Primary Nursing Diagnosis

Pain (acute) related to tissue damage and swelling

OUTCOMES. Comfort level; Pain control behavior; Pain: Disruptive effects; Pain level

INTERVENTIONS. Pain management; Analgesic administration; Positioning; Teaching: Prescribed activity/exercise; Teaching: Procedure/treatment; Teaching: Prescribed medication

^ PLANNING AND IMPLEMENTATION Collaborative

MEDICAL. The initial care of the patient with urinary tract trauma involves airway, breathing, and circulation. Measures to ensure adequate oxygenation and tissue perfusion include establishing an effective airway and supplemental oxygen source, supporting breathing, controlling the source of blood loss, and replacing intravascular volume. As with any traumatic injury, treatment and stabilization of any life-threatening injuries are completed immediately.

SURGICAL. Patients with renal trauma may need urinary diversion with a nephrostomy tube, depending on the location of injury or in situations in which pancreatic and duodenal injury coexist with renal trauma. If the patient is unable to void, the trauma team considers urinary catheterization. If the patient has blood at the urinary meatus or if there is any resistance to catheter insertion, a retrograde urethrogram is performed to evaluate the integrity of the urethra. In the presence of urethral injury, an improperly placed catheter can cause long-term complications, such as incontinence, impotence, and urethral strictures. A suprapubic catheter may be used to manage severe urethral lacerations and urethral disruption. Extraperitoneal bladder rupture is usually managed without surgery but, rather, with urethral or suprapubic catheter drainage. Ongoing monitoring of the amount, character, and color of the patient's urine is important during treatment and recovery. In a patient without renal impairment, the physician usually maintains the urine output at 1 mL/kg per hour. Note any blood clots in the urine, and report an obstructed urinary drainage system immediately.

The indications for surgery depend on the severity of injury. Patients with major renal trauma who are hemodynamically unstable and patients with critical trauma need surgical exploration. Patients with urethral disruption and severe lacerations may have surgery delayed for several weeks or even months, or the surgeon may choose to perform surgical reconstruction immediately. Patients with an intraperitoneal bladder rupture have the bladder surgically repaired, with the extravasated blood and urine evacuated during the procedure. Usually, suprapubic drainage is used during recovery. Laceration of the ureter is immediately repaired surgically or the patient risks loss of a kidney.

Minor renal trauma is usually managed with bedrest and observation. Minor extraperitoneal bladder tears can be managed with insertion of a Foley catheter for drainage, along with antibiotic therapy. Many urethral tears can be managed with insertion of a suprapubic catheter and delayed surgical repair or plasty, provided that bleeding can be controlled. The patient needs to be monitored for complications throughout the hospital stay, such as infection (dysuria, low back pain, suprapubic pain, and foul or cloudy urine), impaired wound healing (seepage of urine from repair sites, flank or abdominal mass from pockets of urine, and crepitus from urine seepage into tissues), and impaired renal function (nausea, irritability, edema, hypertension, oliguria, and anuria).

Pharmacologic Highlights

Medication or

Drug Class Dosage Description Rationale

Phenazopyridine 200 mg PO tid Urinary analgesic Decreases burning, urgency, hydrochloride (Pyridium) and frequency

Other Drugs: Antibiotics for patients with penetrating Injuries or suspected contamination of wounds, analgesia; antispasmodics may be needed for bladder spasm.

922 Urinary Tract Trauma Independent

The most important priority is to ensure the maintenance of an adequate airway, oxygen supply, breathing patterns, and circulatory status. If the patient is stable, apply ice to the perineal area, the scrotum, or the penis to help relieve pain and swelling. Use care to avoid cold burns from ice packs that are in contact with the skin for a prolonged period of time. For severe scrotal swelling, some experts recommend a scrotal support to reduce pain. Use either a commercially available support or a handmade support using an elastic wrap as a sling.

Patients may or may not have residual problems with urinary incontinence or sexual functioning. Loss of urinary continence leads to self-esteem and body image disturbances. Provide the patient with information on reconstructive techniques and methods to manage incontinence. Listen to the patient, and offer support and understanding. Patients often view injury to the urinary tract system as a threat to their sexuality. Reassure patients who are not at risk for sexual dysfunction that their sexuality is not impaired. Sexual concerns should not be ignored during the acute phase of recovery. Be alert to questions about sexuality, which may be phrased in terms that are familiar in the patient's culture. Answer questions honestly, and listen to the patient's questions and responses carefully to understand the full meaning.

Note that the inability to function sexually is an enormous loss to patients of both sexes. It may occur with posterior urethral injury in men when nerve damage occurs in the area. Urinary tract injury in men is often associated with injury to the penis and testes as well. Sexual dysfunction may also occur in women if the ovaries, uterus, vagina, or external genitalia are damaged along with urinary tract structures or the pelvis. Provide specific answers to the patient's questions, such as alternative techniques to intercourse (oral sex, use of a vibrator, massage, or masturbation). Give the patient information about the feasibility and safety of resuming sexual activity, and include the partner in all discussions.

Emotional support of the patient and family is also a key intervention. Patients and their families are often frightened and anxious. If the patient is awake as you implement strategies to manage the airway, breathing, and circulation, provide a running explanation of the procedures to reassure the patient. Explain to the family the treatment alternatives, and keep them updated as to the patient's response to therapy.

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