Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Chapter 7 Urology and Nephrology

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Topics Anatomy and Physiology General Mechanisms of Nontraumatic Tissue Problems General Pathophysiology, Assessment, and Management Renal and Urologic Emergencies

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Anatomy and Physiology (1 of 7) The Urinary System –Female –Male Urology and Nephrology The Kidneys

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Anatomy and Physiology (2 of 7) The Kidneys –Hilum –Medulla –Pyramids –Papilla –Renal Pelvis

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Anatomy and Physiology (3 of 7) Nephrons –Glomerulus –Bowman’s Capsule –Proximal Tubule –Loop of Henle –Distal Tubule –Collecting Duct

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Anatomy and Physiology (4 of 7) Functions of the Kidneys –Forming and Eliminating Urine Maintaining blood volume with proper balance of water, electrolytes, and pH Retaining key compounds such as glucose, while excreting wastes such as urea –Controlling Arterial Blood Pressure –Regulating Erythrocyte Development

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Formation of Urine –Glomerular Filtration GFR –Reabsorption and Secretion Simple diffusion and osmosis Facilitated diffusion Active transport Anatomy and Physiology (5 of 7)

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Anatomy and Physiology (6 of 7) Tubular Handling of Water and Electrolytes –Diuresis and Antidiuresis Tubular Handling of Glucose and Urea –BUN and Creatinine Control of Arterial Blood Pressure –The Renin-Angiotensin System Control of Erythrocyte Production –Erythropoietin

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Anatomy and Physiology (7 of 7) Ureters Urinary Bladder Urethra Testes Epididymus and Vas Deferens Prostate Gland Penis

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ General Mechanisms of Nontraumatic Tissue Problems Inflammatory or Immune-Mediated Disease Infectious Disease Physical Obstruction Hemorrhage

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ General Pathophysiology, Assessment, and Management Differentiating GI and Urologic Complaints Pathophysiologic Basis of Pain –Causes of Pain –Types of Pain Visceral pain Referred pain

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Assessment and Management (1 of 4) Scene Size-up Initial Assessment Focused History –OPQRST History –Prior History of Similar Event –History of Nausea, Vomiting, and Weight Loss –Change in Bowel Habits and Stool –Last Oral Intake –Presence of Chest Pain

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Assessment and Management (2 of 4) Physical Exam –Appearance Uncomfortable appearance. –Posture Lying with knees drawn up Relief with walking –Level of Consciousness Determine if changes are acute or chronic

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Assessment and Management (3 of 4) Apparent State of Health Skin Color Examination of the Abdomen –Inspection for Distention, Ecchymosis, or Scarring –Pain Associated with Percussion of Abdomen –Palpation Normal or ectopic pregnancy Masses Assessment Tools Vital Signs

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Assessment and Management (4 of 4) Management –Airway, Breathing, Circulation –Pharmacologic Interventions IV access and analgesics. –Nonpharmacological Interventions Nothing by mouth (NPO). Maintain position of comfort. Reassess mental status and vital signs frequently. –Transport Considerations

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Renal and Urologic Emergencies Risk Factors –Older Patients –History of Diabetes –History of Hypertension –Multiple Risk Factors Renal and Urologic Emergencies –Acute Renal Failure –Chronic Renal Failure –Renal Calculi –Urinary Tract Infection

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Acute Renal Failure (1 of 6) Pathophysiology –Prerenal Acute Renal Failure Dysfunction before the level of kidneys Most common and most easily reversible –Renal Acute Renal Failure Dysfunction within the kidneys themselves –Postrenal Acute Renal Failure Dysfunction distal to the kidneys

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Acute Renal Failure (2 of 6)

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Acute Renal Failure (3 of 6) Assessment –Focused History Change in urine output Swelling in face, hands, feet, or torso Presence of heart palpitations or irregularity Changes in mental function

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Acute Renal Failure (4 of 6) Physical Assessment –Altered Mental Status –Hypertension –Tachycardia –ECG Indicative of Hyperkalemia –Pale, Cool, Moist Skin

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Acute Renal Failure (5 of 6) Physical Assessment (cont.) –Edema of Face, Hands, or Feet –Abdominal Findings Dependent on the Cause of ARF

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Acute Renal Failure (6 of 6) Management –Airway, Breathing, Circulation –IV Access Protect fluid volume. –Positioning and Transport

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Chronic Renal Failure (1 of 8) Chronic Renal Failure –Permanent Loss of Nephrons –End-Stage Renal Failure (ESRF) Pathophysiology –Similar to Renal ARF Microangiopathy, glomerular injury Tubular cell injury Insterstitial injury

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Chronic Renal Failure (2 of 8)

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Chronic Renal Failure (3 of 8) Impairment of Kidney Functions –Maintenance of blood volume with proper balance of water, electrolytes, and pH Increased sodium, water, and potassium retention –Retention of key compounds such as glucose with excretion of wastes such as urea Loss of glucose and buildup of urea within the blood –Control of arterial blood pressure Disruption of the renin-angiotensin loop resulting in HTN –Regulation of erythrocyte development Development of chronic anemia

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Chronic Renal Failure (4 of 8) Assessment –Differentiate chronic and acute problems. –Focused history and physical exam. Gastrointestinal complaints Changes in mental status Marked abnormalities during physical exam Uremic frost

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Chronic Renal Failure (5 of 8)

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Chronic Renal Failure (6 of 8) Immediate Management –Monitor and support ABCs. –Establish IV access. Regulate fluid volume. –Monitor vital signs and cardiac rhythm. –Expedite transport to an appropriate facility.

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Chronic Renal Failure (7 of 8) Long-Term Management –Renal Dialysis Hemodialysis Common complications

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Chronic Renal Failure (8 of 8) Long-Term Management –Renal Dialysis Peritoneal dialysis Common complications

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Renal Calculi (1 of 3) Pathophysiology –Results when “too much insoluble stuff” accumulates in the kidneys. –Stone types: Calcium salts Struvite stones Uric acid Cystine

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Renal Calculi (2 of 3) Assessment –Focused History Severe pain in one flank that increases in intensity and migrates from the flank to the groin Painful, frequent urination with visible hematuria Prior history of calculi –Physical Exam Difficult due to patient discomfort Tachycardia with pale, cool, and moist skin

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Renal Calculi (3 of 3) Management –Maintain ABCs. –Maintain position of comfort. –Establish IV access. Fluid bolus may promote stone movement and urine formation. –Consider medication administration. Parenteral narcotic analgesics may be indicated.

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Priapism (1 of 2) Painful and prolonged erection of the penis. Priapism affects only the corpora cavernosa. The corpora spongiosum remains flaccid. The most common cause of nontraumatic priapism is sickle cell disease.

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Priapism (2 of 2) Other causes of priapism include: –Leukemia –Multiple myeloma –Tumors –Spinal cord injury –Spinal anesthesia –Carbon monoxide poisoning –Malaria –Black widow spider bites –Prescription and non-prescription drugs

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Urinary Tract Infection (1 of 3) Pathophysiology –Risk Factors Increased risk in female or catheterized patients Sexual activity –Lower and Upper UTIs Urethritis Cystitis Prostatitis Pyelonephritis Community-acquired vs. nosocomial infections

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Urinary Tract Infection (2 of 3) Assessment –Focused History Abdominal pain Frequent, painful urination A “burning sensation” associated with urination Difficulty beginning and continuing to void Strong or foul-smelling urine Similar past episodes

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Urinary Tract Infection (3 of 3) Assessment –Physical Exam Restless, uncomfortable appearance. Presence of a fever. Vital signs vary with degree of pain. Management –Maintain ABCs. –Establish IV access. –Consider analgesics. –Transport to appropriate facility.

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Summary Anatomy and Physiology General Mechanisms of Nontraumatic Tissue Problems General Pathophysiology, Assessment, and Management Renal and Urologic Emergencies