Alexander ch25 lecture

Copyright © 2017, 2012 Pearson Education, Inc. All Rights Reserved.
Advanced EMT
A Clinical-Reasoning Approach, 2nd Edition
Chapter 25
Renal, Genitourinary,
and Gynecologic
Disorders

• Applies fundamental knowledge to provide basic
and selected advanced emergency care and
transportation based on assessment findings for
an acutely ill patient.
• Applies fundamental knowledge to provide basic
and selected advanced emergency care and
transportation based on assessment findings for
an acutely injured patient.
Advanced EMT
Education Standards

1. Define key terms introduced in this chapter.
2. Describe the pathophysiology of acute and chronic
renal failure.
3. Discuss the complications of end-stage renal disease.
4. Explain the assessment and management of patients
with emergencies related to renal failure and dialysis.
5. Explain the processes of hemodialysis and peritoneal
dialysis.
6. Discuss the pathophysiology, assessment, and
management of patients with urinary retention.
Objectives (1 of 4)

management of patients with urinary system
infections.
8. Identify complications associated with catheterization
of the urinary bladder.
management of patients with renal calculi.
10.Discuss the pathophysiology, assessment, and
management of patients with trauma to the male
genitourinary system.
Objectives (2 of 4)

11.Discuss the pathophysiology, assessment, and
management of patients with epididymitis, orchitis,
and Fournier’s gangrene.
12.Describe the basic anatomy and physiology of the
female reproductive system.
13.Obtain a relevant history from patients with a suspected
gynecologic problem.
14.Describe signs and symptoms associated with common
gynecologic and female genitourinary system causes of
acute abdominal pain.
Objectives (3 of 4)

15.Describe special considerations in the assessment
and management of patients who have been sexually
assaulted and patients with vaginal bleeding.
16.Effectively communicate orally and in writing
assessment findings for patients with gynecologic
and genitourinary/renal complaints to other health
care providers.
Objectives (4 of 4)

• Renal disorders
– Negative outcomes of untreated or poorly treated
diabetes and hypertension
• Effect on life from shutdown of kidneys enormous
– Often treatable
• Disorders of urinary system and male and female
reproductive systems can lead patients to seek
emergency treatment.
Introduction

Think About It
• What are the first actions John and Missy
should take?
• What are some initial hypotheses about the
cause of unresponsiveness in this patient?
• What information will help John and Missy
determine the cause of the patient’s problem?

Figure 25-1
The urinary system.

Anatomy and Physiology Review—
Urinary System
• Upper urinary tract
– Kidneys
– Lie in retroperitoneum at costovertebral angles (CVAs)
– Treated by nephrologist
• Lower urinary tract
– Ureters, bladder, urethra
– Treated by urologist

Figure 25-2
Anatomy of the nephron.

Figure 25-3
Anatomy of the kidney.

Kidneys (1 of 5)
• Filters blood; eliminates wastes
• Renal arteries
• Nephrons
• Urine

Kidneys (2 of 5)
• Outer layer (renal cortex) contains glomerulus
and renal tubules.
• Renal tubules travel toward inner layer of kidney
(renal medulla).
– Deposit urine in collecting ducts

Kidneys (3 of 5)
• Interstitium
– Tissues occupy spaces around tubules
and blood vessels.
• Glomerular filtration rate:
– Rate at which filtrate is formed
– 120 mL/minute or 7 L/hour

Kidneys (4 of 5)
• Glomerulus
– Filters waste products and excess fluid in blood
– Begins process of removing excess electrolytes
– Monitors pressure in blood vessels; readjusts blood
pressure

Kidneys (5 of 5)
• After urine leaves kidney, it moves into lower
urinary system.
• Urine leaves calyces of kidney and enters ureters
into urinary bladder.
• Bladder:
– Reservoir that holds urine
– Feeling of full bladder, urge to urinate; urine released
through urethra

Figure 25-4
Anatomy of the male genitourinary system.

Male Reproductive System (1 of 2)
• Organs
– Genitals (genitalia): external or internal
• Urethra
– Shared by urinary and reproductive systems
• Prostate gland
– Located on inferior aspect of bladder
• Epididymis
– Located on posterior of testicle; sperm maturation
and storage

Male Reproductive System (2 of 2)
• Vas deferens
– Tube carries testicular secretions from epididymis
to prostate
• External male genitalia
– Penis and testicles; lie within scrotum. Sperm
produced in testicle
– Prior to ejaculation, sperm enters vas deferens
and prostate.

Figure 25-5
Female external genitalia.

Figure 25-6
Female internal genitalia.

Female Reproductive System (1 of 5)
• External genitalia
– Mons pubis, labia majora, labia minora, and clitoris
• Vagina
– Hollow passageway
• Uterus
– Muscular organ lined with endometrium
– Fundus, body, cervix

• Fallopian tubes
– Passageway from uterus to ovaries
• Ovaries
– Menstrual cycle
– Passageway for ova to travel to uterus

• If sperm present, fertilization takes place in
the outer third of the fallopian tube.
• Fertilized ovum implanted in endometrium
in uterus

• Ovaries and endometrium undergo cyclical
monthly changes (menstrual cycle).
– Day 1: day bleeding begins
– Bleeding lasts about five days; total blood lost
about 30 mL
• Ovulation
– 14 days after first day of menstrual cycle, mature
follicle ruptures, discharging ovum into pelvic cavity
near entrance of fallopian tube

• Menstrual cycle
– Lasts about 28 days
• Menarche
– About age 12
• Menopause
– Average age of 51

Assessment and Management (1 of 9)
• Look for clues to problem.
• Determine chief complaint.
• Form initial impression.
• Clues: dialysis access site; peritoneal dialysis
equipment; presence of Foley catheter; fishy or
ammonia odor, indicating renal failure

• Scene size-up
– Complaints and presentations that may indicate renal
problem:
 Decreased urine output
 Hematuria
 Weakness
 Dyspnea
 Flank pain
 Changes in urination
 Altered mental status

Table 25-1
Signs and Symptoms of Renal Failure
Body System Affected Signs/Symptoms
Fluids and electrolytes Hypertension, hypotension
Peripheral edema
Ascites (fluid within the abdomen)
Crackles (rales) in the lungs
Cardiovascular/hematologic Impaired blood clotting, bruising
Anemia
Neuromuscular/musculoskeletal Headache
Altered mental status/confusion
Weakness
Muscle cramps and twitching
Osteoporosis
Gastrointestinal Loss of appetite (anorexia)
Nausea
GI bleeding
Skin Pruritus, scratches
Uremic frost
Jaundice
Pallor
Rash
Odor of ammonia
Immune Immunosuppression, infection
Renal Decreased urine output

• Primary assessment
– Ensure open airway and ventilations
– Oxygen as indicated
– Assess circulation.
– Hypertension
 Leading cause of renal disease.
– Hypotension
 Complication of renal failure and dialysis

• Primary assessment (continued)
– Electrolyte abnormalities (dialysis or missing dialysis
treatment) may result in dysrhythmias and reduced
cardiac output.
– Bleeding may be a problem with hemodialysis (HD)
patients.

• Secondary assessment
– Baseline vital signs:
 Avoid taking blood pressures in extremities that have an HD
access site (shunt).
– Unresponsive patient:
 Obtain history from family, health care providers, bystanders.
 Perform rapid secondary assessment.

• Secondary assessment (continued)
– Alert patient:
 Focused history and exam based on chief complaint
 Look for signs of dehydration or fluid overload
 Orthostatic vital signs
 Fever
 Cardiac monitor (if allowed)
 Blood glucose level if indicated

• Clinical-reasoning process
– Renal disorder patients often have other medical
conditions.
– Renal problems impair homeostasis.
 Affect organ systems
– Kidney transplant or medications to prevent rejection
 Immune system compromised
– Foley catheter increases suspicion of infection.

• Treatment
– Anemia frequent complication of renal disease
– Be cautious with rate of fluid administration.
 Check breath sounds for indications of fluid overload
frequently.
 Do not give additional fluids if patient has crackles (rales) in
lungs.

• Reassessment
– Establish baseline of mental status, complaints, vital
signs, physical findings.
– Reassess critical patients every 5 minutes.
– Reassess noncritical patients every 15 minutes.

Think About It
• What additional hypotheses could explain
Mr. Thornton’s condition? What hypotheses
could Missy and John eliminate?
• What additional information should John and
Missy obtain?
• Are any additional treatments indicated at this
point?

Renal Disorders
• Related to function of kidney
• Complication of diabetes or hypertension
• Acute or chronic
– Affect kidney filtering system
• Dialysis
– Process of exchanging electrolytes and filtering
wastes; normally done by the kidneys

Renal Disorders (1 of 16)
• Underlying problem occurs
– Prerenal
 Outside urinary system
– Intrinsic
 In kidney
– Postrenal
 After urine leaves kidney

• Renal failure categorized by amount of urine still
made by the kidney
– Oliguria
– Anuria
– Nonoliguric
– Polyuria

• Acute renal failure (ARF)
– Loss of renal function (decreased GFR) over hours
to days
– Accumulation of nitrogen-containing wastes in blood
– Azotemia
– Uremia

• Acute renal failure (ARF) (continued)
– Prerenal renal failure
 Issues or disease elsewhere in body; affects kidney’s
ability to produce urine; 60% of cases
– Intrinsic renal failure
 Diseases in kidneys; 40% of cases
– Postrenal renal failure
 Outflow obstructions that back up urine into kidneys;
5% of cases

• Prerenal acute renal failure
– Elderly patient history of decreased blood volume
– Dry mucous membranes
– Tenting of skin
– Poor capillary refill
– Orthostatic vital signs
– Thirst
– Caused by congestive heart failure, cirrhosis of
liver, sepsis

• Postrenal acute renal failure
– Indications of bladder outlet obstruction
– Results in backflow of urine into kidney
– Acute obstructions: patient can be in agonizing pain
and unable to urinate.
– Giving IV fluids will worsen situation.

• Intrinsic acute renal failure
– Caused by damage to kidney itself
– Categorized by: glomeruli, tubules, interstitium, renal
blood vessels primary involved portion
– Glomerular: systemic lupus erythematosus (SLE), or
lupus, autoimmune disease
– Tubular disorders common; caused by toxins or
ischemia

• Intrinsic acute renal failure (continued)
– Interstitial disorders
 Caused by medications
– Vascular renal disorders
 Blood clots affecting blood flow in kidney; common
cause of renal failure in older adults
– Renal artery stenosis (RAS)
 Reversible cause of hypertension

• Acute renal failure management
– Remove offending agents.
– Maintain fluid status close to normal.
– Any type of renal failure can leave patient without
functioning kidneys; requires dialysis.

• Chronic renal failure
– Irreversible kidney dysfunction with increased urea in
blood for greater than three months
– Patient retains waste products toxic to system.
– Kidney:
 Controls blood pressure; produces renin; activates vitamin D;
produces erythropoietin

• Uremia
– Urea not excreted normally by kidneys
– Fishy odor, nausea, vomiting, diarrhea
– Gastrointestinal bleeding
– Heart failure, dysrhythmias
– Edema, blood clotting disorders
– Pericarditis, pericardial tamponade
– Neurologic signs and symptoms
– Skin rash, itching

• End-stage renal disease (ESRD)
– Uremia requiring transplantation or dialysis
– Hypertension and diabetes
– Glomerulonephritis, polycystic renal disease

Figure 25-7
Vascular access for hemodialysis: a shunt graft.

Figure 25-8
A patient receiving hemodialysis. (© Michal Heron)

• Hemodialysis (HD)
– Catheter placed in subclavian area and access site
(shunt graft) placed in one arm
– Shunt graft: arterial blood leaves body to enter tubing,
conducts it into HD machine
– Dialysis removes wastes from blood.
– Patients on medication: increased risk of infection

• Hemodialysis (HD) (continued)
– Complications
 Blood clot formation, infections, thrombosis, stenosis,
graft will not stop bleeding, psychological issues, malnutrition,
hypertension, hyperlipidemia, pruritus, skin rashes
– Hyperkalemia
 Cause of cardiac arrest in patients with renal failure

• Peritoneal dialysis (PD)
– Catheter in abdomen; large quantities of fluid placed in
abdomen
– Toxins in blood equilibrate by osmosis
– Remove toxins without dialysis machine or trips to
dialysis center
– Portable and small; hypotension is not a side effect
– Less efficient

• Renal transplant
– Greater need than number of organs available
– First-year survival: 85%
– Kidney placed in lower abdomen and attached to iliac
arteries; kidney felt on abdominal exam
– Post-transplant patients on immunosuppressant
medications; most die of cardiac causes or infection

Urinary Tract Disorders (1 of 9)
• Acute urinary retention (AUR)
– Underlying problem of benign prostatic hypertrophy
(BPH); occurs in older men
 Prostate enlarges and prevents flow of urine from bladder and
causes severe discomfort.
 Backup through ureters into kidney, results in ARF
– Spine injuries and overdistension of bladder can lead
to urinary retention.
– Boluses of IV fluids can worsen condition.

Figure 25-10
CT scan showing a kidney stone. (© Edward T. Dickinson, MD)

• Renal calculi
– Kidney stones
– Pass through lower urinary tract: less than 6 mm in
size
– Stretching, dilation, irritation of affected ureter causing
smooth muscle to spasm
– Men more often than women, ages 35 to 45

• Renal calculi (continued)
– Constant, severe flank pain radiating to groin, or lower
abdominal pain, tenderness over costovertebral angle,
nausea, blood in urine
– Bolus of fluid: flush out stone, alleviate pain

• Urinary tract infection
– More common in females than males because of
shorter urethra; bacteria reaches bladder before being
eliminated
– Common in patients who have indwelling Foley
catheters.
– Affect urethra, prostate (in males), bladder

• Urinary tract infection (continued)
– Urethritis: sexually transmitted infections, bacteria
from bowel
– Infection in prostate (prostatitis) very difficult to get rid
of; urethral discharge
– Infection in bladder; painful, frequent, cloudy,
malodorous urine
– Infections of kidney: pyelonephritis

• Urinary tract infection (continued)
– Patient in position of comfort
– Start IV; give fluid bolus.
– Consider analgesics.

Figure 25-11
A Foley catheter.

• Problems arising from Foley catheters
– Patients who are confused and cannot control urination
– Patients with benign prostatic hyperplasia (BPH) prior
to surgery to prevent ARF
– Critically ill patients
– Patients with paralysis due to spinal-cord injuries

• Problems arising from Foley catheters (continued)
– Confused patients may pull on Foley; in some cases,
patients may pull it out with balloon inflated.
– Evaluate for possible blood infections and trauma.
– Look for signs of infection.

• Foley catheter
– Clear plastic tube with balloon at one end; inserted
through urethral meatus and urethra, into bladder
– Clamp on tubing must be released for urine to flow into
collection bag.
– Place bag lower than bladder; unclamp it to prevent
obstruction of urine outflow.

Emergencies Involving the Male
Genitalia (1 of 6)
• Fournier’s gangrene
– Bacterial infection that affects both genitals and
perineum
– Develops from wound to skin
– Men 10 times more likely than women to develop
infection, which can be fatal
– True emergency

Genitalia (2 of 6)
• Phimosis
– Foreskin cannot be pulled back over head of penis;
urine builds in foreskin; infections and irritation
• Paraphimosis
– Foreskin of uncircumcised male is retracted,
constricting lymphatic drainage and causing glans to
swell; tissue death and necrosis
– Apply ice pack to decrease swelling.

Genitalia (3 of 6)
• Priapism
– Painful and prolonged erection of penis, >4 hours
– Corpora cavernosa fills with blood for erection; unable
to drain out.
– Disease of blood buildup; sickle cell disease
– When not treated promptly, scarring and permanent
inability to achieve erection (impotence) can result.
 Apply ice pack to decrease swelling.

Genitalia (4 of 6)
• Testicular torsion
– Testicles rotate and twist spermatic cord, cutting off
blood supply to testicle.
– If torsion not reversed within 6 hours, generally death
of testicle.
– Nausea; vomiting; blood in semen; lower abdominal
pain; lump or swelling in testicle; sudden, severe
testicular pain

Genitalia (5 of 6)
• Epididymitis
– Inflammation of epididymis at posterior pole of testicle
– Young men who have sexually transmitted infections
(STIs); elderly men
– Ice and elevation of testicles will help.
• Orchitis
– Inflammation of testicle itself

Genitalia (6 of 6)
• Trauma
– Blunt or penetrating
– Insertion of foreign body into urethra
– Can be accidental, self-induced, or a result of
sexual assault
– Tears and lacerations to scrotum or penis
– Testicle “falling out” of scrotal sack
– Penis fractured

Gynecologic Disorders
• Assessment and management
– Be caring, comfortable, knowledgeable for patient to
share information.
– Provide patient with privacy.
– Abdominal pain may be caused by:
 Gynecologic problem
 Obstetric problem
 Problem with a different organ system
– Abnormal vaginal bleeding, unusual vaginal discharge

Gynecologic Disorders
• Assessment and management (continued)
– Obtain history of menstrual cycles.
– Pregnant:
 Gravidity
 Parity
– Contraceptive methods
– Management of gynecologic problems in prehospital
setting is supportive.

Gynecologic Disorders (2 of 6)
• Gynecologic causes of abdominal pain
– Pain with ovulation (mittelschmerz)
– Ovarian cysts
– Endometriosis
– Endometritis
– Ectopic pregnancy
– Pelvic inflammatory disease (PID) or cervicitis

• Abnormal vaginal bleeding
– Pregnancy-associated problems
– Heavy periods
– Trauma
– Ask how many sanitary pads or tampons saturated
with blood in hour’s time
– Signs of hypovolemic shock

• Trauma and sexual assault
– Small cuts and lacerations occur in female pediatric
population from straddling injuries.
– Control significant bleeding.
– Discomfort or swelling: apply ice pack
– Consider sexual assault.

• Trauma and sexual assault (continued)
– Patients of all ages may be victims of sexual assault.
– Scene size-up, primary and secondary assessment,
management of injuries
– Preserve evidence.
– Place garments removed in paper bag.
– Discourage patient from bathing.

• Trauma and sexual assault (continued)
– Psychological needs important; reassure patient
– Do not make statements or ask questions that imply
victim is at fault for attack.
– Document anything patient tells you about assault.

Sexually Transmitted Infections (STIs)
in Males and Females
• Patients often feel shame and embarrassment.
• May delay treatment for signs and symptoms
• Be empathetic and nonjudgmental.
• What are five common STIs?

Chapter Summary (1 of 4)
• Understand anatomy, physiology, and
pathophysiology of urinary and male and
female reproductive systems.
• Patients may experience acute or chronic
renal failure.
• Impairment of kidneys’ role in homeostasis can
lead to life-threatening complications.
• Patients with CRF receive hemodialysis or
peritoneal dialysis to remove wastes from blood.

• Patients subject to significant complications
related to shunt grafts and dialysis procedure.
• Urinary tract may be affected by UTIs, urinary
obstruction, renal calculi.
• Care of patients with renal and urinary disorders
is supportive.
• Patients can benefit from IV fluid boluses.

• Renal failure patients in cardiac arrest managed
in prehospital setting same as patients in cardiac
arrest.
• Interventions may be ineffective until underlying
electrolyte abnormalities are corrected.
• Emergencies involving male genitalia may be
medical or traumatic in origin.
• Can be emotionally distressing, can result in
permanent loss of function, can be life
threatening.

• Gynecologic disorders present with abdominal
pain or vaginal bleeding.
• Obtain pregnancy and menstrual history.
• Both males and females of all ages can be victims
of sexual assault.
• Realize importance of emotional support and
preservation of evidence.
• Patients with STI may seek prehospital medical
care.

Alexander ch25 lecture

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