Includes nursing care plans

1. = SEMESTER 6 =
BY: KONG MUN YI
CTM1/17

2. AT THE END OF THE LESSON, THE STUDENT WILL BE ABLE TO:
1. List types of renal trauma
2. Identify clinical manifestations of patients renal trauma
3. State the complications of patient with renal trauma
4. State the diagnostic tests and investigation of patients with renal trauma
5. Explain the emergency care and management of patients with renal trauma
6. Discuss the care of patients with renal trauma using the nursing process
7. Appreciate the importance of emergency care and management of patients with
renal trauma.

3. INTRODUCTION
• The kidneys are protected by the rib cage &
musculature of the back posteriorly and by a
cushion of abdominal wall and viscera anteriorly.
• As long as about one third of one kidney
remains functional, survival is possible.

4. DEFINITION OF RENAL TRAUMA
= injury to the kidney caused by an outside force.

5. TYPES OF RENAL TRAUMA
Classified by the mechanism of injury:
i. Blunt injury
ii. Penetrating injury

6. BLUNT INJURY
• Damage caused by impact from an object that
doesn’t break the skin.
• Causes of blunt injury:
i. Rapid deceleration (eg, motor vehicle crash,
fall from heights)
ii. direct blow to the flank (eg, pedestrian struck,
sports injury)
• More common than penetrating trauma, which
accounts for 80% - 90% of all renal injuries
• Normally, minor & self-limiting

7. PENETRATING INJURY
• Usually results from gunshot wounds &
stabbings.
• More severe & most likely require surgical
management.

8. EPIDEMIOLOGY & ETIOLOGY
Frequency
• Renal trauma accounts for approximately 3% of all trauma admissions and as many
as 10% of patients who sustain abdominal trauma.
Etiology
• Penetrating (eg, gunshot wounds, stab wounds)
• Blunt - Rapid deceleration (eg, motor vehicle crash, fall from heights);
direct blow to the flank (eg, pedestrian struck, sports injury)
• Iatrogenic (eg, endourologic procedures, ESWL ,renal biopsy, percutaneous renal
procedures)
• Intraoperative (eg, diagnostic peritoneal lavage )
• Other (eg, childbirth [may cause spontaneous renal lacerations])

9. Grade Type of
injury
Description Freq
I
Contusion Microscopic or gross hematuria, urologic studies
normal 86%
Hematoma Subcapsular, non-expanding, without parenchymal
laceration
Minor
II
Hematoma Non-expanding perireneal hematoma confined to
renal retroparitoneum 3% Minor
Laceration < 1cm parenchymal depth of renal cortex without
urinary extravasation
III Laceration > 1cm parenchymal depth of renal cortex without
collecting system rupture or urinary extravasation 5%
Major
IV
Laceration Parenchymal laceration extending through the renal
cortex, medulla and collecting system 6% Major
Vascular Main renal artery or vein injury with contained
hemorrhage
V
Laceration Completely shattered kidney
<1%
Major
Vascular Complete avulsion of renal hilum which
devascularizes kidney
GRADE OF RENAL INJURY (ACCORDING TO AAST)
• American Association of the
Surgery of Trauma (AAST)
• used widely for clinical and
scientific research
(Journal of Acute Disease,2016)

10. Grade I
Contusion - Microscopic or gross hematuria,
urologic studies normal
Hematuria - Subcapsular, non-expanding,
without parenchymal laceration
Grade II
Hematoma - Non-expanding perireneal
hematoma, confined to renal
retroparitoneum
Laceration - < 1cm parenchymal depth of renal
cortex without urinary
extravasation
GRADE OF RENAL INJURY (ACCORDING TO AAST)
Kidney
capsule
Subcapsular
hematoma
Contusion = hit by blunt/blow object, no broken
skin
Laceration = Deep cut / tear

11. GRADE OF RENAL INJURY (ACCORDING TO AAST)
Grade III
Laceration - > 1cm parenchymal depth of renal
cortex without collecting system
rupture or urinary extravasation
Grade IV
Laceration - Parenchymal laceration extending
through the renal cortex, medulla
and collecting system
Vascular - Main renal artery or vein injury
with contained hemorrhage
Laceration
> 1cm

12. GRADE OF RENAL INJURY (ACCORDING TO AAST)
Grade V
Laceration - Completely shattered kidney
Vascular - Complete avulsion of renal hilum with devascularized kidney
Complete laceration or thrombus of the main renal artery or vein
Kidney
shattered
Avulsion
of hilum
Avulsion = pulled away / tear
Devascularize = Interruption of
circulation of blood

13. GRADE OF RENAL INJURY (ACCORDING TO AAST)

14. CLINICAL MANIFESTATION OF RENAL TRAUMA
• Kidneys receive half of the blood flow from the abdominal aorta; therefore, even a fairly
small renal laceration can produce massive bleeding.
• often associated with other injuries to the abdominal organs (liver, colon, small intestines)
• Clinical manifestation includes:
i. Hematuria – most common manifestation
ii. Pain - at injury area or other associated injuries
(mild to severe)
iii. Renal colic - due to blood clots or fragment
obstructing the collecting system
iv. Mass or swelling in the flank,
or abdomen

15. CLINICAL MANIFESTATION OF RENAL TRAUMA
v. Ecchymosis - hematoma
vi. Lacerations or wounds of the lateral abdomen & flank
vii. Other associated injury – fractured ribs
viii. Signs & symptoms of hypovolemia
ix. Febrile (low grade) – absorption of clot takes place in retroperitoneal hematoma
injury.

16. Investigations Normal Limit Abnormal Indication
Urinalysis
- Gross
- Microscopic
-ve for blood
Presence of
blood in
urine
(hematuria)
injury involving renal arteries
Hematocrite males:42%-54%,
women:38%-46% Low Bleeding
Hemoglobin males:14 – 18 gm/dL
women:12 - 16 gm/dL
BUSE
- Sodium
- Potassium
- Chloride
135-145mmol/l
3.7-5.3mmol/l
95-110mmol/l High
Impending kidney failure
Renal function
test
- Creatinine
- Urea
0.6 - 1.2 mg/dL
20-40 mg/dL
Urine output >0.5 mL/kg/hr < 400mls/day Kidney failure or hypovolemic
shock
DIAGNOSTIC TESTS AND INVESTIGATION OF RENAL TRAUMA
Laboratory:

17. DIAGNOSTIC TESTS AND INVESTIGATION OF RENAL TRAUMA
- Pelvic ultrasound - helps to immediately detect hemorrhage of other organs, eg: liver,
spleen
- CT Scan – tool of choice, provides essential anatomical & functional information on the
extend of injury

18. COMPLICATIONS OF RENAL TRAUMA
• Occur in between 3% to 33% of the cases.
1.Urinary Extravasation
- most common complication of renal trauma.
= a collection of urine surrounded by fibrous tissue, from leakage through a tear in the
ureter, renal pelvis, or renal calix due to obstruction, or from trauma.
- Urinoma formation is the most common complication, occurring in 1% to 7% of all
patients with renal trauma.
= consist of a collection of urine that may be encapsulated, although they can also manifest
as free fluid.
- presented with signs of sepsis, perinephric abscess formation and declining renal
function.
- Small urinomas will be reabsorbed spontaneously, and drainage is not necessary.
- Urinary extravasation resolves spontaneously in 76% to 87% of cases.

19. COMPLICATIONS OF RENAL TRAUMA
2. Infection
- Perinephric abscesses and infected urinomas may develop.
- Management with percutaneous drainage is often successful
3. Delayed Hemorrhage
- common complication with deep laceration wounds, seen commonly in penetrating
renal
trauma
- present with hematuria, falling hematocrit, or hemodynamic instability.
- It is often associated with pseudoaneurysm or arteriovenous fistula formation.

20. COMPLICATIONS OF RENAL TRAUMA
4. Hypertension
- mediated by increased renin secretion in response to renal ischemia
- Incidence relates to the severity of renal injury
- should have periodic blood pressure monitoring in the long term
- Nephrectomy is occasionally necessary to control renovascular hypertension.
5. Renal Insufficiency
- risk depends on pre-existing renal disease, age, and associated multiorgan failure.

21. EMERGENCY CARE & MANAGEMENT OF RENAL TRAUMA
Management of emergency care for renal trauma is divided to :
• Initial management
- Primary survey assessment &
- Secondary survey recuscitation
• Stable patient
- blunt trauma
- minor injury (Grade I & II)
- major injury, but localized & stable
(Grade III – occasionally)
• Unstable patient
- active bleeding
- Grade IV & V

22. EMERGENCY CARE & MANAGEMENT OF RENAL TRAUMA
• The goals of management in patients with renal trauma are to:
i. control hemorrhage, pain, and infection
ii. preserve and restore renal function
iii. maintain urinary drainage.
• Optimum treatment of injured trauma victims requires rapid, organized assessment and
treatment system.
• Advanced Trauma Life Support is the common language of trauma care, defining two
phases in the initial management of patients with multiple injuries:
i. Primary survey – identify & treat injuries that endanger the pt’s life
ii. Secondary survey – detect all the injuries and initiate definitive treatment

23. INITIAL MANAGEMENT
i. Primary Survey
• Life threatening conditions are identified.
• Assessment of : A = Airway
B = Breathing
C = Circulation
D = Disability
E = Exposure for examination
• Biggest cause of preventable death is early hemorrhage within the first 6 hrs after
incurring an injury.
• Ultrasound is done to determine renal laceration, but cannot definitely assess their
depth and extent.

24. INITIAL MANAGEMENT
ii. Secondary Survey
• Occurs after all life-threatening injuries from primary survey have been identified and
treated, allowing further investigations.
• Aims to identify all injuries sustained, involves a thorough head-to-toe examination, including
full neurological & spine examinations.
• During history taking, ask for: - details of incident (fall, height, type,place)
- penetrating injury (type of instrument, length, bullet, caliber
of weapon)
- pre-existing renal abnormalities
(cyst,nephrolithiasis,hydronephrosis)
• During physical examination, signs of rib fracture and significant flank ecchymosis are
indicators for renal trauma

25. NURSING INTERVENTIONS - INITIAL MANAGEMENT
1. Assessment of : A = Airway, B = Breathing, C = Circulation, D = Disability, E = Exposure
2. Take vital signs of patient (T, BP, Pulse rate & respiration rate)
3. Assure patient
4. Take history from patient on the injury, pain, location, incident, type of weapon / injury,
witness
5. Do head-to-toe inspection, type of trauma and other injuries.
6. To detect hematoma, inspect the area around the lower ribs, upper lumbar vertebrae,
flank, and abdomen is palpated for tenderness.
7. Mark the borders of hematoma or swelling with a permanent marker- for monitoring of
further hemorrhage.
8. Set IV line with larger sized cannula
9. Obtain blood for FBC, BUSE, Renal Profile, Blood for Group & Cross Match

26. NURSING INTERVENTIONS - INITIAL MANAGEMENT
10. Collect urine for urinalysis
11. Monitor for oliguria and signs of hemorrhagic shock
12. Prepare patient for Ultrasound or CT Scan

27. MANAGEMENT OF STABLE PATIENT
• For stable patient, most blunt renal injuries, grade I, II and most grade III and IV injuries,
can be safely treated without active intervention
• Patients require strict bed rest until gross hematuria has resolved, without bladder
irrigation.
• Regular observations, blood tests and clinical examinations are required, especially for
first 24 hrs according to severity of trauma.
• Avoid usage of anticoagulants, to reduce chances of bleeding
• Patients with retroperitoneal hematomas may develop low-grade fever as absorption of the
clot takes place.
• Antimicrobial medications may be prescribed to prevent infection from perirenal hematoma
or urinoma (a cyst containing urine).

28. MANAGEMENT OF UNSTABLE PATIENT
• The patient is often in shock and requires aggressive fluid resuscitation.
• Surgery is indicated in the following situation: - failure to respond to blood transfusion
- massive haematuria
- expanding loin mass
- unstable patient with penetrating trauma
• Active interventions are:
i. Embolization or angioembolization
- a catheter is advanced into the renal artery, and embolizing materials (Gelfoam,
autologous blood clot, steel coils) are injected into the artery and carried in the arterial
blood flow to occlude the vessels mechanically.
ii. Renal exploration – laparotomy
iii. Partial / total nephrectomy
iv. Ureteric stenting – presence of urinoma

29. THE CONSERVATIVE MANAGEMENT OF RENAL TRAUMA: A LITERATURE REVIEW AND PRACTICAL CLINICAL GUIDELINE FROM
AUSTRALIA AND NEW ZEALAND
BJU International
pages 13-21, 9 OCT 2014 DOI: 10.1111/bju.12902
http://onlinelibrary.wiley.com/doi/10.1111/bju.12902/full#bju12902-fig-0001

30. THE NURSING MANAGEMENT FOR : NON SURGICAL /
CONSERVATIVE TREATMENT
1. Patients require strict bed rest until gross hematuria has resolved.
2. Continuous monitoring of: - vital signs
- BUSE, Renal profile, haematocrit, Hb
3. Assess hematoma or swelling twice a day.
4. Monitor urine output and visual inspection for hematuria.
5. Assess pain score.
6. Antibiotics may be prescribed.
7. Patient education to restrict physical activities to minimize the incidence of delayed or
secondary bleeding. (1month)
8. Advice patient the importance of follow up assessments of renal function.

31. THE NURSING MANAGEMENT FOR : POST-SURGERY
1. Patients require strict bed rest until gross hematuria has resolved.
2. Assess and monitor incision site, dressing and drainage tfor bleeding.
3. Continuous monitoring of: - vital signs
- BUSE, renal profile, haematocrit, Hb
4. Monitor urine output and visual inspection for hematuria.
5. Assess pain score.
6. Monitor for signs and symptoms of infections.
7. Broad spectrum antibiotics may be prescribed
8. Patient education to restrict physical activities to minimize the incidence of delayed or
secondary bleeding. (1month)
9. Advice patient the importance of follow up assessments of renal function.

32. NURSING DIAGNOSIS
i. Acute pain related to injuries and trauma
ii. Fear and anxiety related to outcome of trauma
iii. Risk of hypovolemia related to severe blood loss

33. i. Acute pain related to injuries and trauma
Expected outcome: Patient reports decrease in pain
1. Assess for: level of pain, location of pain, and type of pain.
Rationale: provides baseline for evaluation of pain relief strategies.
Outcome: Reports decreasing level of pain
2. Monitor pain level closely & increases in severity are to be reported
promptly to physician.
Rationale: Pain relief medications can be prescribed for effective pain relief.
Outcome: Pain relief medications can be administered as prescribed for
comfort.

34. 3. Administer analgesics to patient according to prescription.
Rationale: Promote pain relief.
Outcome: Patient reports decrease in pain.
4. Encourage deep breathing exercise.
Rationale: Promotes relaxation and relief of muscle pain.
Outcome: Reports relief of pain and discomfort.
5. Advise patient to reduce stressful physical activities.
Rationale: Reduce further injuries due to trauma.
Outcome: Patient avoids heavy physical activities

35. ii. Fear and anxiety related to outcome of trauma
Expected outcome: Reduction of fear and anxiety in patient.
1. Assess patient’s anxiety and fear.
Rationale: Provides a baseline data for post trauma ad injury assessment.
Outcome: Verbalizes reactions and feeling to staff.
2. Assess patient’s knowledge about management of patient’s condition and
expected outcome
Rationale: Provides a basis for further patient’s education.
Outcome: Identifies information needed to promote own adaption and
coping.

36. 3. Encourage patient to verbalize reactions, feelings and fears.
Rationale: Affirms patient’s understanding of and ultimate resolution of
feelings and fears
Outcome: Grieves appropriately for self and changes in role and function.
4. Encourage patient to share feelings with spouse or close relatives.
Rationale: Enable patient to receive mutual support and reduces sense of
isolation for each other.
Outcome: Patient feels comfortable to share feelings with loved ones.
5. Assure patient by informing patient of the procedure to be done.
Rationale: Able to get support and cooperation from patient prior to any
procedure.
Outcome: Understands the procedures to be done and reduce anxiety.

37. iii. Risk of hypovolemia related to severe blood loss.
Expected outcome: Patient will remain hemodynamically stable.
1. Assess cardiovascular status : Blood pressure, pulse rate, and heart rate.
Rationale: Baseline data for prompt intervention in the event of
hypovolemia.
Outcome: Early detection reduces the risk of hypovolemic shock.
2. Monitor blood test results for BUSE, Hematocrit, Hb.
Rationale: Prompt and appropriate interventions can be taken when there
are abnormalities and changes in blood test results indicating
hypovolemia.
Outcome: Avoid risk of hypovolemia.

38. 3.Assess general condition of patient for signs and symptoms of
hypovolemic shock.
Rationale: Prompt and appropriate interventions can be taken when general
condition of patient deteriorates, indicating hypovolemia.
Outcome: Avoid risk of hypovolemia.
4. Cannulate patient intravenously with a bigger cannula and make sure
that it is always patent.
Rationale: Blood products or colloids can be transfused intravenously in case
of hypovolemic shock.
Outcome: Patent intravenous cannula is always ready for emergency
transfusion.

39. 5. Regular monitoring of patient’s injury
Rationale: To detect for early internal or external hemorrhage.
Outcome: Reduce the risk of hypovolemic shock.
6. Insert continuous indwelling bladder drainage for patient if indicated.
Rationale: Output can be monitored for volume and hemorrhage. Reduce
patient’s physical movement.
Outcome: Able to detect early signs of hypovolemia.

40. TAKE HOME NOTE:
The goals of management in patients with renal trauma
are to:
i. control hemorrhage, pain, and infection
ii. preserve and restore renal function
iii. maintain urinary drainage

41. NURSING INTERVENTIONS - INITIAL MANAGEMENT
1. Assessment
2. Take vital signs of patient
3. Assure patient
4. Take history from patient on the injury, pain, location, incident, type of weapon / injury, witness
5. Do head-to-toe inspection, type of trauma and other injuries.
6. To detect hematoma, inspect the area around the lower ribs, upper lumbar vertebrae, flank, and
abdomen is palpated for tenderness.
7. Mark the borders of hematoma or swelling with a permanent marker- for monitoring of further
hemorrhage.
8. Set IV line with larger sized cannula
9. Obtain blood for FBC, BUSE, Renal Profile, Blood for Group & Cross Match
10. Collect urine for urinalysis
11. Monitor for oliguria and signs of hemorrhagic shock
12. Prepare patient for Ultrasound or CT Scan