PHYSICAL FITNESS AND concern in the Philippines.
MINIMIZING/PROPERLY Cell Characteristics
COPING with STRESS may HBV vaccination should prevent
Benign- Well-differentiated cells
decrease the risk of cancer, majority of liver cancer in the
mature cells function poorly.
coronary artery disease, country
hypertension, stroke and diabetes Malignant-Cells are poorly
Human papilloma virus (HPV)
differentiated (anaplastic type)
-A healthy diet is low in animal causes cancer of the uterine cervix
fat, rich in starchy foods (such as and is transmitted through sexual Mode of Growth
cereals, tubers and pulses) with intercourse.
substantial fruits and vegetables. Benign- Remains localized
Safe sex, including the use of
-An unhealthy diet is rich in fat, barrier protective devices such as Malignant- Infiltrates
salt and free sugars, and/or in condoms is currently the most surrounding tissues
smoked salt-pickled-preserved effective means of preventing Speed of Growth
foods. sexually transmitted disease.
Benign- Grows slowly
-Physical fitness is achieved Ultraviolet rays from the sun are
through a lifelong active lifestyle. capable of causing skin cancer Malignant- Grows rapidly
particularly in fair-skinned CAPSULE
-Physically fit individuals are not persons. Excessive sun exposure
overweight, quite productive, with should be avoided and the use of Benign- Encapsulated
high self-esteem, and successful umbrellas wide-brimmed hats and
in coping with stress. Malignant- Not encapsulated
sun-block preparations ought o be
Increasing mental, social encouraged. METASTASIS
psychological and spiritual stress Neoplasms Benign- Never occurs
seems to accompany economic
progress and at the same time Derived from the greek “NEOS” Malignant- Very common
coping mechanism are eroded. new and “PLASIS” molding
RECURRENCE Stage I- The tumor is less than - In general, a lower grade
2cm (0.8 inches) and is not indicates a slower-growing cancer
Benign- Extremely unusual when spreading and a higher grade indicates a
surgically removed faster-growing one.
‘Stage II- the tumor in 2-5cm
Malignant- Common following (0.8-1.97 inches) with or without Grading
surgery lymph node involvement and has
not spread The grading system that is usually
Effect of Neoplasm used is as follows:
Benign- Not harmful to host Stage III- the tumor is larger than
5cm (1.97 inches) but fixed either Grade I - Cancer cells that
Malignant- always harmful to chest wall muscle or skin or has resemble normal cells and aren’t
spread to lymph nodes above the growing rapidly.
PROGNOSIS
collarbone. Grade II- Cancer cells that don’t
Benign- very good prognosis look like normal cells and are
Stage IV- the tumor in any size it
Malignant- Poor prognosis may affect the lymph nodes but growing faster than normal cells
has definitely spread to other parts Grade III- Cancer cells that look
Benign Neoplasm
of the body. abnormal and may grow or spread
Fibromas- found in fibrous tissue more aggressively.
4 basic stages of Cancer
frequently in uterus cause no
manifestations unless, because of 1. Cancer cells microscopic The TNM system
their location, they press on a The American joint committee
bone or nerve 2. Cancer in large enough to the
felt as a lump on cancer (AJCC) and the
Lipomas- Arises in adipose international union for cancer
tissues may expert pressure on 3. Cancer has spread from the control (UICC) maintain the
surrounding tissue as they expand. original sites in surrounding areas TNM classification system as a
tool for doctors to stage different
Leiomyomas- smooth muscles 4. Cancer has spread to the other types of cancer based on certain
origin may develop anywhere in tissue parts of the body. standards. It’s reviewed every 6 to
the body but usual they grow in Grading-Is the pathologic 8 year to include advances in our
the uterus. classification of tumor cells understanding of cancer.
Malignant Neoplasm Grading system In the TNM system each cancers
is assigned a letter or number of
Carcinoma in situ- neoplasm in Seek to defined the type of tissue the described the tumor, node and
epithelial cells that remains from which the tumor originated metastases.
confined to the site of origin. and the degree to which the tumor
cells retain the function and -T stands for tumor. It is based
Fibrosarcoma- Bulky well-
histologic characteristics of the on the size the original ( primary)
differentiated tumor masses in the
tissue of origin (differentiated) tumor and whether it has growth
connective tissues
into nearby tissues
Bronchogenic carcinoma- Samples of cells used to establish
the tumor grade may be obtained - N stand for nodes, it tells
Usually develop in the lower
from tissue scraping, body fluids, whether the cancer has spread to
trachea (can readily metastasize)
secretions, washings, biopsy or the nearby lymph nodes.
TUMOR STAGING AND surgical excision. - M stands for metastasis, it tells
GRADING
Grading whether the cancer has spread to
Treatment options and prognosis distant parts of the body
are based on tumor stage and -refers to the classification of
tumor cells The TNM system
grade
- Seeks to defined the type of The T category describes the
Staging
tissue from which the tumor original (primary) tumor the
-determines the size of the tumor, originated tumor size is usually measured in
the existence of local invasion, centimeters or cm ( 2 and 1 half
lymph node involvement, and -Help us understand how cm= about 1 inch or millimeters
distant metastasis aggressive or malignant a tumor or mm(10mm=1cm)
is.
Stating of Cancer Tx means the tumor can’t be
-It describe the appearance of the measured
Stage 0- Indicates that the cancer cancerous cell
is where it started (in situ) and is T0 means there is no evidence of
not spreading -The grade of a cancer depends on primary tumor it cannot be found
what the cells look like under a
microscope.
-Tis means that the cancer cells Tx- Primary tumor cannot be evidence of anemia due to chronic
are only growing in the most assessed blood loss
superficial layer of tissue, without
growing into deeper tissues. This T0- No evidence of primary -Occult-blood screening test for
may also be called in situ cancer tumor bowel or gastric cancer.
or pre-cancer. Tis- Carcinoma in situ T1, -Blood in the urine-feature of
The number after the T- T2,T3,T4 incresing size and local cancer of the kidney or bladder.
T1,T2,T3 and T4- described the extent of the primary tumor
Bleeding
tumor size and amount of spread REGIONAL LYMPH NODES
into nearby structure. The higher -Internal cancers-stomach, bowel,
the T number the larger the tumor Nx- Regional lymph nodes cannot kidney, bladder, uterus, or lung
and the more it has growth in be assessed. bleeding is often the one of the
nearby tissues. earliest feature,
N0- No regional lymph nodes
T1-5CM decrease: T2-6-9cm: metastasis -Bleeding from the bowel (fresh
T3-1-15 cm 14-15cm increase or dark, red) urine,sputum or mole
N1,N2,N3 Increasing in the skin.
-The N category describes involvement of regional lymph
whether the cancer has spread into nodes -May be an indicator but it does
nearby lymph nodes. not necessarily mean cancer
DISTANT METASTASIS
NX means the nearby lymph LYMPH NODES
Mx- Distant metastasis cannot be ENLARGEMENT
nodes cannot be evaluated assessed
-N0 means nearby lymph nodes -Evidence of metastasis spread of
M0- No distant metastasis cancer may be revealed by
do not contain cancer
M1- Distant metastasis examination of the draining
-Numbers after the N- N1, N2 and lymph nodes areas.
N3- describe the size locations
and the number of lymph nodes -Example: Head and neck CA-
Sign and symptoms of cancer: submandibular, submental and
involve. The higher the N
local and general cervical nodes must be examined.
number,The more lymph nodes
there are that contain cancer. LUMP -Breast cancer of the skin of the
-The M category tells whether -Caner lumps usually harder than arm or chest wall is suspected
there are distant metastases lumps from other causes, not axillary lymph nodes.
( spead of cancer to other parts of cystic and not tender unless quite -CA in lower limb, lower back,
body) advanced scrotum, anus, or vulva-inguinal
-MX means metastasis cannot be - Lump adhere to and invade lymph node
evaluate nearby structures therefore PAIN
becomes less
-M0 means that no distant cancer -Most cancers are painless in their
spread was found. Ulcer early stages
-M1 means that the cancer has -Malignant ulcers often have - Pain may developed after tumor
spread to distant organs or tissues raised or heaped up edges. has become big enough to invade
(Distant) metastases were found). or press upon and damage
-Tend to grow into nearby tissues
TUMOR, NODES, AND on which they lie and there is surrounding tissues or nerves
METASTASES (TNM) usually surrounding swelling and - Small painless lump is more
induration likely to be a cancer than a small
-is one system used to describe
many solid tumor -Malignant ulcer in the mouth and painful lump- people should not
throat-tender in the later stage. wait for pain to develop before
TNM CLASIFICATION seeking medical advice.
SYSTEM -Any such ulcer may be of
potential concern if it has been Weight loss
T- The extent of primary tumor
present for more than 2-3 weeks -Approximately 2/3 of cancer
N- The absence or presence and with no evidence of healing patients will experience weight
extent of regional lymph node loss first symptoms that prompt
BLEEDING AND EVIDENCE
metastasis them to visit their doctor
OF BLOOD LOSS
M- The absence or presence of - Involuntary weight loss and
-There may be obvious blood loss
distal metastasis greater than 5 % in 6 months
or hidden (occult) blood loss with
PRIMARY TUMOR often prognostic indicator for
cancer
- Due to cancer cachexia (look CA in colon – changes in bowel .
gaunt and malnourished)- cause habits c
by tumor metabolically adapted to
the anaerobic utilization of CA in prostate- Interferes with
glucose (glycolysis) such that it passage of urine
consumes a lot of glucose & CA of bladder- difficulty or
produce a lot of lactid acid frequency of passing urine
Interference with tissue op organ CA of the lungs- persistent cough
function
CA of the liver, bile ducts or
-vary a great deal depending upon pancreas- may block flow of the
the site of a cancer bile from liver causing jaundice
- Examples: CA is mouth or
throat make speaking or
swallowing difficult
CA in larynx usually cause
hoarseness or change in voice
CA in stomach- difficulty with
eating or change in appetite or
vomiting