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ASUHAN KEPERAWATAN GAWAT DARURAT

PADA SISTEM PERKEMIHAN
Kusman Ibrahim, Ph.D. Kusman Ibrahim, Ph.D. Kusman Ibrahim, Ph.D. Kusman Ibrahim, Ph.D.
Bagian Keperawatan Klinik
FAKULTAS ILMU KEPERAWATAN
UNIVERSITAS PADJADJARAN
GENERAL STRATEGY
ASSESSMENT
PRIMARY SURVEY
A : AIRWAY AND CERVICAL SPINE
B : BREATHING
C : CIRCULATION
D : DISABILITY (NEUROLOGICAL STATUS)
LEVEL OF CONSCIOUSNESS
GLASGOW COMA SCALE
A : ALERT, AWAKE
V : VERBAL
P : PAIN
U : UNRESPONSIVE
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SECONDARY SURVEY
E : EXPOSURE
F : FREEZING/FAHRENHEIT
G : GET VITALS SIGN
H : HEAD TO TOE, HISTORY
I : INSPECT THE POSTERIOR SURFACE
PSYCHOLOGICAL, SOCIAL AND ENVIROMENTAL RISK FACTORS
PERSONAL HABITS :
UNPROTECTED SEXUAL ACTIVITY
MULTIPLE SEXUAL PARTNERS
NEW SEXUAL PARTNER IN LAST 2 MONTHS
FLUID INTAKE
IMMOBILITY
POOR PERINEAL HYGIEN
OTHER RISK FACTORS:
PREGNANCY
DIABETES
GOUT
SPINAL CORD INJURY
PREVIOUS INFECTIONS
RECENT GENITOURINARY
INSTRUMENTATION
PRESSENCE OF PELVIC FRACTURE
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FOCUSED SURVEY
SUBJECTIVE DATA :
HISTORY OF PRESENT ILLNESS :
PAIN PQRST
DISCHARGE VAGINAL, URETHRAL, RECTAL
CHANGE IN URINARY ELIMINATION PATTERNS
INJURY
FEVER AND CHILLS
CHANGE IN EATING / FEEDING PATTERN
TISSUE / SKIN CHANGES
LETHARGY OR IRRITABILITY
SEXUAL HISTORY
MEDICAL HISTORY
TRAUMA
SURGERY / URETHRAL INSTRUMENTATION
RENAL DESEASE
STDS
CURRENT MEDICATION & MEDICATION
ALLERGIES
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OBJECTIVE DATA
PHISICAL EXAMINATION
GENERAL SURVEY :
GENERAL APPEARANCE
LEVEL OF CONSCIOUSNESS
VITAL SIGNS
INSPECTION :
GUARDING WITH MOVEMENT
WOUND ---- OPEN OR CLOSED
PRESENCE OF VISIBLE FOREIGN OBJECTS
ODOR
PRESENCE OF DISCHARGE, BLEEDING,
INFLAMMATION, RASH, LESSIONS
ASYMETRY OR DEFORMITY OF AFFECTED PART
AUSCULTATION :
BOWEL SOUND
FETAL HEART TONES IF PREGNANT
PERCUSSION
BLADDER DISTENSION
COSTOVERTEBRAL ANGLE (CVA) TENDERNESS
PALPATION
AREA OF TENDERNESS
ABDOMEN
TESTES
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DIGNOSTIC PROCEDURES :
LABORATORY STUDIES
URINALYSIS, URIN STONE ANALYSIS,
BUN/CREATININE, BLOOD COUNT, PT/PTT
RADIOGRAPHIC STUDIES
ABDOMEN / KUB, CYSTOGRAM, IVP, USG,
CT SCAN
SELDOM OCCURS INDEPENDENTLY,
SHOULD BE CONSIDERED IN ANY
PATIENT PRESENTING WITH CHEST,
ABDOMINAL OR BACK TRAUMA
HIGH INCIDENCE WITH VERTEBRAL &
FLANK INJURIES
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MINOR
CONTUSION
CORTICAL
LACERATION
FORNICEAL
DISRUPTION
PATHOPHYSIOLOGY
RENAL TRAUMA
MAJOR
DEEP PARENCHYMAL INJURY
WITH INTACT CAPSUL
DEEP PARENCHYMAL INJURY
WITH DISRUPTED CAPSUL
SHATTERED KIDNEY WITH
INTACT CAPSUL
SHATTERED KIDNEY WITH
DISRUPTED CAPSUL
URETERAL/RENAL PELVIC
INJURY
PEDICLE INJURY
(RENAL ARTERY
OR VEIN)
RENAL DAMAGE
HEMORRHAGE
HYPOPERFUSION
Figure 71-6 Types of blunt renal trauma. Types A and B often respond to nonoperative treatment. Types C and
D usually require operative treatment. Although type C injuries often may be operated on in a delayed fashion,
unless vascular disruptive injuries are recognized immediately and treated promptly, loss of the kidney usually
occurs, and successful repair is rare. (From O'Neill JA Jr: Principles of Pediatric Surgery, 2nd ed. St. Louis,
Mosby, 2003, p 173.)
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Categories of Renal Injuries
Michael Federle placed renal
injuries into four categories:
Minor injury:
renal contusion.
intrarenal and subcapsular
hematoma.
minor laceration with limited
perinephric hematoma without
extension to the collecting
system or medulla.
small subsegmental infarct.
Major injury:
major laceration into medulla
or collecting system.
segmental infarct.
Catastrophical injury:
Maceration of the kidney
Total devascularization due tot
arterial occlusion.
Rupture collecting system.
http://www.radiologyassistant.nl/en/466181ff61073
ASSESSMENT
SUBJECTIVE DATA :
HISTORY OF PRESENT ILLNESS
MECHANISM OF INJURY
PAIN, CVA OR ABDOMINAL
NAUSEA, VOMITING
MEDICAL HISTORY
MEDICATIONS
ALLERGIES
RENAL DESEASES
HYPERTENSION
HISTORY OF RENAL SURGERY
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OBJECTIVE DATA :
PHYSICAL EXAMINATION
GENERAL SURVEI RAPID HR, HYPOTENSION,
PALLOR, MOIST AND COOL SKIN IN PRESENCE
OF HEMORRHAGE
FOCUSED FLANK, ABDOMINAL EXAMINATION
RETROPERITONEAL HEMATOMA
HEMATURIA GROSS
OLIGURIA OR ANURIA
CONTUSIONS, ABRASIONS, LACERATIONS
BOWEL SOUNDS
CVA TENDERNESS
DIAGNOSTIC PROCEDURES :
COMPLETE BLOOD COUNT WITH
DIFFERENTIAL
SERIAL HT.
SERUM ELECTROLYTES
BUN, CREATININE
PT/PTT
URINALYSIS
TYPE AND CROSS MATCH BLOOD
ABDOMINAL X-RAY
IVP
CT SCAN
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NURSING DIAGNOSIS
ALTERED CARDIAC OUTPUT RELATED TO
HEMORRHAGE AND DIMINISHED
CIRCULATING BLOOD VOLUME
TISSUE PERFUSION, ALTERED R.T.
HEMORRHAGE
PAIN R.T. EFFECTS OF TARUMA
RISK FOR INFECTIONS R.T. ALTERATION IN
SKIN INTEGRITY
ANXIETY R.T. UNKNOWN OUTCOME OF
INJURY
PLANNING / INTERVENTIONS
MAINTAIN AIRWAY, BRETHING, CIRCULATION
ESTABLISH LARGE-BORE PERIPHERAL IV ACCESS FOR
ADMINISTRATION OF CRISTALLOID MEDICATIONS,
POSSIBLE BLOOD PRODUCTS AND DX PROCEDURES
CONTINOUSLY MONITOR : HEMODYNAMIC STATUS,
NEUROLOGICAL STATUS, TISSUE PERFUSION, PULSE
OXIMETRY, INTAKE-OUTPUT
PREPARE FOR/ASSIST WITH MEDICAL INTERVENTIONS;
BLOOD PRODUCTS TRANSFUSION, RONTHGENT AND DX.
STUDIES, SURGERY
ADMINISTER PHARMACOLOGICAL THERAPY AS ORDERED;
TETANUS TOXOID/SERUM, ANALGESICS, ANTIBIOTICS
ALLOW SUPORTIVE SIGNIFICANT OTHER TO REMAIN WITH
PATIENT AND PARTICIPATE IN CARE AS APPROPRIATE
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TERMINOLOGY:
ARF : THE ABRUPT FALL OR CESATION OF URINE
VOLUME AND THE RETAINMENT OF METABOLIC WASTE
PRODUCTS.
ACUT TUBULAR NECROSIS (ATN): CLINICAL SYNDROME
OF ARF SECONDARY TO ISCHEMIA OR TOXIC INJURY TO
THE RENAL TUBULES
AZOTEMIA: AN EXCESS OF METABOLIC WASTE PRODUCT
IN THE BLOOD; UREA, NITROGEN, CREATININ
OLIGURIA: URINE VOLUME < 400 ML/24 HOURS
RENAL INSUFFICIENCY: A COMPROMISED STATE OF
KIDNEY FUNCTION IN THE ABSENCE OF CLINICAL
MANIFESTATIONS. LABORATORY TESTS INDICATE
DETERIORATION OF NEPHRONIC FUNCTION.
TYPES OF ACUT RENAL FAILURE
PRERENAL FAILURE
RENAL FAILURE
POSRENAL FAILURE
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PRERENAL FAILURE
OCCURS WHEN THERE IS DECREASE IN EFFECTIVE
ARTERIAL BLOOD VOLUME PERFUSING THE KIDNEY
CAUSES
VOLUME DEPLETION HEMORRHAGE, FLUID LOSSES
FROM SKIN, GIT, DIURETICS
CO CHF, PERICARDIAL TAMPONADE,
ARRHYTHMIAS
ALTERED VASCULAR RESISTANCE VASODILATING
DRUGS, CA CHANNEL BLOCKER, ACE INHIBITORS,
SEPSIS
RENAL FAILURE
RENAL FUNCTION LOSS OCCURS SECONDARY
TO STRUCTURAL DAMAGE WITHIN THE KIDNEY
CAUSES
GLOMERULONEPHRITIS
VASCULAR LESIONS (INFLAMATORY,
TROMBOEMBOLIC), RENAL ARTERI STENOSIS
INTERSTITIAL NEPHRITIS (INFECTIOUS OR
ALLERGIC)
ATN
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POSTRENAL FAILURE
IT IS CAUSED BY CONDITIONS THAT ABSTRUCT
URINE FLOW
CAUSES
URINARY CALCULI, COLLECTING SYSTEM CLOTS,
STRICTURE, HYPERTROPHIED PROSTATE
MECHANICAL OBSTRUCTION BY KINKING OF THE
INDWELLING CATHETER
PHASES OF ACUT RENAL FAILURE
OLIGURIC PHASE:
DAILY URINE OUTPUT < 400 ML
COMPLICATIONS OVERHYDRATION ACCOMPANIED BY
CARDIAC FAILURE, PULMONARY EDEMA, ACIDOSIS,
HYPERKALEMIA, UREMIC SYMPTOMS
DIURETIC PHASE:
INCREASE OF URINE VOLUME,
OSMOTIC DIURESIS HIGH LEVEL OF UREA
INABILITY OF THE KIDNEYS TO CONSERVE SODIUM &
WATER
RECOVERY PHASE:
THE FILTRATING & CONCENTRATING OF KIDNEYS
RESTORED
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CLINICAL DATA
LABORATORY TEST:
URINALYSIS
IN RENAL FAILURE: URINE SODIUM , SPECIFIC GRAVITY
AND OSMOLALITY , URINE SEDIMENT; CAST(+), WBC(+),
RBC (+)
BUN (N: 8-25 MG/100 ML)
PRERENAL, RENAL, POSTRENAL FAILURE BUN
BUN OVERHYDRATION, SEVERE LIVER DAMAGE, A
DIET LOW IN PROTEIN
CREATININ (N: 0,6 1,2 MG/100 ML)
CRETAININ 2X N 50 % NEPHRON LOSS, 8X N 75 %
LOSS OF NEPHRONIC FUNCTION
BUN-CREATINI RATIO 10 : 1
DIAGNOSTIC TESTS
CYTOSCOPY
IVP
X-RAY --- KUB
RENAL ANGIOGRAPHY
RENAL USG
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SYSTEMIC CONSEQUENCES OF ARF
ELECTROLYTE IMBALANCES HYPERKALEMIA
METABOLIC ACIDOSIS KUSMAUL BREATHING, ANOREXIA,
NAUSEA, CONFUSION, SHORTENED MEMORY AND ATTENSION
SPAN, STUPOR OR COMA, IF CONTINUOUS ---
CARDIOVASCULAR EFFECS; CO , BP , ARRHYTHMIAS
INFECTION MACROPHAGE ACTIVITY E.C. UREMIC TOXINS
UREMIA
NEUROLOGICAL SIGNS; CONFUSION, CONVULSIONS, COMA,
CHANGE IN SENSORIUM
GIT; ANOREXIA, VOMITING, BLEEDING
INFECTIONS
BRUISING AND BLEEDING BLOOD COAGULATION FACTOR
DYSFUNCTION
ANEMIA; ERYTHROPOIETIN ,ERYTHROCYTE DESTRUCTION
VOLUME OVERLOAD
NURSING MANAGEMENT
NURSING DIAGNOSIS
FLUID VOLUME DEFICIT R.T. HYPOVOLEMIA
(EXTRACELLULAR DEHYDRATION),
HYPERNATREMIA (INTRACELLULAR DEHYHRATION)
FLUID VOLUME, ALTERATION IN: EXCESS ( EC
OVERHYDRATION, HYPERVOLEMIA, CIRCULATORY
OVERLOAD)
ELECTROLYTE IMBALANCE R.T. : WATER DEFICIT /
WATER EXCESS, HYPERNATREMIA /
HYPONATREMIA
CARDIAC OUTPUT, ALTERATION IN : DECREASE
R.T. :DYSRYTHMIAS, HYPERKALEMIA ( > 5.5 MEQ/L),
HYPOKALEMIA ( < 3.5 MEQ/L)
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NURSING DIAGNOSIS (Cont.)
ACID-BASE BALANCE: ALTERATION IN, R.T.
METABOLIC ACIDOSIS
NUTRITION, ALTERATION IN : LESS THAN BODY
REQUIREMENTS
INFECTION, POTENTIAL FOR : DEPRESSED
IMMUNOLOGIC SYSTEM
INJURY, POTENTIAL FOR : UREMIA-INDUCED G.I
DISORDERS
COMFORT, ALTERATION IN : PAIN (PERICARDITIS)
KNOWLEDGE DEFICIT : DIETARY REGIMEN IN RENAL
DISEASE
ACTIVITY ALTERATION IN : FATIGUE AND ANEMIA
COPING INEFFECTIVE INDIVIDUAL / FAMILY ;
POTENTIAL
NURSING INTERVENTIONS
ASSESS IMPACT OF FLUID VOLUME DEFICIT ON BODY
PROCESSES
ASSESS NEUROLOGIC STATUS; LEVEL OF CONSCIOUSNESS,
BEHAVIORAL CHANGE (IRRITABILITY, RESTLESSNESS,
LETHARGY)
ASSESS STATUS OF HEMODYNAMIC FUNCTION ; HR,
PERIPHERAL PULSES, TACHYPNEA, POSTURAL
HYPOTENSION, CVP
MONITOR BODY TEMPERATURE; FEVER
ASSESS RENAL FUNCTION; BUN, CREATININE, URINE OUTPUT,
SG > 1.030, INTAKE-OUTPUT
ASSESS GI FUNCTION; ANOREXIA, NAUSEA, VOMITING,
ABDOMINAL CRAMPS AND DISTENTION, DIARRHEA
ASSESS BODY WEIGHT (DAILY)
COLLABORATE WITH PHYSICIAN TO CORRECT UNDERLYING
CAUSE OF FLUID IMBALANCE
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NURSING INTERVENTIONS (Cont.)
IMPLEMENT FLUID REPLACEMENT REGIMEN;
ECF : SALINE DEFICIT (HYPONATREMIA):
SALINE FLUID REPLACEMENT ORALLY OR IV UNTILL OLIGURIA
IS RELIEVED, HEMODYNAMIC STABILIZE,NEUROLOGIC STATUS
IS ANTACT, MONITOR REHYDRATION, INSERT FOLEY
CATHETER, MONITOR FOR SIGNS OF FLUID EXCESS.
ICF DEFICIT, WATER DEFICIT (HYPERNATREMIA):
ASSESS NEUROLOGIC FUNCTION: WEAKNESS,
RESTLESSNESS, IRRITABILITY, HYPERPNEA, TETANY
WATER REPLACEMENT ORALLY OR IV WITH 5 % DEXTROSE,
AVOID FURTHER WATER LOSS, KEEP PATIENT AND
ENVIROMENT COOL, USE ANTIPYRETICS MAY BE INDICATED
FOR FEVER
MONITOR SERUM SODIUM LEVELS, SERUM PROTEINS,
URINARY SODIUM, URINE SPECIFIC GRAVITY
MEDICAL MANAGEMENT
OLIGURIC PHASE CONTROL FLUIDS, PREVENT
TISSUE CATABOLISM, ENHANCE WASTE PRODUCT
EXRETION, REGULATE ELECTROLYTE
COMPOSITION.
THERAPY; DYALISIS, FLUID AND DIETARY
RESTRICTION (K , PROTEIN ,CARBOHYDRATE
), TPN ( AMINO ACID ,GLUCOSA ),
KAYEXALATE, NAHCO3, ANTIBIOTICS, MINIMAL USE
INVASIVE LINES AND CATHETER
DIURETIC PHASE; REGULATION OF
ELECTROLYTES, MAINTENANCE OF FLUID
VOLUME, DIETARY RESTRICTIONS
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DIALYSIS IN ARF, INDICATIONS:
URAEMIC SYMPTOMS, e.g.,PERICARDITIS
VOLUME OVERLOAD
HYPERKALEMIA
METABOLIC ACIDOSIS
CONTINUOUS RENAL REPLACEMENT THERAPY
THREE CATEGORIES:
SLOW CONTINUOUS ULTRAFILTRATION (SCUF)
CONTINUOUS HEMOFILTRATION (CAVH, CVVH)
CONTINUOUS (AV,VV) HAEMODIALYSIS AND
PERITONEAL DIALYSIS
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MANAGEMENT OF SPECIFIC CONDITIONS
HYPERKALEMIA
HEMODIALYSIS
ORAL OR RECTAL POTASSIUM EXCHANGE AGENTS (CALCIUM
RESONIUM)
INTRAVENOUS INSULIN + DEXTROSE
VOLUME OVERLOAD
FLUID INTAKE RESTRICTIONS (EQUAL THE DAILY URINE
OUTPUT PLUS 300-500 Ml)
DALYSIS
METABOLIC ACIDOSIS
LIMITING THE LEVEL INTAKE OF PROTEIN
INFUSE SODIUM BICARBONATE BE AWARE FLUID
OVERLOAD & HYPERNATREMIA
BICARBONATE HD
DONOR :
AGE ; 0 75 YEARS
CONTRAINDICATIONS HISTORY OF INVASIVE
CANCER, PRESENCE UNTREATED SYSTEMIC
BACTERIAL, VIRAL OR FUNGAL INFECTIONS, HIV
ANTIBODY (+), HBSAG (+)
RECIPIENT :
HUMAN LEUKOCYTE ANTIGEN (HLA) MATCHING
BETWEEN DONOR RECIPIENT
ABO BLOOD GROUP CROSSMATH
REVIEV OF ALL BODY SYSTEMS CV
PSYCHOLOGICAL & IMMUNOLOGIC EVALUATION
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TRANSPLANT REJECTION :
HYPERACUTE REJECTION (MINUTE HOURS)
ACCELERATED REJECTION (FIRST WEEK)
ACUTE REJECTION A CELL MEDIATED
RESPONSE; T , GENERAL MALAISE,
TENDERNESS OVER GRAFT, BP , URINE
OUTPUT , PERIPHERAL EDEM, BW
CRONIC REJECTION A HUMORAL RESPONSE;
RENAL FUNCTION (MONTHS YEARS)
IMMUNOSUPPRESSION :
CYCLOSPORINE PREVENT REPLICATION OF T
LYMPHOCYTES BY INHIBITING THE PRODUCTION
INTERLEUKIN-2
ANTILYMPHOCYTE GLOBULIN (ALG) USED TO
TREAT ACUT REJECTION BY DESTROYING THE
CIRCULATORY LYMPHOCYTES
PREDNISONE
AZATHIOPRINE INHIBITING PROLIFERATION OF
LYMPHOCYTES
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Clinical Management Clinical Management
Preoperative: Preoperative:
Provide Provide routine preoperative routine preoperative care care
Assess Assess knowledge and feelings about the knowledge and feelings about the
procedure, procedure, answering questions answering questions and clarifying and clarifying
information as needed. Listen information as needed. Listen and address and address
concerns about surgery, the source of the donor concerns about surgery, the source of the donor
organ and organ and possible complications. possible complications.
Continue Continue dialysis as ordered. dialysis as ordered.
Administer Administer immunosuppressive drugs as immunosuppressive drugs as
ordered before ordered before surgery surgery
Clinical Management Clinical Management
Postoperative: Postoperative:
Provide Provide routine postoperative routine postoperative care care
Maintain Maintain urinary catheter patency and a closed urinary catheter patency and a closed
system. system.
Measure Measure urine output every 30 to 60 minutes urine output every 30 to 60 minutes
initially. initially.
Monitor Monitor vital signs and hemodynamic pressures vital signs and hemodynamic pressures
closely. closely.
Maintain Maintain fluid replacement, generally calculated fluid replacement, generally calculated
to to replace urine replace urine output over the previous 30 or output over the previous 30 or
60 minutes, milliliter 60 minutes, milliliter for milliliter for milliliter. .
Administer Administer diuretics as ordered. diuretics as ordered.
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Clinical Management Clinical Management
Postoperative: Postoperative:
Remove the catheter within 2 to 3 days or as Remove the catheter within 2 to 3 days or as
ordered. Encourage to void every 1 to 2 hours ordered. Encourage to void every 1 to 2 hours
and assess frequently for signs of urinary and assess frequently for signs of urinary
retention following catheter removal. retention following catheter removal.
Monitor serum electrolytes and renal function Monitor serum electrolytes and renal function
tests. tests.
Monitor for possible complications: Monitor for possible complications:
Hemorrhage Hemorrhage
Urethral Urethral anastomosis anastomosis failure failure
Renal artery thrombosis Renal artery thrombosis
infection infection
Health Education Health Education
The use and effects of prescribed medications, including The use and effects of prescribed medications, including
antihypertensive medications, immunosuppressive agents, antihypertensive medications, immunosuppressive agents,
prophylactic antibiotics, and others as ordered. prophylactic antibiotics, and others as ordered.
Monitoring vital signs (including temperature) and weight. Monitoring vital signs (including temperature) and weight.
Manifestations of organ rejection, such as swelling and Manifestations of organ rejection, such as swelling and
tenderness over the graft site, fever, joint aching, weight tenderness over the graft site, fever, joint aching, weight
gain, and decreased urinary output. Stress the importance gain, and decreased urinary output. Stress the importance
of promptly reporting signs and symptoms to the physician. of promptly reporting signs and symptoms to the physician.
Ordered or recommended dietary restrictions such as Ordered or recommended dietary restrictions such as
restricted carbohydrate and sodium intake, and increased restricted carbohydrate and sodium intake, and increased
protein intake. protein intake.
Measures to prevent infection, such as avoiding crowds and Measures to prevent infection, such as avoiding crowds and
obviously ill individuals. obviously ill individuals.
Provide Provide psychologic psychologic support, address concerns, and provide support, address concerns, and provide
information as needed information as needed
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Terima Kasih Terima Kasih Terima Kasih Terima Kasih