Assessment

HISTORY. Obtain a relevant history from the patient or significant others. If the patient is critically injured, note that the history, assessment, and early management merge in the primary survey. Determine as much as you can from witnesses to the trauma or the life squad.

If the patient's condition is stable enough to warrant a separate history, ask questions about allergies, current medications, preexisting medical conditions, and factors surrounding the injury. Note that patients with preexisting renal diseases such as polycystic kidney disease and pyelonephritis are at higher risk for renal injury than are those with normal kidneys. If you suspect a lower urinary tract injury, ask if the patient has experienced suprapubic tenderness, the inability to void spontaneously, or bloody urine. If you suspect kidney injury, ask the patient if he or she is experiencing flank pain, pain at the costovertebral angle, back tenderness, colicky pain with the passage of blood clots, or bloody urine. Note that if the patient has a positive blood alcohol level, the patient may not be sensitive to painful stimuli even if he or she has experienced a severe injury.

PHYSICAL EXAMINATION. If the patient is stable enough for you to perform a complete head-to-toe assessment, determine if there are any physical signs indicating kidney injury.

920 Urinary Tract Trauma

Note, however, that physical signs may be masked because of the protection of the kidneys by the abdominal organs, muscles of the back, and bony structures. Inspect the area over the 11th and 12th ribs and flank area for obvious hematomas, wounds, contusions, or abrasions. Inspect the lower back and flank for Grey-Turner's sign, or bruising because of a retroperitoneal hemorrhage. Note any abdominal distension. To identify lower urinary tract trauma, inspect the urinary meatus to determine the presence of blood. Note any bruising, edema, or discoloration of the genitalia or tracking of urine into the tissues of the thigh or abdominal wall.

Auscultate for the presence of bowel sounds in all quadrants. Although the absence of bowel sounds does not indicate urinary tract injury for certain, increase your index of suspicion when bowel sounds are absent because abdominal injury often accompanies urinary tract injury. If you note a bruit near the renal artery, notify the physician at once because an intimal tear may have occurred in the renal artery. Percussion may reveal excessive dullness in the lower abdomen or flank. When you palpate the flank, upper abdomen, lumbar vertebrae, and lower rib cage, the patient may experience pain. Other signs of urinary tract trauma include crepitus and a flank mass. Bladder rupture leads to severe pain in the hypogastrium on palpation or swelling from extravasation of blood and urine in the suprapubic area. Signs of peritoneal irritation (abdominal rigidity, rebound tenderness, and voluntary guarding) may also be present because of extravasation of blood or urine into the peritoneal cavity.

PSYCHOSOCIAL. The patient with urinary tract trauma requires immediate emotional support because of the nature of any sudden traumatic injury. The sudden alteration in comfort, potential body image changes, and possible impaired functioning of vital organ systems can often be overwhelming and can lead to maladaptive coping. Determine the patient's and family's level of anxiety and their ability to cope with stressors.

Diagnostic Highlights

Test

Normal Result

Abnormality with Condition

Explanation

Retrograde urethro-

Normal structure of

Transected or torn

Urethra irrigated with contrast

gram

urethra

urethra

media to determine location and extent of injury

Kidney-ureter-

Normal structures of

Location and extent

Contrast media and radiography

bladder x-ray and radionuclide imaging

urinary tract

of injury

used to identify areas of injury

Renal and lower uri

Normal structures

Location and extent

Identifies radiographic slices

nary tract computed tomography

of urinary tract

of injury

with or without contrast

Other Tests: Complete blood count, urinalysis, renal ultrasound, excretory urogram (intravenous pyelogram)

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