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Paramedic Care: Principles & Practice
Fourth Edition
Volume 4: Medicine
CHAPTER
7
Urology and
Nephrology
Multimedia Directory
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Kidney Animation
Kidney Anatomy Exercise
Kidney Stones Video
Urinary Catheterization Animation
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Standard
• Medicine (Genitourinary/Renal)
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Competency
• Integrates assessment findings with
principles of epidemiology and
pathophysiology to formulate a field
impression and implement a
comprehensive treatment/disposition
plan for a patient with a medical
complaint.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Introduction
• Urinary system maintains blood volume
and proper balance of water,
electrolytes, pH (acid-base balance).
• It ensures key substances such as
glucose remain in bloodstream and
removes toxic wastes from blood.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Introduction
• Urinary systems plays major role in
arterial blood pressure regulation.
• It controls development of red blood
cells, or erythrocytes.
• Body eliminates water and other
substances removed from blood in form
of fluid urine.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Introduction
• Kidneys' regulation of water and
important substances in blood is
example of homeostasis.
• Metabolism creates waste products.
• Ammonia highly toxic to body cells,
particularly brain cells.
• Liver cells convert ammonia into urea,
a less toxic compound.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Introduction
• Kidneys remove urea efficiently from
blood and pass it into urine.
• Urinary system eliminates many foreign
chemicals.
• Urinary system in women physically
distinct from reproductive system: they
share no structures.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Introduction
• Urinary system in men shares some
structures with reproductive system.
• Term genitourinary system used
with men.
• Nephrology: medical specialty
devoted to kidney disorders.
• Urology: surgical specialty devoted
to care of entire urinary system in
both women and men.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Introduction
• Renal and urologic disorders common;
many very serious.
• More than 50,000 Americans die
annually from kidney disease.
• More than 250,000 Americans suffer
from long-term kidney failure; endstage renal failure.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Introduction
• Causes of end-stage renal failure:
– Poorly controlled diabetes mellitus (both
type I and type II)
– Uncontrolled or inadequately controlled
hypertension.
• Among acute, or sudden-onset,
disorders, renal calculi (kidney stones)
very common.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Introduction
• Woman complaining of burning pain on
urination: infection in urinary system.
• Men with same complaint: infection
from urinary system or sexually
transmitted disease.
• Noncancerous enlargement of prostate
gland (benign prostatic hypertrophy)
affects 60% of men by age 50; 80% by
age 80.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Anatomy and Physiology
• Urinary system has four major
structures:
– Kidneys
– Ureters
– Urinary bladder
– Urethra
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Anatomy of the urinary system, posterior view.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Anatomy and Physiology
• Kidneys
– Left kidney in upper abdomen behind
spleen; right kidney behind liver.
– Healthy kidney: size of fist; contains 1
million nephrons, microscopic structures
that produce urine.
– With aging comes loss of nephrons.
– Be alert to possibility of compromised
kidney function in elderly patients.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Anatomy and Physiology
• Kidneys
– Renal artery and vein, nerves, lymphatic
vessels, ureter, pass into kidney
through notched region called hilum.
– Tissue of kidney visibly divided into
outer region (cortex) and inner region,
(medulla).
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Anatomy and Physiology
• Kidneys
– Medullary tissue divided into fan-shaped
regions (pyramids).
– Each pyramid ends in portion of tissue
called papilla; projects into hollow space
of renal pelvis.
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Paramedic Care: Principles & Practice, 4th Ed.
Cross section of the kidney.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Anatomy and Physiology
• Kidneys
– Spaces of pelvis come together at
origin of ureter.
– Urine forms in cortical and medullary
tissue of kidney; leaves kidney through
renal pelvis and ureter.
– Functional unit of kidney (nephron)
forms urine.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Anatomy and Physiology
• Kidneys
– Nephron: tubule divided into different
portions and capillaries that form net of
vessels covering surface of tubule.
– Blood that has entered kidney through
renal artery flows through smaller
vessels until it reaches a glomerulus.
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Paramedic Care: Principles & Practice, 4th Ed.
Anatomy of the nephron.
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Paramedic Care: Principles & Practice, 4th Ed.
Kidney Animation
Click here to view an animation on the topic of kidney anatomy and nephron
function.
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Paramedic Care: Principles & Practice, 4th Ed.
Anatomy and Physiology
• Kidneys
– Glomerulus is cluster of capillaries
surrounded by Bowman's capsule, cupshaped, hollow structure; first part of
nephron.
– Water and chemical substances enter
tubule through Bowman's capsule.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Anatomy and Physiology
• Kidneys
– After passage through parts of tubule—
proximal tubule, descending loop of
Henle, ascending loop of Henle, distal
tubule—urine drips into collecting duct
before entering renal pelvis and ureter.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Anatomy and Physiology
• Kidneys
– Forming and eliminating urine basis
for two of kidneys' major functions:
 Maintaining blood volume with proper
balance of water, electrolytes, pH.
 Retaining key compounds such as
glucose while excreting wastes such
as urea.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Anatomy and Physiology
• Kidneys
– Controlling arterial blood pressure,
relies on urine formation.
– Renin-angiotensin system does not
involve urine production.
– Kidney cells regulate erythrocyte
development; does not involve urine
formation in any way.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Anatomy and Physiology
• Kidneys
– Processes involved in formation of
urine:
 Glomerular filtration.
 Reabsorption of substances from renal
tubule into blood.
 Secretion of substances from blood into
renal tubule.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Anatomy and Physiology
• Kidneys
– As blood flows through capillaries of
glomerulus, water and chemical
materials filtered out of blood and into
Bowman's capsule.
– Rate at which blood filtered, glomerular
filtration rate (GFR), 180 L/day.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Anatomy and Physiology
• Kidneys
– Filtration nonselective process based on
molecular size (electrical charge
secondary factor); essential to urine
formation.
– Reabsorption of substances into blood
and secretion of substances into renal
tubule highly selective processes.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Anatomy and Physiology
• Kidneys
– Processes of reabsorption and secretion
essential to forming urine with correct
composition and volume to maintain
homeostasis.
– Reabsorption and secretion involve
intercellular transport.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Anatomy and Physiology
• Kidneys
– Simple diffusion: molecules small
enough to pass through cell membrane
randomly move into and out of cell.
– Net movement from region of higher
concentration to lower concentration.
– Water molecules move by simple
diffusion.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Anatomy and Physiology
• Kidneys
– Facilitated diffusion: molecules still
move from region of higher
concentration to lower concentration.
– Molecule-specific carrier in membrane
acts as tunnel; speeds molecules'
movement through membrane.
– Cells' handling of glucose is example.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Anatomy and Physiology
• Kidneys
– Active transport: only process that can
produce net movement of molecules
from region of lower concentration to
one of higher concentration.
– Vital to renal tubular physiology; allow
for precise balance of reabsorption and
secretion.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Anatomy and Physiology
• Kidneys
– Tubular handling of water and
electrolytes, including sodium (Na+),
potassium (K+), hydrogen (H+), chloride
(Cl–), basis for control of blood volume
and maintenance of electrolyte balance,
including pH.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Anatomy and Physiology
• Kidneys
– About 65% of filtered Na+ and Cl–
reabsorbed in proximal tubule.
– An active Na+ reabsorption is coupled
with secretion of H+ into tubule.
– H+ secretion raises pH of arterialderived blood flowing in capillaries.
– Determines pH both of venous blood
leaving kidneys and urine.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Anatomy and Physiology
• Kidneys
– As filtrate moves through nephron, loop
of Henle, its volume and composition
change further.
– 20% of filtrate's water reabsorbed.
– Passive and active reabsorption of
significant amounts of electrolytes occurs.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Anatomy and Physiology
• Kidneys
– Reabsorption of electrolytes without
reabsorption of water produces dilute
fluid that exits collecting duct as urine.
– Healthy kidneys can produce urine with
osmolarity as low as 1/6 osmolar
concentration of blood plasma
(diuresis).
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Anatomy and Physiology
• Kidneys
– Antidiuresis can form very concentrated
urine with osmolarity as high as four
times that of plasma.
– Ability of kidneys to handle significant
swings in water and electrolyte intake
remarkably large.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Anatomy and Physiology
• Kidneys
– Glucose retained in body; wastes such
as urea excreted.
– Glucose freely filtered into Bowman's
capsule as element of filtrate.
– Osmotic diuresis: at excessively high
blood glucose levels, so much glucose
enters filtrate that proximal tubule's
capacity to reabsorb is insufficient.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Anatomy and Physiology
• Kidneys
– Urea, a waste product, freely filtered
into Bowman's capsule.
– Urea passively reabsorbed throughout
tubule; half of filtered load will remain
urine.
– Kidneys' ability to excrete urea depends
on glomerular filtration rate.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Anatomy and Physiology
• Kidneys
– Blood urea nitrogen test (BUN) directly
measures blood concentration of urea;
indirect indicator of GFR.
– Creatinine, another waste product of
metabolism, has larger molecules than
urea; is not reabsorbed.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Anatomy and Physiology
• Kidneys
– Regulate systemic arterial blood
pressure.
– Control body's balance of water and
electrolytes, maintaining blood volume
at healthy level.
– Juxtaglomerular cells respond to low
blood pressure by releasing enzyme
called renin.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Anatomy and Physiology
• Kidneys
– Release of renin produces active
hormone angiotensin I.
– As angiotensin I flows through lungs,
angiotensin converting enzyme (ACE)
produces angiotensin II.
– Angiotensin II acts both on kidney
tubular cells and on adrenal cells,
causing secretion of aldosterone.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Anatomy and Physiology
• Kidneys
– Produce 90% of erythropoietin,
hormone that regulates rate at which
erythrocytes mature in bone marrow.
– Impact of renal tissue death; nonkidney
sources of erythropoietin can produce
only about 1/3 to 1/2 red cell mass
needed by body.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Kidney Anatomy Exercise
Click here to complete an exercise on the anatomy of the kidney.
Back to Directory
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Anatomy and Physiology
• Ureters
– Urine drains from renal pelvis into
ureter, long duct that runs from kidney
to urinary bladder.
– Ureters' nerves derive from renal,
gonadal, or hypogastric nerve trunks.
– Important in understanding symptoms
caused by kidney stones.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Anatomy and Physiology
• Urinary Bladder
– Anteriormost organ in pelvis of both men
and women, stores urine.
– Bladder neck held in place by ligaments.
– Women: connective tissue attaches
bladder's posterior wall to anterior
vaginal wall.
– Men: bladder wall structurally continuous
with prostate gland.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Anatomy of the male genitourinary system.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Anatomy and Physiology
• Urethra
– Duct that carries urine from bladder to
exterior of body.
– In women, urethra 3 to 4 cm long;
opens to external environment via small
orifice anterior to vagina.
– In men, urethra 20 cm long; ends at tip
of penis.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Anatomy and Physiology
• Urethra
– Female urethra's shortness one reason
female urinary system vulnerable to
bacterial infection from environmental
sources.
– Because male urethra carries both urine
and male reproductive fluid, it can be
point of entry for sexually transmitted
diseases.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Anatomy and Physiology
• Testes
– Primary male reproductive organs.
– Produce both hormones responsible for
sexual maturation and sperm cells, male
sex cells.
– Outside abdomen in muscular sac called
scrotum.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Anatomy and Physiology
• Epididymis and Vas Deferens
– Sperm cells from testis into epididymis,
small sac where they are stored.
– Sperm are channeled from epididymis
into vas deferens, muscular duct that
carries them into pelvis, through
prostate gland to urethra.
– Sperm cells mix with special fluid before
passing into urethra for ejaculation.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Anatomy and Physiology
• Prostate Gland
– Surrounds male urinary bladder neck;
part of urethra runs through its tissue.
– Major source of fluid that combines with
sperm to form semen, the ejaculated
male reproductive fluid.
– Any enlargement of prostate that
narrows or obstructs urethra can block
urine flow.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Anatomy and Physiology
• Penis
– Male organ of copulation.
– Spongy internal tissues fill with blood to
produce penile erection.
– Skin covering end of penis (foreskin)
often surgically removed in infancy
through circumcision.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
General Mechanisms of
Nontraumatic Tissue Problems
• Kidneys' retroperitoneal location
protects them well against injury.
• Nontraumatic renal and urologic
disorders result from:
– Inflammatory or immune-mediated
disease
– Infectious disease
– Physical obstruction
– Hemorrhage
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
General Pathophysiology,
Assessment, and Management
• Pathophysiologic Basis of Pain
– Some nerves respond when damage to
epithelial lining of organ exposes
underlying tissue layer, where nerve
endings located.
– Others nerves respond to stretching
forces generated when organ inflamed
or enlarged by internal hemorrhage or
obstruction.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
General Pathophysiology,
Assessment, and Management
• Pathophysiologic Basis of Pain
– Bacterial infection damages epithelial
tissue; causes pain when urine flows
over affected tissue during urination.
– Bacteria can cause infections in women.
– In men, pain on voiding often due to
sexually transmitted disease such as
gonorrhea.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
General Pathophysiology,
Assessment, and Management
• Pathophysiologic Basis of Pain
– Distention of ureter by renal calculus
(kidney stone) causes sharp pain.
– Visceral pain arises in hollow structures
such as ureters, urinary bladder,
urethra, or vas deferens or epididymis
in males.
 Aching or crampy pain felt deep within
body and poorly localized.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
General Pathophysiology,
Assessment, and Management
• Pathophysiologic Basis of Pain
– Referred pain felt in location other than
its site of origin.
– Pyelonephritis, inflammation with kidney
infection, associated with pain in flank;
sometimes pain in neck or shoulder.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
General Pathophysiology,
Assessment, and Management
• Assessment and Management
– Assessment steps same for all
abdominal emergencies.
– Do not try to pinpoint cause of
abdominal pain in field.
– Manage life-threatening conditions such
as shock; provide historical and physical
information.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
General Pathophysiology,
Assessment, and Management
• Assessment and Management
– During scene size-up, look for
evidence of traumatic versus medical
cause and for signs of life-threatening
situation.
– Employ personal protective equipment
and proper handling.
– Primary assessment concentrates
on ABCs.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
General Pathophysiology,
Assessment, and Management
• Assessment and Management
– When chief complaint is pain or involves
pain, use OPQRST template:
 Onset
 Provocation/palliation
 Quality
 Region/radiation
 Severity
 Time
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
General Pathophysiology,
Assessment, and Management
• Assessment and Management
– Increased pain on urination, particularly
with fever: urinary/genitourinary tract
infection.
– Pain associated with inability to urinate,
particularly in elderly men, points
toward urethral obstruction due to
prostatic enlargement.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
General Pathophysiology,
Assessment, and Management
• Assessment and Management
– Improvement with knees drawn up to
chest points toward peritonitis.
– Improvement with walking may indicate
kidney stone has moved.
– Vague discomfort followed by change to
sharp pain in flank indicates ureteral
obstruction due to kidney stone.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
General Pathophysiology,
Assessment, and Management
• Assessment and Management
– Listen for patterns of referred pain.
– Sudden changes to sharp pain may
indicate rupture of internal organ.
– Abdominal pain lasting 6 hours or longer
considered surgical emergency.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
General Pathophysiology,
Assessment, and Management
• Assessment and Management
– Obtain previous history of similar event.
– Severe pain often associated with
nausea, vomiting, profuse sweating,
clammy skin, rapid heart rate.
– Ask about changes in bowel habits and
stool.
– Ask about weight loss.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
General Pathophysiology,
Assessment, and Management
• Assessment and Management
– Last oral intake, including fluid intake.
– Chest pain, particularly left sided, does
not necessarily indicate myocardial
infarction (MI).
– Physical examination: form overall
impression and examine abdomen.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
General Pathophysiology,
Assessment, and Management
• Assessment and Management
– Patient may show discomfort by rigidly
maintaining position of least pain or by
constantly pacing.
– Someone who is feverish and walks
hunched up, leaning to one side,
complaining of back pain may have
pyelonephritis (kidney infection).
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
General Pathophysiology,
Assessment, and Management
• Assessment and Management
– In absence of fever, acute-onset
decreases in responsiveness suggest
hemorrhage and hypovolemic shock.
– Determine if change in responsiveness
is acute or chronic.
– Extreme thinness, pale skin or mucous
membranes, or home health equipment
all suggest chronic problems.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
General Pathophysiology,
Assessment, and Management
• Assessment and Management
– Pale, dry, cool skin and mucous
membranes suggest chronic anemia or
chronic renal failure.
– Pale clammy skin suggests severe pain
or shock; dry skin may accompany
fever.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
General Pathophysiology,
Assessment, and Management
• Assessment and Management
– Components of abdominal exam:
inspection, auscultation, percussion,
palpation.
– Always inspect abdomen first.
– Percussion of abdomen may produce
clues to origin of urologic problem.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
General Pathophysiology,
Assessment, and Management
• Assessment and Management
– Pain induced by percussion of flanks,
accompanied by fever, suggests
pyelonephritis (kidney infection).
– Pain on percussion above pelvic rim,
accompanied by fever and increased
urge to void, suggests cystitis—bladder
infection.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
General Pathophysiology,
Assessment, and Management
• Assessment and Management
– Constant, sharp pain increased by
percussion of affected flank may
indicate where kidney stone has lodged
in ureter.
– In women, abdominal palpation may
reveal pregnancy.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
General Pathophysiology,
Assessment, and Management
• Assessment and Management
– Palpation of lower abdomen may help
diagnose acute urinary obstruction in
older men due to prostatic enlargement.
– Male abdominal exam: include
inspection of penis and scrotum.
– Purulent discharge from penis may
indicate sexually transmitted disease.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
General Pathophysiology,
Assessment, and Management
• Assessment and Management
– Palpation of scrotum may detect
testicular mass.
– Tenderness of testicle can result from
testicular torsion.
– Hematocrit may detect significant or
chronic bleeding.
– Fever suggests infectious process.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
General Pathophysiology,
Assessment, and Management
• Assessment and Management
– Uncontrolled chronic hypertension
common cause of nephron damage and
chronic renal failure.
– Field management starts with ABCs.
– If patient hypoxic, provide supplemental
oxygen; avoid hyperoxia.
– Be prepared for vomiting in patient with
severe pain.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
General Pathophysiology,
Assessment, and Management
• Assessment and Management
– Circulatory support vital.
– Monitor blood pressure closely.
– Large-bore IV line for volume
replacement or drug administration.
– Nausea treated with antiemetics.
– Pain treated preferably with opiate.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
General Pathophysiology,
Assessment, and Management
• Assessment and Management
– Patients with acute abdominal problem
are possible surgical cases.
– Nothing should be given by mouth.
– Patient with abdominal pain of greater
than 6 hours considered surgical
emergency.
– Rapidly yet gently transport.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Renal and Urologic Emergencies
• Leading causes of kidney failure:
diabetes mellitus (both types) and
uncontrolled or inadequately controlled
hypertension.
• Nephron number decreases with age.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Renal and Urologic Emergencies
• Acute Renal Failure (ARF)
– Sudden (often over period of days) drop
in urine output to less than 400–500 mL
per day (oliguria).
– Output may fall to zero (anuria).
– Condition may be reversible.
– Overall mortality 50%.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Renal and Urologic Emergencies
• Acute Renal Failure (ARF)
– Three types
 Prerenal
 Renal
 Postrenal
– Clinical presentation
 Sudden-onset oliguria or anuria
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Renal and Urologic Emergencies
• Acute Renal Failure (ARF)
– Prerenal ARF
 Dysfunction before level of kidney;
insufficient blood supply to kidneys, or
hypoperfusion.
 Highest proportion of ARF: 40 to 80%.
 Often reversible through proper
perfusion.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Renal and Urologic Emergencies
• Acute Renal Failure (ARF)
– Prerenal ARF
 Triggers: hemorrhage, heart failure (MI
or congestive heart failure [CHF]),
sepsis, shock, anomaly directly affecting
blood flow into kidneys.
 If hypoperfusion: GFR decreases; less
filtrate means less urine formation.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Renal and Urologic Emergencies
• Acute Renal Failure (ARF)
– Prerenal ARF
 If hypoperfusion: nephron tubular cells
become ischemic and active reabsorption
and secretion decrease or cease.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Renal and Urologic Emergencies
• Acute Renal Failure (ARF)
– Renal ARF
 Pathological process within kidney tissue,
or renal parenchyma, itself.
 Injury to small blood vessels
(microangiopathy) or glomerular
capillaries; nephron function lost.
 Injury to tubular cells.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Renal and Urologic Emergencies
• Acute Renal Failure (ARF)
– Renal ARF
 Tubular cell death (acute tubular
necrosis) can follow prerenal ARF or
develop directly due to toxin deposition.
 Inflammation or infection in interstitial
tissue surrounding nephrons; due to
toxic compounds, including drugs.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Renal and Urologic Emergencies
• Acute Renal Failure (ARF)
– Postrenal ARF
 Originates in structure distal to kidney—
ureters, bladder, or urethra.
 Reversible by removing obstruction
preventing elimination of urine.
 If obstruction not cleared, may develop
secondary to nephron and interstitial
injury caused by renovascular
obstruction.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Renal and Urologic Emergencies
• Acute Renal Failure (ARF)
– Focused history will provide clues to
severity, duration, degree of ARF
present, antecedent condition,
immediate threats to life.
– Impaired mentation or decreases in
consciousness suggest severe ARF and
potential threat to life.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Renal and Urologic Emergencies
• Acute Renal Failure (ARF)
– If shock triggered ARF, profound
hypotension may be present with
tachycardia and hyperkalemia.
– Look for edema in face, hands, feet.
– Hematocrit useful if acute hemorrhage
or chronic anemia suspected.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Edema of the feet consistent with fluid retention in acute renal failure.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Renal and Urologic Emergencies
• Acute Renal Failure (ARF)
– Urinalysis can offer information quickly.
– Proteinuria and glycosuria suggest renal
dysfunction.
– Renal function evaluated by laboratory
analysis of blood.
 Blood urea nitrogen (BUN) level and
serum creatinine.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Renal and Urologic Emergencies
• Acute Renal Failure (ARF)
– ARF can lead to life-threatening
metabolic derangements.
– Monitoring and supporting ABCs vital.
– Use supplemental oxygen if hypoxic.
– Avoid hyperoxia.
– Initial fluid resuscitation required if
hypovolemia present.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Renal and Urologic Emergencies
• Acute Renal Failure (ARF)
– Chief prevention strategies:
 Protecting fluid volume and
cardiovascular function.
 Eliminating or reducing exposure to
nephrotoxic agents or medications.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Renal and Urologic Emergencies
• Chronic Renal Failure (CRF)
– Inadequate kidney function due to
permanent loss of nephrons; 70%.
– Metabolic instability does not occur until
80% of nephrons destroyed (end-stage
renal failure).
– Must have dialysis or kidney transplant
to survive.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Renal and Urologic Emergencies
• Chronic Renal Failure (CRF)
– Anuria not present in CRF or end-stage
renal failure.
– Diabetes mellitus and hypertension
cause half of all cases.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Renal and Urologic Emergencies
• Chronic Renal Failure (CRF)
– Three pathological processes initiate
nephron damage:
 Microangiopathy or glomerular capillary
injury
 Tubular cell injury
 Inflammation or infection in interstitial
tissue
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Renal and Urologic Emergencies
• Chronic Renal Failure (CRF)
– Same process as those underlying renal
ARF; same cycle of ongoing nephron
damage becomes established.
– Nephrons: dilated, abnormal glomeruli,
and nonfunctional nephrons, heavily
scarred glomeruli or no visible
glomeruli, only sclerotic tissue.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Renal and Urologic Emergencies
• Chronic Renal Failure (CRF)
– Reduced nephron mass: visible at level
of gross anatomy as shrunken, scarred
kidneys; reduced renal mass.
– Each of kidney's four major functions
highly disturbed or absent depending on
degree of renal failure.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Renal and Urologic Emergencies
• Chronic Renal Failure (CRF)
– Maintenance of blood volume with
proper balance of water, electrolytes,
and pH.
 In CRF, active transport in tubules
decreases significantly or ceases.
 Can lead to hyperkalemia.
 Hypocalcemia common.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Renal and Urologic Emergencies
• Chronic Renal Failure (CRF)
– Retention of key compounds such as
glucose with excretion of wastes such as
urea.
 Glucose and other substances normally
actively reabsorbed are lost in urine as
filtrate flows passively through nephron.
 Severe CRF termed uremia for
characteristic buildup of blood urea.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Renal and Urologic Emergencies
• Chronic Renal Failure (CRF)
– Control of arterial blood pressure.
 Renin-angiotensin loop disrupted; even
small amounts of renin can lead to
severe hypertension.
 Hypertension may develop due to
retention of Na+ and water.
 Cardiac decompensation can develop
suddenly.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Renal and Urologic Emergencies
• Chronic Renal Failure (CRF)
– Regulation of erythrocyte development.
 Because erythropoietin no longer
produced in normal quantities (or at all),
chronic anemia develops.
 Can contribute to cardiac failure.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Renal and Urologic Emergencies
• Chronic Renal Failure (CRF)
– Focused history and physical exam; look
for characteristics of uremia.
– Can precipitate shock or major physiologic
instability.
– GI symptoms such as anorexia and
nausea, sometimes with vomiting.
– Patient's mentation as he speaks clue to
central nervous system (CNS) impairment.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Renal and Urologic Emergencies
• Chronic Renal Failure (CRF)
– Skin pale, moist, cool.
– Scratches and ecchymoses common
skin changes with CRF.
– Jaundice may be present.
– Skin condition (uremic frost) appears
when excessive amounts of urea
eliminated through sweat.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Renal and Urologic Emergencies
• Chronic Renal Failure (CRF)
– Major organ systems show
abnormalities on direct examination.
– Due to failure of urinary system
functions, cardiovascular stress can be
enormous.
– Hypertension or hypotension may occur.
– Muscle cramps and "restless legs”
syndrome.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Renal and Urologic Emergencies
• Chronic Renal Failure (CRF)
– Separate chronic findings from recent
onset or aggravated by emergency.
– Hematocrit and urinalysis have less
value in CRF than in ARF.
– CRF can lead to life-threatening
complications.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Renal and Urologic Emergencies
• Chronic Renal Failure (CRF)
– Monitoring and supporting ABCs vital.
– Supplemental oxygen if hypoxic.
– Small IV bolus for fluid resuscitation if
hypovolemia.
– Monitor electrocardiogram (ECG)
readings closely.
– Expedite transportation to appropriate
facility.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Renal and Urologic Emergencies
• Chronic Renal Failure (CRF)
– Chief prevention strategies:
 Regulation of fluid volume and
cardiovascular function and major
electrolyte disturbances.
 Elimination or reduction of exposure to
nephrotoxic agents or medications.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Renal and Urologic Emergencies
• Chronic Renal Failure (CRF)
– Renal dialysis: artificial replacement of
some of kidney's critical functions.
 Fact of life for most patients with CRF
and end-stage disease.
 Risk: destabilizing shifts in blood volume
and composition and arterial blood
pressure.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Hemodialysis has allowed many renal failure patients to live a relatively normal life. (© Michal Heron)
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Renal and Urologic Emergencies
• Chronic Renal Failure (CRF)
– Two technologies, hemodialysis and
peritoneal dialysis.
– Both rely on osmosis and equalization of
osmolarity across semipermeable
membrane such as renal nephron.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Renal and Urologic Emergencies
• Chronic Renal Failure (CRF)
– In dialysis, blood flows past a
semipermeable membrane that has
special cleansing fluid.
– Effect is to temporarily lessen or
eliminate volume overload and toxically
high blood concentrations of
electrolytes, urea, other substances.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Renal and Urologic Emergencies
• Chronic Renal Failure (CRF)
– In hemodialysis, blood passed through
machine that contains artificial
membrane and dialysate solution.
– Vascular access required.
– If healthy artery and vein not available,
surgeon inserts vascular graft made of
artificial material.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Renal and Urologic Emergencies
• Chronic Renal Failure (CRF)
– Indwelling catheter may need to be
placed in internal jugular vein.
– Complications: bleeding from needle
puncture site and local infection;
narrowing or closing of internal fistula.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Renal and Urologic Emergencies
• Chronic Renal Failure (CRF)
– Chronic ambulatory peritoneal dialysis
(CAPD)
 Peritoneal membrane within abdomen as
semipermeable dialysis membrane.
 Dialysate solution introduced and
removed from abdominal cavity via
indwelling catheter.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Renal and Urologic Emergencies
• Chronic Renal Failure (CRF)
– Chronic ambulatory peritoneal dialysis
(CAPD)
 Complication: infection in catheter,
abdominal tunnel containing catheter, or
peritoneum itself.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Renal and Urologic Emergencies
• Chronic Renal Failure (CRF)
– Dialysis complications: hypotension,
shortness of breath, chest pain,
neurologic abnormalities ranging from
headache to seizure or coma.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Renal and Urologic Emergencies
• Renal Canculi
– Kidney stones (renal calculi): crystal
aggregation in kidney's collecting
system.
– Brief hospitalization common due to
severity of pain.
– Stone travels from renal pelvis, through
ureter, to bladder, eliminated in urine.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
CT scan of abdomen. Arrow points to kidney stone. (© Dr. Bryan E. Bledsoe)
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Renal and Urologic Emergencies
• Renal Canculi
– Inpatient treatment: shockwave
lithotripsy; sound waves break large
stones into smaller ones.
– More common in men than women;
hereditary factors.
– Medications (anesthetics, opiates,
psychotropic drugs) increase risk for
stones.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Kidney Stones Video
Click here to view a video on the pathology of renal calculi.
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©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Renal and Urologic Emergencies
• Renal Canculi
– Stones may form in metabolic disorders
(gout and hyperparathyroidism);
produce excessive amounts of uric acid
and calcium, respectively.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Renal and Urologic Emergencies
• Renal Canculi
– Balance between water conservation
and dissolution of insoluble substances
(mineral ions and uric acid) lost;
excessive amounts of insolubles
aggregate into stones.
– Stones of calcium salts most common.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Renal and Urologic Emergencies
• Renal Canculi
– Struvite stones: chronic urinary tract
infection (UTI) or frequent bladder
catheterization.
– Far less common stones made of uric
acid or cystine.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Renal and Urologic Emergencies
• Renal Canculi
– Focused history always centers on pain.
– Visceral pain in one flank.
– 30 to 60 minutes: extremely sharp
pain; may remain in flank or migrate
downward and toward groin.
– Migrating pain indicates stone has
passed into ureter.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Renal and Urologic Emergencies
• Renal Canculi
– Stones that lodge in ureter cause
frequency during day or during night
(nocturia), urgency, painful urination.
– Walking sometimes reduces pain.
– Abdominal examination may be difficult.
– Management begins with ABCs.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Renal and Urologic Emergencies
• Renal Canculi
– Positioning centers on comfort.
– Be prepared for vomiting due to severe
pain.
– Medications such as hydromorphone,
morphine, or fentanyl can be effective.
– IV fluid to promote urine formation and
movement through system.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Renal and Urologic Emergencies
• Priapism
– Painful and prolonged erection of penis.
– Common cause of nontraumatic
priapism: sickle cell disease.
– Causes: leukemia, multiple myeloma,
tumors, spinal cord injury, spinal
anesthesia, carbon monoxide poisoning,
malaria, black widow spider bites.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Renal and Urologic Emergencies
• Priapism
– Associated with numerous drugs.
– Medical emergency; requires prompt
intervention by urologist to prevent
permanent damage and penile
dysfunction.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Renal and Urologic Emergencies
• Testicular torsion
– Twisting of spermatic cord; cuts off
blood supply to testicle and surrounding
structures within scrotum.
– Severe testicular and abdominal pain.
– More common during infancy and
beginning of adolescence.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Renal and Urologic Emergencies
• Testicular torsion
– Sudden onset of severe testicular pain
(usually limited to one testicle).
– Exquisitely tender and swollen; often
high in scrotum.
– Nausea, vomiting, dizziness common.
– Prehospital treatment: identification of
condition and pain control.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Renal and Urologic Emergencies
• Urinary tract infection (UTI)
– Affects urethra, bladder, or kidney,
prostate gland in men.
– Extremely common.
– Pathogenic colonization of bladder by
bacteria that enter through urethra.
– Urinary stasis: person at higher risk.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Renal and Urologic Emergencies
• Urinary tract infection (UTI)
– Divided into those of:
 Lower urinary tract, urethritis (urethra)
 Cystitis (bladder)
 Prostatitis (prostate gland)
 Upper urinary tract, pyelonephritis
(kidney)
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Renal and Urologic Emergencies
• Urinary tract infection (UTI)
– Lower UTIs more common.
– Females: bacteria found in bowel
colonize urethra and bladder.
– Joint symptomatic infection of urethra
and bladder (urethritis and cystitis,
respectively).
– Sexually active females at higher risk.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Renal and Urologic Emergencies
• Prostatitis
– Inflammation of prostate gland;
inflammation secondary to bacterial
infection; general inflammatory
condition.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Renal and Urologic Emergencies
• Pyelonephritis
– Infectious inflammation of renal
parenchyma: nephrons, interstitial
tissue, or both.
– Acute pyelonephritis 10 times more
common in women than men.
– Intrarenal abscesses form within renal
parenchyma.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Renal and Urologic Emergencies
• Community-acquired infections
– Gram-negative enteric bacteria
predominate.
– E. coli accounts for 80% of infections.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Renal and Urologic Emergencies
• Nosocomial infections
– Cases acquired in inpatient setting or
related to catheterization; Proteus,
Klebsiella, and Pseudomonas commonly
identified.
• Sexually transmitted pathogens
– Such as Chlamydia and N. gonorrhoeae.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Urinary Catheterization Animation
Click here to view an animation on the topic of urinary catheterization.
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©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Renal and Urologic Emergencies
• Urinary tract infection (UTI)
– Focused history centers on: painful
urination, frequent urge to urinate,
difficulty in beginning and continuing to
void.
– Patient may complain of strong or foul
odor in urine.
– Pain may be referred to shoulder or
neck.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Renal and Urologic Emergencies
• Urinary tract infection (UTI)
– Patients with pyelonephritis appear
more ill and likely to have fever.
– Skin will be pale, cool, moist (lower UTI)
or warm and dry (febrile upper UTI).
– Lloyd's sign, tenderness to percussion of
lower back at costovertebral angle
(CVA), indicates pyelonephritis.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Renal and Urologic Emergencies
• Urinary tract infection (UTI)
– ABCs and circulatory support.
– If pain severe, help to comfortable
position.
– Risk of aspiration during vomiting.
– Analgesics considered.
– Hydration to increase blood flow
through kidneys and to produce more
dilute urine.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Summary
• The urinary system:
– Maintains blood volume and proper
balance of water, electrolytes, pH.
– Enables blood to retain key substances
and removes toxic wastes from blood.
– Plays major role in regulation of arterial
blood pressure.
– Controls maturation of red blood cells.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Summary
• Kidney nephrons produce urine.
• Homeostasis through urine production
responsible for first two functions and
assists in third, regulating blood
pressure, by producing renin, enzyme
that controls blood pressure.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Summary
• Other kidney cells produce
erythropoietin, hormone that stimulates
red blood cell maturation.
• Renal and urologic emergencies
typically present as acute abdomen.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Summary
• Most common emergencies:
– Acute renal failure (ARF)
– Chronic renal failure (CRF, with subset
of end-stage renal disease)
– Renal calculi
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Summary
• Both ARF and CRF may present with
life-threatening complications and
impaired function of other systems.
• Be prepared for apparently stable
patients to acutely develop
destabilizing complications.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Summary
• Urinary tract infections (UTIs) divided
into lower urinary tract (urethra,
bladder, prostate in men), upper
urinary tract (kidney).
• Both can present with considerable
pain; pyelonephritis more serious, with
fever and complications possible.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Summary
• Because renal function often lowered in
elderly and persons with hypertension
or diabetes, consider it potentially
impaired in all of these patients.
• Best prevention strategies are to
minimize likelihood of prerenal failure.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.