Genitourinary Emergencies

CHAPTER 17 Genitourinary Emergencies

Kathleen Sanders Jordan, RN, MSN, FNP, APRN, BC

General Strategy

Analysis: Differential Nursing Diagnoses/Collaborative Problems

Planning and Implementation/Interventions

Evaluation and Ongoing Monitoring

Documentation of Interventions and Patient Response

Age-Related Considerations

Specific Genitourinary Emergencies

Acute Renal Failure

Urinary Tract Infection

Urinary Calculi

Testicular Torsion

I. GENERAL STRATEGY

A. Assessment

1. Primary and secondary assessment/resuscitation (see Chapter 1)

2. Focused assessment

a. Subjective data collection

1) History of present illness/chief complaint

a) Pain: PQRST (see Chapter 9)

(2) Abdominal, flank, or back

(3) Testicular, scrotal, groin

b) Change in urine/urinary elimination patterns

(1) Frequency, dysuria, urgency

(4) Oliguria/anuria

(5) Dribbling/incontinence, difficulty initiating stream, enuresis, nocturia

c) Discharge: vaginal, urethral, rectal (onset, color, character, odor, amount)

d) Injury: mechanism (see Chapter 30), prehospital treatment, previous injuries, use of foreign objects

e) Fever and chills

f) Change in eating/feeding patterns (nausea, vomiting, anorexia)

g) Tissue/skin changes (swelling, rash, turgor, deformity, pallor/cyanosis, open wounds)

h) Lethargy or irritability

i) Sexual history (active, orientation, safe sex practices)

j) Efforts to relieve symptoms

(1) Home remedies

(2) Alternative therapies

(3) Medications

(a) Prescription

(b) Over-the-counter

b. Objective data collection

1) General appearance

a) Level of consciousness, behavior, affect

f) Level of distress/discomfort

a) Guarding with movement

b) Wound: open or closed

c) Presence of visible foreign objects

d) Presence of discharge, bleeding, inflammation, rash, lesions

3) Auscultation

a) Bowel sounds

b) Breath sounds

c) Fetal heart tones if pregnant

3. Diagnostic procedures

a. Laboratory studies

1) Urine dipstick: blood, leukocytes, nitrite

2) Urinalysis; pregnancy test in female patients of childbearing age

3) Urine culture and sensitivity

4) Renal stone analysis

5) Complete blood count (CBC) with differential

6) Serum chemistries including glucose, blood urea nitrogen (BUN), and creatinine

7) Liver function tests

8) Arterial blood gas (ABG) determination

9) Coagulation profile: prothrombin time (PT), partial thromboplastin time (PTT)

10) Serology: syphilis and human immunodeficiency virus (HIV) infection

11) Gram stain of discharge

12) Gonococcus (GC) culture

13) Chlamydia culture

14) Wet mount of discharge: saline and potassium hydroxide (KOH)

b. Imaging studies

1) Abdominal: kidney, urethra, bladder (KUB) radiograph

2) Retrograde urethrogram

4) Intravenous (IV) pyelogram (IVP)

6) Computed tomography scan (CT)

7) Magnetic resonance imaging (MRI)

8) Renal arteriogram

9) Doppler studies

1) 12- to15-lead electrocardiogram (ECG)

B. Analysis: Differential Nursing Diagnoses/Collaboration Problems

1. Ineffective breathing pattern

2. Impaired tissue perfusion

3. Acute pain

4. Excess fluid volume

5. Deficient fluid volume

6. Deficient knowledge

8. Impaired urinary elimination

9. Risk for infection

C. Planning and Implementation/Interventions

1. Determine priorities of care

a. Maintain airway, breathing, and circulation (seeChapter 1)

b. Provide supplemental oxygen as indicated

c. Establish IV access for administration of crystalloid fluid/medications as needed

d. Obtain and set up equipment and supplies

e. Prepare for/assist with medical interventions

f. Administer pharmacologic therapy as ordered

2. Relieve anxiety/apprehension

3. Allow significant others to remain with patient if supportive

4. Educate patient and significant others

D. Evaluation and Ongoing Monitoring (see Appendix B)

1. Continuously monitor and treat as indicated

2. Monitor patient response/outcomes, and modify nursing care plan as appropriate

3. If positive outcomes are not demonstrated, reevaluate assessment and/or plan of care

E. Documentation of Interventions and Patient Response

F. Age-Related Considerations

1. Pediatric

a. Growth or development related

1) Symptoms of urinary tract infection (UTI) in younger children are often nonspecific. The prevalence of UTIs in girls aged 2 months to 2 years is twice that of boys and must be a consideration in febrile illness without a source

2) Catheterization or suprapubic bladder aspiration should be used to obtain urine in boys younger than 6 months of age and girls younger than 2 years of age. A normal urinalysis does not exclude UTI or pyelonephritis; therefore, a bagged specimen cannot be correctly interpreted as either true infection or contamination. A urine culture is the basis for making the diagnosis

3) Increased risk for testicular torsion during the first year of life and during adolescence

4) Enuresis may be the presenting symptom of UTI

5) The kidneys are injured more frequently in children than adults because of the proportionately larger size of children’s kidneys and the incomplete ossification of the 10th and 11th ribs until the third decade of life

b. “Pearls”

1) Child may fear punishment for insertion of foreign bodies

2) STDs in children may indicate child maltreatment

2. Geriatric

a. Aging related

1) At risk for UTIs/calculi if immobile

2) Epididymitis associated with bacterial causes

b. “Pearls”

1) May have decreased fluid intake, increasing risk for UTIs and calculi

2) Prostatic hypertrophy may be cause of bladder distention

3) As women age, occurrence of UTIs increases

II. SPECIFIC GENITOURINARY EMERGENCIES

A. Acute Renal Failure

Acute renal failure (ARF) is defined as the deterioration in renal function that develops over a period of hours to days and results in the accumulation of nitrogenous wastes in the body. It leads to the disruption of extracellular fluid volume, electrolyte balance, and acid-base status. ARF is not a disease by itself, but a potential complication of many other disorders. It can also be superimposed on a patient with chronic renal failure. ARF is classified into one of three categories, based on precipitating factors (Table 17-1). Prerenal failure, the most common cause of ARF, accounts for 40% to 80% of all cases. It is the result of any condition that decreases renal perfusion and leads to the kidneys’ inability to filter blood or regulate fluid and electrolytes. The goal of treatment is to correct the underlying cause and increase kidney perfusion. Postrenal failure develops when an obstructive process impedes the outflow of urine. Subsequently, the retrograde flow of urine occurs through the urinary system, thus causing hydronephrosis and pressure on the renal parenchyma and leading to ischemia. Treatment is aimed at relieving the obstruction. Intrarenal failure results from direct intrarenal damage, and it can result from untreated prerenal and postrenal causes as well as toxic exposures, trauma, and inflammation. Therapy consists of treating the underlying cause and preventing repeated toxic exposures. The most common fluid and electrolyte imbalances seen in ARF include hyperkalemia, hyponatremia, hypocalcemia, hyperphosphatemia, volume overload, and metabolic acidosis. Emergency dialysis is mandatory for those patients with severe fluid overload, intractable hypertension with pulmonary edema, and life-threatening metabolic derangements that do not respond to conservative medical management. Depending on the underlying cause and treatment course, ARF may be reversed or may result in chronic renal insufficiency or failure.

Table 17-1 CATEGORIES AND CAUSES OF THE THREE TYPES OF ACUTE RENAL FAILURE

Pathologic Change	Causes
*Prerenal*
Decreased blood flow to the kidneys leading to ischemia in the nephrons; prolonged hypoperfusion can lead to tubular necrosis and acute renal failure (ARF)	Conditions that cause decreased cardiac output: Shock Heart failure Pulmonary embolism Anaphylaxis Pericardial tamponade Sepsis
*Intrarenal (Intrinsic)*
Actual tissue damage to the kidney caused by inflammatory or immunologic processes or from prolonged hypoperfusion	Acute interstitial nephritis Exposure to nephrotoxins Acute glomerulonephritis Vasculitis Hepatorenal syndrome Acute tubular necrosis (ATN) Renal artery or vein stenosis/thrombosis
*Postrenal*
Obstruction of the urinary collecting system anywhere from the calices to the urethral meatus Obstruction of the bladder must be bilateral to cause postrenal failure unless only one kidney is functional	Urethral or bladder cancer Renal calculi Atony of bladder Prostatic hyperplasia or cancer Cervical cancer Urethral stricture

From Ignatavicius, D. D., & Workman, M. L. (2002). Medical-surgical nursing: Critical thinking for collaborative care (4th ed., p. 1666). Philadelphia: Saunders.

1. Assessment

a. Subjective data collection

b. Objective data collection

2) Diagnostic procedures

b) Serum chemistries: especially serum potassium, BUN, creatinine, calcium, phosphate, and magnesium

(1) BUN:creatinine ratio greater than 20:1 in prerenal failure

c) CBC with differential

d) Creatine phosphokinase (CPK): rhabdomyolysis

e) Liver function tests

h) Chest radiograph

i) Renal and/or abdominal sonography

j) Abdominal, kidney CT scan without contrast

k) IVP, retrograde pyelogram

l) Doppler scan: useful in detecting renal blood flow

m) Renal arteriogram

(1) May not be performed because of dye load and risk of further renal damage

(2) Aortorenal angiography: helpful in diagnosis of renal vascular disease

2. Analysis: differential nursing diagnoses/collaborative problems

a. Ineffective breathing pattern

b. Impaired gas exchange

c. Ineffective tissue perfusion: renal

d. Excess fluid volume

e. Impaired urinary elimination

f. Anxiety/fear

g. Acute pain

3. Planning and implementation/interventions

a. Maintain airway, breathing, and circulation (seeChapter 1)

b. Provide supplemental oxygen as indicated

1) High-flow oxygen

c. Establish IV access for administration of crystalloid fluids/medications as needed

1) Administer fluids cautiously to avoid overload

d. Prepare for/assist with medical interventions

1) Institute cardiac and pulse oximetry monitoring

2) Insert indwelling urinary catheter as needed

3) Catheter placement and monitoring of pulmonary artery pressure (see Chapter 7)

4) Assist with subclavian or femoral dual-lumen venous access placement for dialysis

5) Assist with hospital admission for dialysis and possible surgery

e. Administer pharmacologic therapy as ordered

1) Antihypertensives

2) Vasopressors

3) Inotropic agents

4) Potassium binding agents

a) Temporary measures with a duration of action of approximately 4 to 6 hours

b) Sodium polystyrene sulfonate (Kayexalate) for asymptomatic patients with a serum potassium greater than 5.5 mEq/L

c) Calcium gluconate intravenously (for cardiac and neuromuscular protection), insulin and glucose, and sodium bicarbonate for patients with a serum potassium greater than 6.5 mEq/L or ECG abnormalities consistent with hyperkalemia

7) Calcium channel blockers

8) Non-narcotic analgesics

4. Evaluation and ongoing monitoring (see Appendix B)

a. Level of consciousness

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Nov 8, 2016 | Posted by admin in NURSING | Comments Off

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