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BACK PAIN
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81
◆ Pancreatitis (acute). Pancreatitis is a life-
threatening disorder that usually produces fulminating, continuous upper abdominal pain
that may radiate to both flanks and to the back.
To relieve this pain, the patient may bend forward, draw his knees to his chest, or move
about restlessly.
Early associated signs and symptoms include
abdominal tenderness, nausea, vomiting, fever,
pallor, and tachycardia; some patients experience abdominal guarding and rigidity, rebound
tenderness, and hypoactive bowel sounds. Jaundice may be a late sign. Occurring as inflammation subsides, Turner’s sign (ecchymosis of the
abdomen or flank) or Cullen’s sign (bluish discoloration of skin around the umbilicus and in
both flanks) signals hemorrhagic pancreatitis.
◆ Perforated ulcer. In some patients, perfora-
tion of a duodenal or gastric ulcer causes sudden, prostrating epigastric pain that may radiate
throughout the abdomen and to the back. This
life-threatening disorder also causes boardlike
abdominal rigidity, tenderness with guarding,
generalized rebound tenderness, absence of
bowel sounds, and grunting, shallow respirations. Associated signs include fever, tachycardia, and hypotension.
◆ Prostate cancer. Chronic aching back pain
may be the only symptom of prostate cancer.
This disorder may also cause hematuria and decreased urine stream.
◆ Pyelonephritis (acute). Pyelonephritis pro-
duces progressive flank and lower abdominal
pain accompanied by back pain or tenderness
(especially over the costovertebral angle). Other
signs and symptoms include high fever and
chills, nausea and vomiting, flank and abdominal tenderness, and urinary frequency and urgency.
◆ Reiter’s syndrome. In some patients,
sacroiliac pain is the first sign of Reiter’s syndrome. Pain is accompanied by the classic triad
of conjunctivitis, urethritis, and arthritis.
◆ Renal calculi. The colicky pain of renal cal-
culi usually results from irritation of the ureteral
lining, which increases the frequency and force
of peristaltic contractions. The pain travels from
the costovertebral angle to the flank, suprapubic
region, and external genitalia. It varies in intensity but may become excruciating if calculi travel down a ureter. Calculi in the renal pelvis and
calyces may cause dull and constant flank pain.
Renal calculi also cause nausea, vomiting, urinary urgency (if a calculus lodges near the bladder), hematuria, and agitation due to pain. Pain
resolves or significantly decreases after calculi
move to the bladder. Encourage the patient to
recover any expelled calculi for analysis.
◆ Sacroiliac strain. Sacroiliac strain causes
sacroiliac pain that may radiate to the buttock,
hip, and lateral aspect of the thigh. The pain is
aggravated by weight bearing on the affected
extremity and by abduction with resistance of
the leg. Associated signs and symptoms include
tenderness of the symphysis pubis and a limp or
a gluteus medius or abductor lurch.
◆ Smallpox (variola major). Worldwide eradi-
cation of smallpox was achieved in 1977; the
United States and Russia have the only known
storage sites of the virus. The virus is considered a potential agent for biological warfare.
Initial signs and symptoms include high fever,
malaise, prostration, severe headache, backache, and abdominal pain. A maculopapular
rash develops on the oral mucosa, pharynx,
face, and forearms and then spreads to the
trunk and legs. Within 2 days, the rash becomes
vesicular and later pustular. The lesions develop
at the same time, appear identical, and are
more prominent on the face and extremities.
The pustules are round, firm, and deeply embedded in the skin. After 8 to 9 days, the pustules form a crust, which later separates from
the skin, leaving a pitted scar. Death may result
from encephalitis, extensive bleeding, or secondary infection.
◆ Spinal neoplasm (benign). Spinal neo-
plasm typically causes severe localized back
pain and scoliosis.
◆ Spinal stenosis. Resembling a ruptured in-
tervertebral disk, spinal stenosis produces back
pain with or without sciatica, which commonly
affects both legs. The pain may radiate to the
toes and may progress to numbness or weakness unless the patient rests.
◆ Spondylolisthesis. A major structural disor-
der characterized by forward slippage of one
vertebra onto another, spondylolisthesis may
produce no symptoms or may cause low back
pain with or without nerve root involvement.
Associated symptoms of nerve root involvement
include paresthesia, buttock pain, and pain radiating down the leg. Palpation of the lumbar
spine may reveal a “step-off” of the spinous
process. Flexion of the spine may be limited.
◆ Transverse process fracture. This type of
fracture causes severe localized back pain with
muscle spasm and hematoma.
◆ Vertebral compression fracture. A verte-
bral compression fracture may be painless
82 BACK PAIN
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PATIENT-TEACHING AID
Exercises for chronic low back pain
Dear Patient:
If you have chronic low back pain, the exercises illustrated here may help relieve your discomfort and prevent further lumbar deterioration. When you perform these exercises, keep
in mind the following points:
◆ Breathe slowly, inhaling through your nose
and exhaling completely through pursed lips.
◆ Begin gradually, performing each exercise
only once per day and progressing to 10 repetitions.
◆ Exercise moderately; expect mild discomfort,
but stop if you experience severe pain.
Back press
Lie on your back, with your arms on your chest
or abdomen and your knees bent. Press the
small (lower portion) of your back to the floor
while tightening your abdominal muscles and
buttocks. Count to 10; then slowly relax.
Knee grasp
Lie on your back, with your knees bent. Bring
one knee to your chest, grasping it firmly with
both hands; lower your knee. Repeat with the
other knee—then with both knees, as shown
here.
Knee bend
Stand with your hands on
the back of a chair for support. Keeping your back
straight, slowly bend your
knees until you’re in a
squatting position. Return
to your starting position.
Trunk curl
Lie on your back, with your knees bent and
feet flat. Cross your arms on your chest. Lift
your head and shoulders off of the floor, and
hold for a count of 2. Repeat 10 times. Work up
to at least 30, taking brief rests as needed.
This patient-teaching aid may be reproduced by office copier for distribution to patients. © 2011, Lippincott Williams &
Wilkins.
BARREL CHEST
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83
initially. Several weeks later, it causes back pain
aggravated by weight bearing and local tenderness. Fracture of a thoracic vertebra may cause
referred pain in the lumbar area.
◆ Vertebral osteomyelitis. Initially, vertebral
osteomyelitis causes insidious back pain. As it
progresses, the pain may become constant,
more pronounced at night, and aggravated by
spinal movement. Accompanying signs and
symptoms include vertebral and hamstring
spasms, tenderness of the spinous processes,
fever, and malaise.
◆ Vertebral osteoporosis. Vertebral osteo-
porosis causes chronic aching back pain that is
aggravated by activity and somewhat relieved
by rest. Tenderness may also occur.
O
THER CAUSES
◆ Neurologic tests. Lumbar puncture and
myelography can produce transient back pain.
S
PECIAL CONSIDERATIONS
Monitor the patient closely if the back pain
suggests a life-threatening cause. Be alert for
increasing pain, altered neurovascular
status in the legs, loss of bowel or bladder
control, altered vital signs, sweating, and
cyanosis.
Until a tentative diagnosis is made, withhold
analgesics, which may mask symptoms. Also
withhold food and fluids in case surgery is necessary. Make the patient as comfortable as possible by elevating the head of the bed and placing a pillow under his knees. Encourage
relaxation techniques such as deep breathing.
Prepare the patient for a rectal or pelvic examination. He may also require routine blood tests,
urinalysis, computed tomography scan, appropriate biopsies, and X-rays of the chest, abdomen, and spine.
Fit the patient for a corset or lumbosacral
support, but instruct him not to wear it in bed.
He may also require heat or cold therapy, a
backboard, a convoluted foam mattress, or
pelvic traction. Explain these pain-relief measures to the patient. Teach the patient about alternatives to analgesic drug therapy, such as
biofeedback and transcutaneous electrical
nerve stimulation.
Be aware that back pain is notoriously associated with malingering. Refer the patient to
other professionals, such as a physical therapist,
an occupational therapist, or a psychologist, if
indicated.
P
EDIATRIC POINTERS
Children may have difficulty describing back
pain, so be alert for nonverbal clues, such as
wincing or refusing to walk. Closely observe the
family dynamics during history taking for clues
of child abuse.
Back pain in children may stem from intervertebral disk inflammation (diskitis), neoplasms,
idiopathic juvenile osteoporosis, and spondylolisthesis. Disk herniation typically doesn’t
cause back pain. Scoliosis, a common disorder
in adolescents, rarely causes back pain.
G
ERIATRIC POINTERS
Suspect metastatic cancer—especially of the
prostate, colon, or breast—in older patients with
a recent onset of back pain that usually isn’t relieved by rest and worsens at night.
P
ATIENT COUNSELING
If the patient has chronic back pain, reinforce
instructions about bed rest, analgesics, antiinflammatories, and exercise. (See Exercises for
chronic low back pain.) Also, suggest that he
take daily warm baths to help relieve pain. Help
the patient recognize the need to make necessary lifestyle changes, such as losing weight or
correcting poor posture. Advise patients with
acute back pain secondary to a musculoskeletal
problem to continue their daily activities as tolerated, rather than staying on total bed rest.
Barrel chest
In barrel chest, the normal elliptical configuration of the chest is replaced by a rounded one in
which the anteroposterior diameter enlarges to
approximate the transverse diameter. The diaphragm is depressed and the sternum pushed
forward with the ribs attached in a horizontal,
not angular, fashion. As a result, the chest appears continuously in the inspiratory position.
(See Recognizing barrel chest, page 84.)
Typically a late sign of chronic obstructive
pulmonary disease (COPD), barrel chest results
from augmented lung volumes due to chronic
airflow obstruction. The patient may not notice
it because it develops gradually.
H
ISTORY AND PHYSICAL
EXAMINATION
Begin by asking about a history of pulmonary
disease. Note chronic exposure to environmental
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Recognizing barrel chest
In a normal adult chest, the ratio of anteroposterior to transverse (or lateral) diameter is 1:2. In
patients with barrel chest, this ratio approaches 1:1 as the anteroposterior diameter enlarges.
NORMAL CHEST
Anteroposterior
diameter
Spinal
cord
Transverse
diameter
BARREL CHEST
Anteroposterior
diameter
Spinal
cord
Transverse
diameter
irritants such as asbestos. Also ask about the
patient’s smoking habits.
Then explore other signs and symptoms of
pulmonary disease. Does the patient have a
cough? Is it productive or nonproductive? If it’s
productive, have him describe the sputum’s color and consistency. Does the patient experience
shortness of breath? Is it related to activity? Although dyspnea is common with COPD, many
patients fail to associate it with the disease. Instead, they blame “old age” or “getting out of
shape” for causing dyspnea.
Auscultate for abnormal breath sounds, such
as crackles and wheezing. Then percuss the
chest. Hyperresonant sounds indicate trapped
air; dull or flat sounds indicate mucus buildup.
Be alert for accessory muscle use, intercostal
retractions, and tachypnea, which may signal
respiratory distress.
Finally, observe the patient’s general appearance. Look for central cyanosis in the cheeks,
nose, and mucosa inside the lips. In addition,
look for peripheral cyanosis in the nail beds.
Also note clubbing, a late sign of COPD.
M
EDICAL CAUSES
◆ Asthma. Typically, barrel chest develops only
in chronic asthma. An acute asthma attack
causes severe dyspnea, wheezing, and a productive cough. It can also cause prolonged
BATTLE’S SIGN
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85
expiratory time, accessory muscle use, tachycardia, tachypnea, perspiration, and flushing.
◆ Chronic bronchitis. A late sign in chronic
bronchitis, barrel chest is characteristically preceded by a productive cough and exertional
dyspnea. This form of COPD may also cause
cyanosis, tachypnea, wheezing, prolonged expiratory time, and accessory muscle use.
◆ Emphysema. Barrel chest is a late sign in
this form of COPD. Typically, emphysema begins
insidiously, with dyspnea the predominant
symptom. Eventually, it may also cause chronic
cough, anorexia, weight loss, malaise, accessory muscle use, pursed-lip breathing, tachypnea,
peripheral cyanosis, and clubbing.
S
PECIAL CONSIDERATIONS
To ease breathing, have the patient sit and lean
forward, resting his hands on his knees to support the upper torso (tripod position). This position allows maximum diaphragmatic excursion,
facilitating chest expansion.
P
EDIATRIC POINTERS
In infants, the ratio of anteroposterior to transverse diameter is normally 1:1. As the child
grows, this ratio gradually changes to 1:2 by age
5 to 6. Cystic fibrosis and chronic asthma may
cause barrel chest in children.
G
ERIATRIC POINTERS
In elderly patients, senile kyphosis of the thoracic spine may be mistaken for barrel chest.
However, patients with senile kyphosis lack
signs of pulmonary disease.
P
ATIENT COUNSELING
Advise the patient to avoid bronchial irritants,
especially smoking, which may exacerbate
COPD. Tell him to report purulent sputum production, which may indicate upper respiratory
tract infection. Instruct him to space his activities to help minimize exertional dyspnea.
Battle’s sign
Battle’s sign—ecchymosis over the mastoid
process of the temporal bone—is commonly the
only outward sign of a basilar skull fracture. In
fact, this type of fracture may go undetected even
by X-ray of the skull. If left untreated, a basilar
skull fracture can be fatal because of associated
injury to the nearby cranial nerves and brain stem
as well as to blood vessels and the meninges.
Appearing behind one or both ears, Battle’s
sign is easily overlooked or hidden by the patient’s hair. During emergency care of a trauma
victim, it may be overshadowed by imminently
life-threatening or more apparent injuries.
A force that’s strong enough to fracture the
base of the skull causes Battle’s sign by damaging supporting tissues of the mastoid area and
causing seepage of blood from the fracture site
to the mastoid. Battle’s sign usually develops 24
to 36 hours after the fracture and may persist
for several days to weeks.
H
ISTORY AND PHYSICAL
EXAMINATION
Perform a complete neurologic examination,
beginning with the history. Ask the patient
about recent trauma to the head. Did he sustain
a severe blow to the head? Was he involved in a
motor vehicle accident? Note the patient’s level
of consciousness as he responds. Does he respond quickly or slowly? Are his answers appropriate, or does he appear confused?
Check the patient’s vital signs; be alert for
widening pulse pressure and bradycardia,
signs of increased intracranial pressure. Assess cranial nerve function in nerves II, III, IV,
VI, VII, and VIII. Evaluate pupillary size and
response to light as well as motor and verbal
responses. Relate these data to the Glasgow
Coma Scale. Also, note cerebrospinal fluid
(CSF) leakage from the nose or ears. Ask
about postnasal drip, which may reflect CSF
drainage down the throat. Look for the halo
sign—a bloodstain encircled by a yellowish
ring—on bed linens or dressings. To confirm
that drainage is CSF, test it with a Dextrostix;
CSF is positive for glucose, whereas mucus
isn’t. Follow up the neurologic examination
with a complete physical examination to detect other injuries associated with a basilar
skull fracture.
M
EDICAL CAUSES
◆ Basilar skull fracture. Battle’s sign may be
the only outward sign of a basilar skull fracture,
or it may be accompanied by periorbital ecchymosis (raccoon eyes), conjunctival hemorrhage,
nystagmus, ocular deviation, epistaxis, anosmia, a bulging tympanic membrane (from CSF
or blood accumulation), visible fracture lines on
the external auditory canal, tinnitus, difficulty
hearing, facial paralysis, or vertigo.
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Identifying Biot’s respirations
Biot’s respirations, also known as ataxic respirations, have a completely irregular pattern. Shallow and deep breaths occur randomly, with haphazard, irregular pauses. The respiratory rate
tends to be slow and may progressively decelerate to apnea.
S
PECIAL CONSIDERATIONS
Expect a patient with a basilar skull fracture to
be on bed rest for several days to weeks. Keep
him flat to decrease pressure on dural tears and
to minimize CSF leakage. Monitor his neurologic status closely. Avoid nasogastric intubation
and nasopharyngeal suction, which may cause
cerebral infection. Also, caution the patient
against blowing his nose, which may worsen a
dural tear.
The patient may need skull X-rays and a
computed tomography scan to help confirm a
basilar skull fracture and to evaluate the severity
of the head injury. Typically, these fractures and
any associated dural tears heal spontaneously
within several days to weeks. However, if the
patient has a large dural tear, a craniotomy may
be necessary to repair the tear with a graft
patch.
P
EDIATRIC POINTERS
Children who are victims of abuse commonly
sustain basilar skull fractures from severe blows
to the head. As in adults, Battle’s sign may be
the only outward sign of fracture and, perhaps,
the only clue to child abuse. If you suspect child
abuse, follow hospital protocol for reporting the
incident.
the medulla coinciding with brain stem compression.
EMERGENCY INTERVENTIONS Observe
the patient’s breathing pattern for several
minutes to avoid confusing Biot’s respirations with
other respiratory patterns. (See Identifying Biot’s
respirations.) Prepare to intubate the patient and
provide mechanical ventilation. Next, take vital
signs, noting especially increased systolic
pressure
.
M
EDICAL CAUSES
◆ Brain stem compression. Biot’s respirations
are characteristic in brain stem compression—a
neurologic emergency. Rapidly enlarging lesions may cause ataxic respirations and, eventually, complete respiratory arrest.
S
PECIAL CONSIDERATIONS
Monitor vital signs frequently. Elevate the head
of the patient’s bed 30 degrees to help reduce
intracranial pressure. Prepare the patient for
emergency surgery to relieve pressure on the
brain stem. Computed tomography scans or
magnetic resonance imaging may confirm the
cause of brain stem compression.
Because Biot’s respirations typically reflect a
grave prognosis, keep the patient’s family informed and provide emotional support.
Biot’s respirations
[Ataxic respirations]
A late and ominous sign of neurologic deterioration, Biot’s respirations are characterized by
irregular and unpredictable rate, rhythm, and
depth. This rare breathing pattern may appear
abruptly and may reflect increased pressure on
P
EDIATRIC POINTERS
Biot’s respirations are rarely seen in children.
Bladder distention
Bladder distention—abnormal enlargement of
the bladder—results from an inability to excrete
BLADDER DISTENTION 87
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urine, which then accumulates in the bladder.
Distention can be caused by a mechanical or
anatomic obstruction, a neuromuscular disorder, or the use of certain drugs. Relatively common in all ages and both sexes, it’s most common in older men with prostate disorders that
cause urine retention.
Distention usually develops gradually, but it
occasionally has a sudden onset. Gradual distention usually causes no symptoms until
stretching of the bladder produces discomfort.
Acute distention produces suprapubic fullness,
pressure, and pain. If severe distention isn’t corrected promptly by catheterization or massage,
the bladder rises within the abdomen, its walls
become thin, and renal function can be impaired.
Bladder distention is aggravated by the intake
of caffeine, alcohol, large quantities of fluid, and
diuretics. (See Bladder distention: Causes and as-
sociated findings, pages 88 and 89.)
EMERGENCY INTERVENTIONS If the pa-
tient has severe distention, insert an indwelling urinary catheter to help relieve discomfort and prevent bladder rupture. If more than 700
ml is emptied from the bladder, compressed blood
vessels dilate, which may make the patient feel
faint. Typically, the indwelling urinary catheter is
clamped for 30 to 60 minutes to permit vessel
compensation.
H
ISTORY AND PHYSICAL
EXAMINATION
If distention isn’t severe, begin by reviewing the
patient’s voiding patterns. Find out the time and
amount of the patient’s last voiding and the
amount of fluid consumed since then. Ask if he
has difficulty urinating. Does he use Valsalva’s
or Credé’s maneuver to initiate urination? Does
he urinate with urgency or without warning? Is
urination painful or irritating? Ask about the
force and continuity of his urine stream and
whether he feels that his bladder is empty after
voiding.
Explore the patient’s history of urinary tract
obstruction or infections; venereal disease; neurologic, intestinal, or pelvic surgery; lower abdominal or urinary tract trauma; and systemic
or neurologic disorders. Ask about his drug history, including his use of over-the-counter
drugs.
Take the patient’s vital signs, and percuss
and palpate the bladder. (Remember that if the
bladder is empty, it can’t be palpated through
the abdominal wall.) Inspect the urethral meatus, and measure its diameter. Describe the appearance and amount of any discharge. Finally,
test for perineal sensation and anal sphincter
tone; in male patients, digitally examine the
prostate gland.
M
EDICAL CAUSES
◆ Benign prostatic hyperplasia (BPH). In
BPH, bladder distention develops gradually as
the prostate enlarges. Occasionally, its onset is
acute. Initially, the patient experiences urinary
hesitancy, straining, and frequency; reduced
force of and inability to stop the urine stream;
nocturia; and postvoiding dribbling. As the disorder progresses, it produces prostate enlargement, sensations of suprapubic fullness and incomplete bladder emptying, perineal pain,
constipation, and hematuria.
◆ Bladder calculi. Bladder calculi may pro-
duce bladder distention, but pain is usually the
only symptom. The pain is usually referred to
the tip of the penis, the vulvar area, the lower
back, or the heel. It worsens during walking or
exercise and abates when the patient lies down.
It’s usually most severe when micturition ceases. The pain may be accompanied by urinary
frequency and urgency, terminal hematuria, and
dysuria.
◆ Bladder cancer. By blocking the urethral ori-
fice, neoplasms can cause bladder distention.
Associated signs and symptoms include hematuria (most common sign); urinary frequency
and urgency; nocturia; dysuria; pyuria; pain in
the bladder, rectum, pelvis, flank, back, or legs;
vomiting; diarrhea; and sleeplessness. A mass
may be palpable on bimanual examination.
CULTURAL CUE Bladder cancer is twice as
common in Whites as in Blacks. It’s relatively
uncommon among Asians, Hispanics, and Native
Americans.
◆ Multiple sclerosis. In this neuromuscular
disorder, urine retention and bladder distention
result from interruption of upper motor neuron
control of the bladder. Associated signs and
symptoms include optic neuritis, paresthesia,
impaired position and vibratory senses, diplopia,
nystagmus, dizziness, abnormal reflexes,
dysarthria, muscle weakness, emotional lability,
Lhermitte’s sign (transient, electric-like shocks
that spread down the body when the head is
flexed), Babinski’s sign, and ataxia.
◆ Prostate cancer. Prostate cancer eventually
causes bladder distention in about 25% of
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SIGNS & SYMPTOMS
Bladder distention: Causes and associated findings
Major associated signs and symptoms
Common
causes
Benign prostatic
hyperplasia
Bladder calculi
Bladder cancer
Multiple sclerosis
Prostate cancer
Prostatitis (acute)
Prostatitis (chronic)
Spinal neoplasms
Urethral calculi
Urethral strictures
patients. Usual signs and symptoms include dysuria, urinary frequency and urgency, nocturia,
weight loss, fatigue, perineal pain, constipation,
and induration of the prostate or a rigid, irregular prostate on digital rectal examination. In
some patients, urine retention and bladder distention are the only signs.
CULTURAL CUE Prostate cancer is more
common in Blacks than in other ethnic
groups.
◆ Prostatitis. In acute prostatitis, bladder dis-
tention occurs rapidly along with perineal discomfort and a sensation of suprapubic fullness.
Other signs and symptoms include perineal
pain; tense, boggy, tender, and warm enlarged
prostate; decreased libido; impotence; decreased force of the urine stream; dysuria;
hematuria; and urinary frequency and urgency.
Additional signs and symptoms include fatigue,
Ataxia
•
Constipation
Dysuria
Fatigue
•
••
••
•
••
•
••••
••
••••
•
Fever
Hematuria
Muscle weakness
Myalgia
Nausea
Nocturia
Pain, buttock and
sacral
Pain, flank
Pain, lower back
•
•
••••
•
•
•
•
•
•
•
•
malaise, myalgia, fever, chills, nausea, and
vomiting.
Bladder distention is rare in chronic prostatitis, which may be accompanied by perineal discomfort, a sensation of suprapubic fullness,
prostatic tenderness, decreased libido, urinary
frequency and urgency, dysuria, pyuria, hematuria, persistent urethral discharge, ejaculatory
pain, and dull pain radiating to the lower back,
buttocks, penis, or perineum.
◆ Spinal neoplasms. Disrupting upper neuron
control of the bladder, spinal neoplasms cause
neurogenic bladder and resultant distention.
Associated signs and symptoms include a sense
of pelvic fullness, continuous overflow dribbling, back pain that often mimics sciatica pain,
constipation, tender vertebral processes, sensory deficits, and muscle weakness, flaccidity,
and atrophy. Signs and symptoms of urinary
tract infection (dysuria, urinary frequency and
Pain, pelvic
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Pain, penile
Pain, perineal
Pain, vulvar
Prostatic
enlargement
Prostatic rigidity
Pyuria
Suprapubic
fullness
Urethral
BLADDER DISTENTION
discharge
Urinary
frequency
Urinary stream
changes
Urinary urgency
89
Vomiting
•
•
•• •
•
•
•
•
••
•
•
•
••
•
urgency, nocturia, tenesmus, hematuria, and
weakness) may also occur.
◆ Urethral calculi. In urethral calculi, urethral
obstruction leads to interrupted urine flow and
bladder distention. The obstruction causes pain
radiating to the penis or vulva and referred to
the perineum or rectum. It may also produce a
palpable stone and urethral discharge.
◆ Urethral stricture. Urethral stricture results
in urine retention and bladder distention with
chronic urethral discharge (most common sign),
urinary frequency (also common), dysuria, urgency, decreased force and diameter of the
urine stream, and pyuria. Urinoma and urosepsis may also develop.
O
THER CAUSES
◆ Catheterization. Using an indwelling urinary
catheter can result in urine retention and bladder distention. While the catheter is in place,
•
••
•
•
••
•
••
•
•
•
•••
•
•
•
••
•
•
••
inadequate drainage due to kinked tubing or an
occluded lumen may lead to urine retention. In
addition, a misplaced urinary catheter or irritation due to catheter removal may cause edema,
thereby blocking urine outflow.
◆ Drugs. Parasympatholytics, anticholinergics,
ganglionic blockers, sedatives, anesthetics, and
opiates can produce urine retention and bladder
distention.
S
PECIAL CONSIDERATIONS
Monitor the patient’s vital signs and the extent
of bladder distention. Encourage the patient to
change positions to alleviate discomfort. Provide an analgesic if necessary.
Prepare the patient for diagnostic tests (such
as endoscopy and radiologic studies) to determine the cause of bladder distention. You may
need to prepare him for surgery if interventions
•
•
•
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fail to relieve bladder distention and obstruction
prevents catheterization.
P
EDIATRIC POINTERS
Look for urine retention and bladder distention
in any infant who fails to void normal amounts.
(In the first 48 hours of life, an infant excretes
about 60 ml of urine; during the next week, he
excretes about 300 ml of urine daily.) In males,
posterior urethral valves, meatal stenosis,
phimosis, spinal cord anomalies, bladder diverticula, and other congenital defects may cause
urinary obstruction and resultant bladder
distention.
P
ATIENT COUNSELING
If the patient doesn’t require immediate urinary
catheterization, provide privacy and suggest
that he assume the normal voiding position.
Teach him to perform Valsalva’s maneuver, or
gently perform Credé’s maneuver. You can also
stroke or intermittently apply ice to the inner
thigh, or help him relax in a warm tub or sitz
bath. Use the power of suggestion to stimulate
voiding. For example, run water in the sink,
pour warm water over his perineum, place his
hands in warm water, or play tapes of aquatic
sounds.
Blood pressure decrease
[Hypotension]
Low blood pressure refers to inadequate intravascular pressure to maintain the body’s oxygen requirements. Although commonly linked
to shock, this sign may also result from cardiovascular, respiratory, neurologic, or metabolic
disorders. Hypoperfusion states especially affect
the kidneys, brain, and heart, and may lead to
renal failure, change in level of consciousness
(LOC), or myocardial ischemia. Low blood pressure may also be caused by certain diagnostic
tests—most commonly those using contrast
media—and the use of certain drugs. It may stem
from stress or a change of position—specifically,
rising abruptly from a supine or sitting position
to a standing position (orthostatic hypotension).
Normal blood pressure varies considerably;
what qualifies as low blood pressure for one
person may be perfectly normal for another.
Consequently, every blood pressure reading
must be compared against the patient’s baseline. Typically, a reading below 90/60 mm Hg,
or a drop of 30 mm Hg from the baseline, is
considered low blood pressure.
Low blood pressure can reflect an expanded
intravascular space (as in severe infections, allergic reactions, or adrenal insufficiency), reduced intravascular volume (as in dehydration
and hemorrhage), or decreased cardiac output
(as in impaired cardiac muscle contractility). Because the body’s pressure-regulating mechanisms are complex and interrelated, a combination of these factors usually contributes to low
blood pressure.
EMERGENCY INTERVENTIONS If the pa-
tient’s systolic pressure is less than 80 mm
Hg, or 30 mm Hg below his baseline, suspect
shock immediately. Quickly evaluate the patient
for a decreased LOC. Check his apical pulse for
tachycardia and respirations for tachypnea. Also,
inspect the patient for cool, clammy skin.
Elevate his legs above the level of his heart, or
place him in Trendelenburg’s position if the bed
can be adjusted. Then start an I.V. line using a
large-bore catheter to replace fluids and blood
or to administer drugs. Prepare to administer
oxygen with mechanical ventilation if necessary.
Monitor the patient’s intake and output, and
insert an indwelling urinary catheter for the
accurate measurement of urine. The patient
may also need a central venous access device or
a pulmonary artery catheter to facilitate monitoring of fluid status. Prepare for cardiac
monitoring to evaluate cardiac rhythm. Be
ready to insert a nasogastric tube to prevent
aspiration in the comatose patient. Throughout
emergency interventions, keep the patient’s
spinal column immobile until spinal cord trauma is ruled out.
H
ISTORY AND PHYSICAL
EXAMINATION
If the patient is conscious, ask him about associated symptoms. For example, does he feel unusually weak or fatigued? Has he had nausea,
vomiting, or dark or bloody stools? Is his vision
blurred? Gait unsteady? Does he have palpitations, chest or abdominal pain, or difficulty
breathing? Has he had episodes of dizziness or
fainting? Do these episodes occur when he
stands up suddenly? If so, take the patient’s
blood pressure while he’s lying down, sitting,
and then standing and compare readings. A
drop in systolic or diastolic pressure of 10 mm
Hg or more and an increase in heart rate of
more than 15 beats/minute between position
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