ASUHAN KEPERAWATAN GAWAT DARURAT

PADA SISTEM PERKEMIHAN

Kusman Ibrahim, Ph.D.

Bagian Keperawatan Medikal Bedah

FAKULTAS KEPERAWATAN
UNIVERSITAS PADJADJARAN

GENERAL STRATEGY
ASSESSMENT
PRIMARY SURVEY
A : AIRWAY AND CERVICAL SPINE
B : BREATHING
C : CIRCULATION
D : DISABILITY (NEUROLOGICAL STATUS)

LEVEL OF CONSCIOUSNESS 
A : ALERT, AWAKE
V : VERBAL
P : PAIN

GLASGOW COMA SCALE 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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 PATHOPHYSIOLOGY
RENAL TRAUMA

MINOR MAJOR PEDICLE INJURY

•CONTUSION • DEEP PARENCHYMAL INJURY (RENAL ARTERY
•CORTICAL WITH INTACT CAPSUL OR VEIN)
LACERATION • DEEP PARENCHYMAL INJURY
•FORNICEAL WITH DISRUPTED CAPSUL
DISRUPTION • SHATTERED KIDNEY WITH
INTACT CAPSUL
• SHATTERED KIDNEY WITH
DISRUPTED CAPSUL
• URETERAL/RENAL PELVIC
INJURY

HEMORRHAGE

HYPOPERFUSION

RENAL DAMAGE

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

Terima Kasih

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