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Certified Emergency Nurse (CEN) Exam Review
Jeff Solheim
GASTROINTES TINAL EMERGENCIES
Objectives:
At the completion of this section, the learner will be able to:
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Priorit ize treat ments for patients with esophageal emergencies
Recognize signs of gastritis
Verbalize d ischarge instructions for patients with hepatitis
Differentiate between symptoms of small bowel obstructions and large bowel obstructions
Identify the abdominal organ most frequently injured in trau matic situations
The CEN exam contains ten questions on gastrointestinal emergencies which invol ve the followi ng topics:
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Acute Abdomen (e.g. peritonitis, appendicitis
Bleeding
Cholecystitis
Cirrhosis
Divert iculitis
Esophageal varices
Esophagitis
Foreign bodies
Gastritis
Gastroenteritis
Hepatitis
Hernia
Inflammatory Bowel Disease
Intussusception
Obstructions
Pancreatitis
Trau ma
Ulcers
 Esophageal problems



Esophageal obstruction
 Consider potential for airway obstruction
 Glucagon or nitroglycerin (s mooth muscle relaxants) given if object can safely be passed through the GI system.
 Esophagoscopy considered when medication is ineffect ive or the object cannot safely pass through the GI system.
Mallory-Weiss tears (small tears in the junction of the esophagus and stomach caused by violent wretching and vomiting.)
 Bleeding is usually self limiting
 In rare cases, may need flu id resuscitation and injection of epinephrine to control bleeding.
Boerhaave’s syndrome (Rupture of the esophageal wall secondary to violent wretching and vomiting.)
 IV fluids
 Antibiotics
 Surgical repair
 Esophageal varices (bleeding from distended blood vessels in the esophagus and stomach, usually secondary to liver disease)
 Treat ment
 Treat hypovolemic shock with intravenous fluids and blood products
 Vasopressin (Pitressin) or sandostatin (Octreotide) – may be g iven with nitroglycerin to prevent cardiac ischemia
 Vitamin K (aquaM EPHYTON) to reverse underlying coagulopathies of liver disease
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Endoscopic procedures to control bleeding
Sengstaken-Blakemo re tube or Minnesota tube
1 |P age
Certified Emergency Nurse (CEN) Exam Review
Jeff Solheim
 Esophagitis and Gastritis
Esophagitis
Causes
Sympto ms
Gastroesophageal Reflu x Disorder (GERD), Achalasia
(impaired mot ility of the lower 2/ 3 of the esophagus),
Helicobacter Pylori infection, ingestion of noxious
substances, stress, tobacco
Esophageal infections, drugs that inflame the esophagus.
Pain
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Ep igastric pain relieved by eating food
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Burning in the chest
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Nausea and vomiting (hematemesis)

Worse with activities that increase intra-abdominal
pressure
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Diarrhea

Anorexia

Worse 30 – 60 minutes after eating.

Intestinal gas

Cholinergics, such as bethanechol (Urecholine), increase lower esophageal sphincter pressure and promote
gastric emptying.
Dopami ne antagonists, such as metoclopramide (Reglan), move food through the gastrointestinal system
faster.
Antaci ds, such as aluminum and magnesium (Maalo x), neutralize stomach acid.
Histami ne (H2 )-receptor antagonists, such as ranitidine (Zantac), block acid production.
Proton pump inhi bitors, such as lansoprazole (Prevacid), shut down the acid pump in the stomach.
Aci d-protecti ve agents, such as sucralfate (Carafate), provide a thick protective coat over the lower
esophagus and stomach.
Avoid irritating substances (NSAIDs, alcohol)
Avoid foods which decrease pressure on lower esophagus (chocolate, fatty foods, onion, garlic, peppermint,
spearmint, tea and coffee).
Avoid medicat ions which relax the lower esophagus (anticholinergics, beta-blockers, calciu m channel
blockers, diazepam, morphine sulfate, n icotine, nitrates, progesterone, estrogen and theophylline)
Eat s mall meals
Elevate HOB on 6 – 8” b locks
Encourage weight loss and smoking cessation

Treat ment
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Discharge
Gastritis

instructions
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 Ulcers
Duodenal ulcers
Gastric ulcers
•Common between the ages of
30 and 55
•Pain starts prior to meals and is
relieved by food or antacids
•Common between the ages of
55 and 70.
•Pain usually occurs after eating
Regardless of site of
ulcer, typical pain is
described as
“squeezing”,
“indigestion”,
“gnawing”,
“colicky”, “aching”
or “feeling of
fullness” that is often
epigastric and may
radiate through to the
mid back
Definiti on:
 Disorders of organs of the bile duct (liver, gall b ladder, pancreas)
Murphy’s sign –
 Cholecystits
inability of the patient
 Signs and symptoms
to inhale deeply during
palpation under the
 Pain
right costal margin
 RUQ tenderness, guarding and rigid ity, aggravated by taking a deep breath
near the liver
 Typically follows ingestion of fried ro fatty foods or ingesion of a large meal.
 Murphy’s sign (inability to inhale deeply during palpation under the right costal marg in near the liver).
 Fever (with infection)
 Jaundice/dark urine
2 |P age
Certified Emergency Nurse (CEN) Exam Review
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

Jeff Solheim
Diagnosis

Elevated white blood cell count, serum and urine bilirubin and A LT.

Thickened gallbladder wall, gallstones and pericholecystic fluid on u ltrasound.
Treat ment

IV fluids

Antiemetics and analgesics

NPO/ Gastric tube

Antibiotics
 Cholecystectomy (after infection has subsided)
Pancreatitis (inflammation of the pancreas)

Clin ical manifestations

Pain - Rapid onset epigastric through to the back aggravated by eating, alcohol intake,
walking or ly ing supine but relieved by leaning forward or assuming fetal position

Abdomen tender to palpation
 Abnormal labs include elevated WBC, serum amylase, seru m glucose and serum trig lycerides.
Co mplications associated with pancreatitis
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Pleural effusion and acute
respiratory distress
syndrome (A RDS)
Pancreatic abscess and
sepsis
Retroperitoneal b leeding
and hypovolemia
Hypocalcaemia

Pancreatic inflammation can lead to activation of the inflammatory response with
capillary permeab ility can lead to fluid accu mu lation in the lungs (ARDS) and pleural
effusions.
The infection can lead to pancreatic abscesses and sepsis. Sympto ms may include a
worsening fever, increasing abdominal pain and indicat ions of sepsis.
Autolysis caused by release of pancreatic enzy mes can cause bleeding fro m the pancreas
and other abdominal structures. Signs and symptoms include hypotension, tachycardia,
a diminishing hematocrit, abdominal distension, bruising of the flanks and u mbilicus
Sympto ms include tetany and serum calciu m levels below 8 mg/ 100 dL.
Treat ment
Agent
Purpose
Analgesia
Nitrog lycerin or papaverine
Antispasmodics such as dicyclomine (Bentyl
or propantheline bromide (Pro-Banthine)
Carbonic anhydrase inhibitor such as
acetazolamide (Diamo x)
Antacids
Histamine H2 -receptor antagonists such as
cimetid ine (Tagamet) and ranitid ine (Zantac)
Calciu m gluconate
Corticosteriods
Relief of pain
Relaxation of smooth muscles (pain relief)
Glucagon
Decrease vagal stimu lation and release of pancreatic en zy mes
Reduction in volu me and concentration of pancreatic juices)
Neutralize gastric secretions
Decreases hydrochloric acid which can d iminish pancreatic secretions
Treat ment of hypocalcemia
Treat ment of sepsis
Reduces pancreatic inflammation and decreases serum amy lase as
well as supressing pancreatic secretions
 Hepatitis
Transmission
Notes
•
•
Causes epidemic
Vaccine available
Hepatitis A
Fecal/Oral
Hepatitis B
Parenteral/Sexual/ occupational exposure/
perinatal/human bites
•
Parenteral/occupational exposure/deviant
sexual p ractices, perinatal
Defective RNA virus that requires HBV
for duplicat ion and survival
• 50% become chronic
May be asymptomat ic at first
• Similar to Hepatitis B
• HBV and HDV  risk for cirrhosis
• Similar to Hepatitis A
Rare in the USA, mo re co mmon in Asia, Mexico and Africa
Hepatitis C
Hepatitis D
Hepatitis E
Enteric – contaminated fish/water
Can be acute (< 6 months) or chronic (> 6 months)
• Vaccine available
•
•
3 |P age
Certified Emergency Nurse (CEN) Exam Review

Jeff Solheim
Indications of liver dysfunction
 Elevated ammon ia levels/decreased urea levels (treated with lactulose)
 Decreased albumin and calciu m levels with generalized edema and ascites (treated with albumin ad ministration and
removal of fluid fro m the peritoneum)
 Lack of clotting factors leading to petechiae, easy bruising and bleeding (treatedwith vitamin K)
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Elevated serum and urine b ilirubin (decreased fecal b ilinogens).
Clay colored stools and dark colored urine (which foams when shaken).
Jaundice
Steattorhea
Liver en zy mes (ALP, SGOT, SGPT and GGT) elevate.
Albumin decreases
Definiti on: Steatorrhea – Chunky yellow foul
 PT and PTT climb
smelling fatty stools which float in toilet water
Clin ical Manifestations (hepatitis)
 Mild cases – malaise, fatigue, anorexia, nausea and vomit ing, right upper quadrant pain, jo int pain
 Severe cases – jaundice, clay colored stools, dark colored urine
Treat ment
Discharge Instructions for Hepatit is
 Acute cases must run their course
Fecal/Oral (A and E)
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Severity of chronic cases may be diminished with:
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Interferon-alpha
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Pegylated interferon
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Adefovir dipivo xil
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Lamivudine
 Riboflavin
 Appendicitis (Inflammation of the appendix)
 Sympto ms
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Pain (starts umbilical, then localizes to McBurney’s point in
the RLQ).
Pressure on the LLQ results in pain in the RLQ (Rovsing’s
sign).
Flexion of the knees decreases pain
Pain may be in the RUQ in pregnant wo men
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 Private BR at ho me
Avoid handling food eaten by others
Parenteral (B, C, D)
Do not donate blood, organs or other
tissue
 Protected sex
Do not share personal items (toothbrush,
razors)
All (A, B, C, D, E)
 Avoid alcohol
Small frequent feedings low in fat, high
in carbohydrates
 Avoid steroid medications.
 Elevated WBC
 Fever
 Vo mit ing
 En larged appendix on ultrasound or CT scan.
 Treat ment: Surgery
 Peritonit is (inflammation of the peritoneum)
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Sympto ms
 Pain
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Diffuse abdominal pain which worsens with movement or coughing.
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Relieved with flexion of the knees
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 Tenderness to palpation
Rigid (washboard) abdomen.
Fever/sepsis
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Decreased bowel sounds
Dehydration/electrolyte imbalances
Respiratory difficulties
4 |P age
Certified Emergency Nurse (CEN) Exam Review

Jeff Solheim
Treat ment
 NPO/Surgery
 IV fluids and antibiotics
 Analgesics/Antiemet ics/Antipyretics
 Divert iculitis (Inflammation of the diverticula of the colon, usually the sigmoid colon.)
 Clin ical manifestations
 Generalized abrupt onset aching cramp ing pain wh ich localizes to the LLQ.
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 Fever and  WBC
 Abdominal tenderness
Treat ment
 NPO/gastric tube to rest bowel
 IV fluid rep lacement
 Antibiotics
 Surgery for ruptured diverticuli
 Bowel obstruction
 Potential co mplications:
 Dehydration/electrolyte imbalances
 Bowel ischemia
 Rupture of the bowel
Discharge Instructions (Diverticulitis)
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Avoid straining while defecating
Drink 8 g lasses of water daily
Low-fat, lo w-fiber diet during the acute
phase
High-fiber diet after the acute phase (fruits,
vegetables, and grains)
Stool-softeners
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Small versus large bowel obstruction:
Clinical Mani festati on
Small Intestine
Large Intestine
Onset
Rapid
Gradual
Vo mit ing
Frequent and copious (bile and feces)
Rare
Colicky, cramp -like, intermittent,
Pain
Low-grade, crampy, abdominal pain
wave-like pain
Bowel Movement
Feces for a short period of time
Absolute constipation
Abdominal Distension
Minimally increased
Greatly increased
• Fever and tachycardia
• Hypertension (early) leading to hypotension (late)
• High pitched peristaltic rush pro ximal to the obstruction  absent bowel sounds
Shared characteristics
(late)
• Borboryg mi
•  WBC
 Specific bowel obstructions
Pyloric stenosis
Intussuscepti on
Marked hypertrophy and hyperplasia of the pylorus
Definiti on
Telescoping of the bowel within itself
muscle and narrowing of the gastric antru m
Most common near the ileocecal valve or a
Common
Pylorus muscle between the stomach and the small
Merkel’s diverticu lu m (in adults, may occur near a
locati on
intestine
colon tumor or polyp)
Age
95% occur during the first 3 – 12 weeks of life.
Most common between 3 months and one year.
Colicky pain associated with peristalsis.
Child may sleep fo r 15 – 30 minutes, then
scream with pain and pull legs to abdomen for
Projectile vo miting
15-30 minutes, then fall back asleep
Poor weight gain
Lethargy and fever wh ich worsen due to
Continual hunger and constipation
increased ischemia o f the bowel.
Frequent
Jaundice
Mucusy bloody stool that may look like grape
symptoms
Gastric peristalsis prior to emesis
jelly
Mobile, hard, “olive” shaped mass over pylorus
Vo mit ing food, mucus or fecal matter
Elevated bilirubin, hypochloremia, and
Increased bowel sounds during painful
hypokalemia
episodes
Tender, palpable “sausage-shaped” mass over
the site of the intussusceptions in the right
lower and middle abdomen
5 |P age
Certified Emergency Nurse (CEN) Exam Review

Jeff Solheim
Treat ment for bowel obstruction
 IV fluids for flu id and electrolyte imbalance.
 Antiemetics and analgesics
 Rest the bowel (NPO and gastric tube)
 Bariu m enema – Intussuception
 Surgery –
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Vo lvulus
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Pyloric stenosis
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Indications of perforation
 Functional bowel syndromes
•
Degree of d isease
Clin ical
man ifestations
•
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Regional ileitis
Inflammatory disease of the ileu m
(may affect other parts of the GI
tract)
Affects all layers
Abdominal d istension
Anemia
Weight loss
Low-grade fever
Nausea and Vo miting
Dehydration and fluid/electro lyte
imbalances
Abdominal cramping and
tenderness
Flatulence
3 – 4 semi-soft stools daily with
no blood, some fat is present and
stools are foul smelling
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Potential co mplications of functional bowel syndromes
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 Fistulas (with regional ileitus)
 Intestional obstructions
 Malnutrition
 Bowel performation
 Toxic megacolon
Treat ment
•
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Ulcerative colitis
Chronic inflammatory d isease affecting only the
large intestine commonly in the sigmo id and
rectal areas.
Affects only the mucosal and submucosal layers
Abdominal d istension
Anemia
Weight Loss
Fever
Nausea and Vo miting
Dehydration and fluid/electro lyte imbalances
Abdominal cramping typically in the left lo wer
quadrant
Diarrhea (5 – 25 stools/day) with blood, mucus
and pus but no fat
Rectal Bleeding
Discharge Instructions for functional bowel
syndromes
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Avoid foods that are bothersome.
Typical offenders include:
 Raw fruits
 Vegetables
 Spicy foods
Reduce stress
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No cure – requires lifestyle changes
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Analgesia and antipyretics
IV rehydration
Anticholinergics to reduce intestinal spasms
Antidiarrheals to control diarrhea
Anti-inflammatories such as sulfasalazine{Azu lfidine] to reduce inflammation
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Antimicrobials to prevent infection
Corticosteriods to reduce inflammation
Immunosuppressant such as Mercaptopurine (Pu rinethol) or Azathioprine (Imuran) to suppress antibody/antigen
reactions
6 |P age
Certified Emergency Nurse (CEN) Exam Review
Jeff Solheim
 Abdominal t rauma
Organ
Notes
Spleen
 Most frequently injured abdominal organ
 Associated with fractures of ribs 10 – 12 on the left.
Liver
 Associated with fractures of ribs 8 – 12 on the right.
Signs and symptoms
 LUQ pain (referred to left shoulder)
 LUQ bruising
 Hypovolemia
 Signs of peritoneal irritability
 RUQ pain (referred to right shoulder)
 RUQ b ruising
 Hypovolemia
 Rigid abdomen/rebound tenderness
Stomach
 Rare in b lunt trauma, more co mmon in penetrating
trauma and pediatric patients.
 Treated surgically. Consider gastric tube and
antibiotics in ED.
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


Pancreas
 Frequently missed injury with high mortality rate.
 Consider mechanism of injury
 Ep igastric pain (often delayed)
 Abdominal d istension
 Requires surgical intervention.
  bowel sounds
 Rebound tenderness
  serum amy lase, lipase and glucose (delayed
up to six hours)
 Small bowel inju red more frequently than large
bowel.
 Requires surgical intervention.
 Sympto ms often delayed.
 Generalized abdominal pain
 N&V
Bowel
trauma
Hematemesis
 bowel sounds
Rebound tenderness
Rigid abdomen
Free air on CXR
 Hypovolemia/sepsis
  bowel sounds
 Abdominal tenderness, rebound tenderness,
abdominal rigid ity.
7 |P age
Certified Emergency Nurse (CEN) Exam Review
Jeff Solheim
Practice Questions
Which of the follo wing lab values is likely to be decreased in a patient with cirrhosis of the liver?
a)
b)
c)
d)
Seru m b ilirubin
Seru m ammonia
Blood urea nitrogen
Partial thro mboplastin time
Which of the follo wing presentations is most consistent with a patient who has pancreatitis?
a.
b.
c.
d.
Ep igastric pain that radiates to the umbilical reg ion
Ep igastric pain that radiates midline through to the back
Left upper quadrant pain that radiates to the left shoulder
Right upper quadrant pain that radiates to the right shoulder
Which of the follo wing conditions will likely go direct ly to the operating room fro m the emergency department?
a.
b.
c.
d.
Pancreatitis
Cholecystitis
Ulcerative colitis
Boerhaave’s syndrome
The emergency nurse knows a patient with end stage cirrhosis of the liver has understood their discharge instructions if they state that
they will min imize their intake of:
a)
b)
c)
d)
Starch
Protein
Carbohydrates
Fresh fruits and vegetables
ANSWERS: C, B, D, B
8 |P age
Certified Emergency Nurse (CEN) Exam Review
Jeff Solheim
GENITOURINARY, OBS TETRICAL AND GYN ECOLOGICAL EMERGENCIES
Objectives:
At the completion of this section, the learner will be able to:
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Priorit ize interventions appropriate for genitourinary trau ma
Differentiate between various sexually transmitted diseases based on a patient’s presenting complaint
Verbalize nursing care for a patient with a fractured penis
Differentiate between various causes of ovarian cysts based on a patient’s complaints
Define six types of abortion
List the steps involved in assisting with childbirth
The CEN exam contains ten questions on genitourinary, obstetrical and g ynecol ogical emergencies which invol ve the following
topics:
Genitourinary
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Foreign bodies
Infection (e.g., urinary tract
infection, pyelonephritis,
epididymit is, orchitis, STDs)
Phimosis
Priapism
Prostate conditions
Renal calculi
Testicular torsion
Trau ma
Urinary retention (e.g. caused by
trauma or neurological disorders)
Gynecology
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
Bartholin’s cyst
Bleeding/dysfunctional (vaginal)
Foreign bodies
Hemorrhage
Infection (e.g. discharge, pelvic
inflammatory disease, STD)
Ovarian Cyst
Sexual assault/battery
Obstetrics
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
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

Threatened/spontaneous
abortion
Ectopic Pregnancy
Emergent Delivery
Antepartum bleed ing
Hyperemesis gravidarum
Neonatal resuscitation
Preeclampsia, eclampsia,
HELLP syndrome
Preterm labor
Trau ma

Genitourinary trau ma
o Kidney
 Frequent mechanis m of injury is blunt trau ma:
 MVC
 Fall fro m great height
 Often associated with posterior lo wer rib fractures or fractured lower spinous processes.
 Penetrating trauma
 Clin ical manifestations
Key points
 Abdominal, flank o r back tenderness
 Flank bruising
 Hematuria (66% of cases have frank hematuria, may be occult or absent in the rest)
o
 Hypovolemia
Bladder and urethral trau ma
 Risk factors include fu ll bladder, pelvic fractures and pediatric patients.
 Straddle in juries
 Genital trau ma
 Foreign bodies
 Clin ical manifestations
 Inability or difficulty voiding (partial tears may be able to void.)
 Suprapubic, perineal or genital pain related to voiding, attempting to void or bladder distension
 Blood in the urinary meatus/hematuria
 Indications of hypovolemia
 Lower abdominal or perineal hematomas and/or distension
9 |P age
Certified Emergency Nurse (CEN) Exam Review


Do NOT catheterize if patient has a known or suspected partial or co mplete transaction.

Elevate knees for bladder injuries (unless the patient has thoracic or head trauma)

Surgical candidates:
o Hemodynamic instability
o Renal pedicle damage
o

Most bladder and urethral in juries
Renal co lic (accumulation of materials within the renal pelvis into a stone which typically exits out the genitourinary system
causing significant discomfort.)
o
o

Jeff Solheim
Treat ment
 Analgesia
Sympto ms
 Flank, abdominal or genital pain
 Frank o r occult hematuria
Treat ment
 Pharmacological agents
 Analgesics
 Anti-emet ics
 Anti-inflammatory agents
 Antibiotics
 IV fluid rehydration
 Measure intake and output
 Strain urine
 Admission for large stones, indications of sepsis, poor pain management, and altered elimination.
Sexually Transmitted Diseases
o Genital Herpes (This chronic, incurable sexually
transmitted disease is caused by the herpes simplex virus
type 2)


o
First symptoms are flu-like sympto ms
immed iately after exposure to the virus followed
by stinging and burning around the genetalia
than eruption of blisters in the area of the pain.
The symptoms will usually resolve in after
several weeks, but may recur 3 to 4 t imes per
year, especially in times of stress or with local
trauma to the genital area. There is no cure.
 Treat ment: antiviral medicat ions, warm baths,
topical anesthetics, analgesics
Gonorrhea and Chlamyd ia
 Sympto ms: A thick yellow or white d ischarge

fro m the genitalia 2 – 7 days after exposure. Other
symptoms such as abnormal vaginal bleeding,
vaginal itching, and dysuria sometimes occur.
Women may also develop pelvic inflammatory
disease.
Treat ment: Antibiotics
•
•
•
•
•
•
•
Discharge teaching for genital herpes
Use barrier protection during intercourse and
avoid intercourse during periods of outbreak.
Intercourse should not be resumed until the
lesions have crusted over.
Women with this virus have an increased risk of
cervical cancer and should be routinely
monitored with pap smears.
Keep lesions clean and dry
Avoid using lubricants and creams wh ich can
increase healing time
Wear loose clothing and cotton underwear to
decrease pressure and irritation
Use drying agents such as Campho-Phenique
Use soaks, sitz baths and cool compresses for
local pain relief
Chlamyd ia is a primary cause of infertility
in females and nongonococcal urethritis in
heterosexual males. Chlamydia has also
been linked to preterm labor and
postpartum endometriosis.
10 | P a g e
Certified Emergency Nurse (CEN) Exam Review

Jeff Solheim
Testicular disorders
Testicular torsion
Definition
Co mmon age
of onset
Onset of pain
Quality of pain
Precip itating
factors
Sympto ms
other than pain
Treat ment


Twisting of the testicle on the spermatic cord
causing testicular hypoxia.
66% occurs between the ages of 12 and 18
when maximal hormone stimulat ion is present
although it may occur at any age.
Rapid onset of pain as soon as torsion occurs
Usually described as a severe pain in the
lower abdomen and inguinal canal.
50% are init iated during sleep, but exertion
such as heavy lift ing or sporting activities as
well as testicular trau ma may also precip itate
the condition. Elevation or man ipulation of
the scrotum may increase the pain
Nausea, vomit ing, lo w grade fever, scrotal
enlargement, redness, pallor, elevated testicle
on the affected side with the epididymis ly ing
anterior secondary to twisting of the testicle.
The affected testicle may also be firm and
tender to palpation. Lack of cremasteric
reflex.
Testicular detorsion may be attempted under
sedation in the emergency department through
the scrotal sac or in the surgical suite under
anesthesia. Detorsion should be performed as
quickly as possible. If performed within six
hours, the testicular salvage rate is as high as
80 – 100%, but after 12 hours, orchiecto my
will likely be required.
Orchit is (inflammation of the testicle)
o Sympto ms
 Testicular pain and swelling
 Hematuria
 Ejaculation of blood
o Treat ment
 NSAIDs
 Steroids
 Elevation of scrotum on an ice pack
Phimosis/Paraphimosis
Definiti on: Phi mosis A condition
where the foreskin does not fully
retract over the head of the penis

Ep ididy mit is
Infection of the epididy mitis, In younger males the
infection is usually secondary to a sexually transmitted
infection such as Chlamydia trachomatis and in older
males, it is more likely to be caused by bacteria such as
E. Coli secondary to underlying obstructive urinary
disease.
Because this condition is secondary to either sexually
transmitted infections or obstructive urinary disease, it
is more co mmonly found in males over the age of 20.
Gradual onset of pain as infection worsens.
Dull ache in the lower abdomen and scrotum. Elevation
of the scrotum and wearing supportive garments may
dimin ish the pain.
Sexual activity may exacerbate the pain. In so me cases,
the cause may be ext reme physical strain or exert ion.
Urinary frequency, urgency or dysuria, nausea, fever,
chills, urethral d ischarge, “duck waddle” gait,
edematous and erythematous epididymit is and scrotum,
scrotal warmth and tenderness, pyuria, and elevated
white blood cell count
Admin istration of antibiotics, antipyretics, and
analgesics. Discharge instructions include bed rest for 3
– 4 days. When they are out of bed, scrotal support
should be worn. Sexual activity and physical strain
should be avoided until the infection has cleared.
Indications of worsening infection (sustained fever,
increasing abdominal pain, o r continued dysuria) should
result in fo llo w-up with a med ical p rovider. Because
the causative agent is often a sexually transmitted
disease, safe sexual p ractices as well as follow up for
sexual partners should be encouraged.
Mumps and untreated or undertreated
epididymit is are frequent causes of
orchitis
Definiti on: Paraphi mosis Forceful retract ion of the foreskin
over the head of the penis creating a tight band that can
obstruct urinary flo w and create ischemia to the penile head.
Treat ment involves application of ice to reduce swelling for manual reduction. If this is unsuccessful, surgery may be
needed.
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o
o
Vaginal pH
Discharge
Normal
vaginal
discharge
3.8
White,
clear
Odor
Main
patient
complaint
Absent
None
Treat ment
None






•
Jeff Solheim
Fractured penis (Rupture of the tunica albuginea surrounding the corpora cavernosa causing blood to extravasate into the
penile shaft.)
o Patient may co mplain of hearing a “popping noise during sexual intercourse or sexual p lay followed by severe pain,
swelling and discoloration of the penis.
o Treat ment
 Ice to reduce swelling
 Analgesia
 Catheterization if no urethral damage suspected. (otherwise swelling can lead to urinary obstruction.)
 Surgery
Gynecological emergencies
o Vu lvovaginitis
Bacterial vaginosis
Tricho monas vaginitis
Candida vulvovaginitis
Less than 4.5
Thin, ho mogeneous,
white, adheres to vaginal
walls
Fishy
Discharge, bad odor
which may be worse
after intercourse,
possible itching
Antibiotics
Greater than 4.5
Watery, yellow, gray or
green, frothy or bubbly
Less than 4.5
White, curdy, “cottage cheese
like”; adheres to vaginal walls
If present, fishy
Frothy discharge, vulvar
pruritus, dysuria
Absent
Itching/burning, discharge
Metronidazole (Flagyl) o r
clotrimazo le vaginally.
Sit z baths may be
comfo rting
Gynazole (Butoconazole)
cream intravaginally, Diflucan
(Fluconazole) PO or
Clotrimazo le (Lotrimin,
Mycelex) intravaginally
Discharge Instructi ons for Vul vovaginitis
Cleanse perineum fro m front to back with mild soap and water
Avoid sprays, scented soaps, douches
Wear cotton rather than synthetic underwear and avoid tight-fitting clothes and panty hose
Abstain fro m sexual activity until treat ment is co mplete and no further symptoms
Have your partner checked and treated
Patients on metronidazo le should abstain fro m alcohol use while on the medication and
seven days after comp leting the medication to prevent an antabuse reaction.
Pelvic infla mmatory disease (An infection of the upper genital tract including the endometriu m, fallopian tubes, ovaries, pelvic
peritoneum, o r pelv ic connective tissue.)
o Clin ical manifestations
 Pain exacerbated by:
If N. gonorrheae is the cause, the pain usually
 Walking
occurs within 5 – 7 days of menstruation, if C.
 Defecating and/or urinating
trachomatis is the cause, the pain is not related to
 Performing Valsalva maneuver
menstruation.
 Sexual intercourse


Other symptoms
 Foul-smelling thick white vaginal discharge
 Break-through vaginal bleeding
 Dysuria
 Vo mit ing
 Fever and chills
Laboratory findings
 Leukocytosis with a “shift to the left”
 Elevated erythrocyte sedimentation rate (ESR) and C-reactive protein
 Possibly the presence of a sexually transmitted dis ease or other causative agent
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Jeff Solheim

Treat ment
 Antibiotics
 Analgesics
 Admission for the following indications:
o Adolescents and children
o Pregnant patients
o HIV infection
o Palpable pelvic mass
o Significantly elevated temperature
o Indications of peritonitis
o Dysfunctional Uterine Bleeding – DUB (Bleed ing secondary to hormonal imbalance)
 Co mmon causes:
 Uterine fib roids
 Trau ma
 Infection
 Malignant disease
 Coagulopathies
 Certain drugs:
Breakthrough bleeding with
 Hormone replacement therapy
contraceptive therapy is the most
 Steroids
common cause of abnormal b leeding
 Androgens
and often indicates poor compliance or
 Dig italis
inadequate daily doses.
 Anticoagulants
 Low calorie d iets
 Rapid weight change
 Obesity
 Thyroid or adrenal d isorders
 Cirrhosis
 Hypertension
o Normal menses equates to a blood loss of 25 – 60 mL o f blood daily for 4 – 5 days.
 Heavy bleeding is defined as saturating one pad or tampon per hour for several consecutive hours.
 An average pad or tampon holds 20 -30 mL of b lood when fully saturated.
 Less than 21 days between episodes of bleeding is termed dysfunctional uterine bleeding.
 Painless DUB is most often associated with hormonal imbalances whereas painful bleed ing or pain with
Key points
intercourse is commonly associated with endometriosis.
 Treat ment
 Low dose oral contraceptive therapy
 Iron supplements (as required)
 Hypovolemia = fluid resuscitation and probable suction and curettage.
• Bartholin’s cyst (Blockage of outlet ducts or bacterial invasion in one of a pair of glands in the labia min ora)
o Sympto ms
 Labial swelling
Definiti on:
 Pain
Dys pareuni a – Painfu l
 Increased with walking/sitting
sexual intercourse
 Dyspareunia
 (Sudden relieve could indicate spontaneous rupture)
o Treat ment
 Encourage sitz baths (3 t imes per day)
 Incision and drainage (either local anesthetic or conscious sedation) with packing (to be removed in t wo
days)
• Ovarian cyst (Pockets on the ovaries which may contain fluid, semi-fluid o r solid material)
o Follicu lar cysts – Rupture with strenuous exercise or sexual intercourse in the first two weeks of the cycle.
o Corpus luteum cyst – occurs during the last two weeks of the cycle
o Mittelschmerz – rupture of a cyst mid-cycle (causes unilateral pain)
o Frequently composed of endometrial tissue that has overgrown
o Blood filled cysts can lead to hypovolemia when they rupture
o Sympto ms
 Dull ache on the affected side
 Prolonged menstruation
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o
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Jeff Solheim
Treat ment
 NSAIDs or narcotics
 Surgery
Co mplications
 Large cysts can cause the fallopian tube to twist with ovarian ischemia
 Sudden sharp pain on one side
 Fever
 Dysuria
 Nausea and vomiting
Obstetrics
Definiti on: Threatened
abortion – Cervical os
remains closed despite
bleeding and cramping
Definiti on: Inevitable abortion –
Cerv ical os is opened with bleeding
and cramp ing, membranes have
ruptured.
Definiti on: Inco mplete abortion –
Cerv ical os is open, tissue in the
cervix, but there is inco mplete
expulsion of products of conception.
Definiti on: Co mp lete
Abortion – Comp lete
expulsion of the products
of conception
Definiti on: M issed Abortion –
Prolonged retention of dead
products of conception after the os
has closed.
Definiti on: Septic abortion –
Intrauterine infect ion due to
retained products of conception




Treat ment
 Rh immune globulin to all Rh negative mothers
 Oxytocin and/or Methergine (methylergonovine)
 Antibiotics
 Suction Curettage
 Psych-social care
Discharge Instructi ons (Threatened
Abortion)
 Bed rest
 Pelvic rest
 Avoid douching
 Avoid tampons
 Follow up with obstetrician
Discharge Instructi ons (Co mplete abortion)
 Avoid tampons
 Take temperature QID
 Pelvic rest
 Return if fever, b leeding or pain increases
Ectopic pregnancy (implantation of a fertilized ovum outside of the normal uterine cavity. [Frequent place of implantation is
the fallopian tube, although it can occur in the peritoneal cavity, uterine cornu, ovary, or cervix.])
 Clin ical manifestations


Classic sign is pain

May be unilateral o r bilateral

Vague discomfort which progresses to sharp colicky pain

Rupture is often marked by sudden sharp pain which may progress to shoulder pain.

All wo men of ch ild -bearing age with abdominal pain should be worked up for ectopic pregnancy.
 Vaginal bleeding may or may not be present
Treat ment

Initiate IV line due to risk of rupture

Draw Quantitative BHCG, CBC, and type and cross

Methotrexate (Fo lex) to terminate fetal growth

Surgery for indications of rupture or imminent rupture

Psych-social care
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


Placenta Prev ia (A condition where the placenta is abnormally implanted in the lower uterine segment or partially
obstructs the cervical os.)
Abruptio Placenta (placenta separates from its normal site of i mplantation before delivery of the fetus.)



Jeff Solheim
Bleeding after the 20th week of pregnancy
Clin ical manifestations
Symptom
Placenta Previa
Abrupti o Placenta
Bleeding
Sudden onset of bright red vaginal
bleeding which may be profuse
Dark red vaginal bleed ing (may be concealed)
Pain
Absent
Backache
Uterine rig idity or painful contractions
Sudden, colicky abdo minal pain
Treat ment

Monitor maternal hemodynamic status, fundal height, pain and bleeding.

Monitor fetal heart rate

Maintain mother in left lateral decubitus position

Rh immune globulin (Rh negative mother)
 Cesarean section may be considered
Preeclampsia (Elevated blood pressure (diagnostic when two readings taken six hours apart with patient on her left side yield
similar results) after the 20th week of pregnancy until 72 hours after delivery.)
 Clin ical manifestations


SBP > 140 mm Hg and/or DBP > 90 mm Hg ( in SBP > 30 mm Hg with a DPB 15 mm Hg over first trimester
baseline.)

Albuminuria and/or oliguria

Edema to the face, hands or sacrum

Weight gain of 2 lb or more per week.

Visual Changes and/or headaches

Nausea

Ep igastric or right upper quadrant pain
 Increased deep tendon reflexes
Treat ment

Oxygen and IV

Fetal monitoring

Position mother on left side

Antihypertensives



hydralazine (Apresoline)

labetalol (Normodyne, Trandate)

nitroprusside (Nipride)
Nursing care wh ile giv ing Magnesium
 Monitor blood pressure,
respiratory rate, deep tendon
reflexes, urinary output, and
magnesiu m levels.
 Signs of toxicity include
hypotension, respiratory rate <
12/ minute, loss of reflexes,
urinary output < 100 mL/4 hours
 If signs of toxicity appear, stop
the infusion and given calcium
gluconate 10 mL IV over 3
minutes. This may need to be
repeated hourly until signs of
toxicity are reversed
Magnesium sulfate
Eclampsia and HELLP syndrome
Definiti on: Eclampsia – extension of preeclampsia characterized by convulsions, coma,
or both. Treated with intravenous lorazepam
(ativan) and probable emergency Cesarean
section
Definiti on: HELLP Syndrome –
Hemo lysis, Elevated Liver En zy mes,
Low Platelets.
Treated with close observation and
likely Cesarean section
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Jeff Solheim
Trau ma and Pregnancy

Treat ment

ABCD remains the priority - adequate oxygenation and fluid
delivery is heightened to protect the unborn fetus.

Nurse in the side-ly ing position or tip the backboard so the
pregnant patient is not supine.

Rh immune globulin (Rhogam or Rhophylac) to Rh negative mothers.
Definiti on: Kleihauer -Betke Test –
determine if fetal-maternal mixture of
blood occurred secondary to the
traumatic event
 Prolapsed cord (Condition where the umbilical cord precedes the fetus through the birth canal, becomes entrapped when the fetus
passes through the birth canal and obstructs the fetal circulation.)
 Treat ment
 Considered an obstetrical emergency
 Oxygen
 Put mother in knee-chest position
 Put a gloved hand in the vagina and elevate the fetal head (do not handle the cord or attempt to return it to the uterus.)
 Wrap the exposed cord in saline gauze to prevent it fro m dry ing out.
 Emergency Delivery
 Place the wo man in the dorsal recu mbent position with her knees bent or the side -lying position with her knees bent and raise
the buttocks slightly on an object.
 If t ime permits, cleanse the perineum with soap and water or pour antiseptic solution over the perineal area.
 To reduce the risk of infect ion, be as sterile as the situation allows. Drape the perineal area with sterile towels and keep
fingers out of the vagina.
 Every effort should be made to decrease a rapid, explosive delivery which can tear the perineu m. Encourage the mother to
pant while the head is being delivered to reduce the urge to bear down.
 As the head is delivered, place gentle pressure to prevent explosive delivery. If the memb ranes are still intact over t he head,
snip them at the nape of the neck and pull them away fro m the infant’s face. Feel fo r the presence of a cord around the neck.
If this is felt, attempt to slip the cord over the infants head between contractions. If this is not possible, immedia tely clamp
the cord in two places and cut the cord between the clamps.
 To deliver the shoulders, place the palms of the hands on either side of the infant’s head and gently direct it down ward to
deliver the anterior shoulder and then upward to assist with delivery of the posterior shoulder.
 Once the cord stops pulsating, place one clamp 4 – 5 centimeters fro m the infant’s abdomen and another clamp
approximately 4 – 5 centimeters toward the mother and cut the cord between the two clamps using a sterile scissors or
scalpel. If sterile equip ment is not available, it is not necessary to cut the umbilicus, keep the infant at or belo w the le vel of
the mother until the cord is cut.
 Post-delivery infant care
 Place head in sniffing position and suction mouth an d then nose
 Measure Apgar scores at 1,5 and 10 minutes
 Dry the in fant
 Cover the infants head
 Place on the mother’s chest and encourage breast-feeding to stimulate
oxytocin
 Cover with dry blan kets
 Palpate fundus q 5 minutes after delivery of placenta
 Massage boggy uterus until firm. Do not massage firm uterus
 Apgar score
Objecti ve Sign
0
1
2
Heart Rate
Absent
< 100 BPM
> 100 BPM
Respiratory Effort
Absent
Irregular, slo w
Cry ing, good
Muscle tone
Flaccid
Some flexion
Active motion
Reflex irritability
No response
Grimace, weak cry
Sneeze, cough, cry
Color
Blue
Pink body, blue
Co mpletely pink
extremities
(A score of 7 – 10: good outcome, 4 – 6: moderate outcome, 1 – 3: poor outcome)
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Jeff Solheim
Neonatal resuscitation
 If central cyanosis persists after suctioning and drying, apply supplemental o xygen
 If cyanosis persists, HR < 100 BPM or respirations are gasping after 30 seconds of oxygen, start PPV
 If no improvement in 90 seconds, intubation will be considered.
 IF HR persists < 60 BPM, start chest compressions (90/ minute with ventilation after every third co mpression), do not
ventilate and compress simultaneously)
 Although rarely used, medications considered as part of a neonatal resuscitation include:
 Ep inephrine
 Nalo xone
Newborn chest compressions - Use
 Glucose
the two thumb technique with both
 If flu id boluses are required, they are given at a rate of 10 mL/kg.
thumbs on the lower third of the
sternum and fingers encircling and
supporting the back, depressing
approximately one third the
anteroposterior diameter of the chest.
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Practice Questions
A patient is suspected of having Gonorrhea. The emergency nurse knows that which of the fo llo wing conditions often co -exists with
this condition?
a)
b)
c)
d)
Syphilis
Chlamyd ia
Endo metriosis
Candida alb icans
Which of the follo wing categories is NOT part of measurement of the Apgar score?
a)
b)
c)
d)
Color
Muscle tone
Respiratory rate
Reflex irritability
The emergency nurse would anticipate that which of the following trau ma patients is most likely to be transferred to the surgical suite
for operative repair of their in jury?
a)
b)
c)
d)
A patient with a bladder contusion who complains of pain on voiding
A patient with a contused kidney whose mean arter ial pressure is 86 mm Hg
A patient who has contrast mediu m noted in the pelvic s pace on computerized tomography
A patient with a known renal lacerat ion whose urinalysis is pos itive for microscopic hematuria
The emergency nurse knows that treatment for ep ididy mit is is having its intended effect if wh ich of the following occurs?
a.
b.
c.
d.
Dimin ished scrotal pain
Increase in urinary output
Reduction in serum creatin ine level
Urethral discharge changes from green to clear
Answers B, C, C, A
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