Transcript Highlights of the Developing Urinary System

Highlights of the Developing
Urinary System
• Fluid constitutes a larger fraction of total
body weight in infants and children
• Kidney immaturity until 2 years of age
• Kidneys more vulnerable to trauma
• Glomerular filtration and absorption are
relatively low until 1-2 years of age
– More prone to fluid volume excess and
dehydration
Phimosis
• Narrowing of the foreskin which prevents
it from being retracted over the penis
• Normal in newborns
• Disappears by 3 years of age
• May effect urinary stream
• RX: circumcision
• Paraphimosis: requires immediate
evaluation
Hypospadias and Epispadias
• Urinary meatus is mislocated
• Hypospadias located somewhere on the
ventral side of the shaft
• Epispadias located somewhere on the
dorsal side of the shaft
• See pictures page 686
Hypospadias/Epispadias
Treatment
• Surgical correction before 18 months
• Need to use foreskin therefore important
not to circumcise at birth
Exstrophy of the Bladder
Exstrophy of the bladder
• Lower portion of abdominal wall and
anterior wall of the bladder are missing
• Bladder is open and exposed and urine is
draining from it
• Nsg care before surgery is to cover with
dressing to protect it but allow for drainage
• Nursing care also involves protection of
surrounding skin
Hydronephrosis and Polycystic
Kidney
• Hydropnephrosis: Distension of the renal
pelvis because of an obstruction
• Polycystic Kidney: fluid filled cysts form
in place of healthy kidney tissue in the
fetus; inherited autosomal recessive
Treatment of obstructive disease
• Urinary diversion or urinary stoma
UTI in Children
• Fever typically indicates renal involvement
and standard of care is IV therapy
• Cranberry juice causes anti adherence of
bacteria to wall of bladder
• trimetroprim/ sulfamethoxazole (Bactrim,
Septra)
• or nitrofurantoin (Macrodantin, Furadantin,
Macrobid).
Vesicoureteral Reflux
• Abnormal retrograde flow of bladder urine into
the ureters
• Associated with recurring kidney infections and
renal scarring
• Puts children at risk for bladder infection
• Bacteria from the bladder has access to the
kidney
• Renal complications due to both back pressure
and infection
Vesicoureteral Reflux
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Vesicoureteral Reflux
Treatment for Vesicoureteral
Reflux
• Daily lo dose of antibiotics
– trimetroprim/ sulfamethoxazole (Bactrim, Septra)
– nitrofurantoin (Macrodantin, Furadantin, Macrobid).
– Infants under two months amoxicillin
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Urine cultures every 3 months
Children often out grow the disorder
Deflux
Surgery
Deflux endoscopic procedure
The gel forms a bump
which keeps urine
from flowing back into
the ureter. Eventually,
new tissue can grow
around the gel and can
provide long-term
results for some
children.
References
• http://www.eradiography.net/radpath/v/vcr.htm
• http://www.nlm.nih.gov/medlineplus/ency/
imagepages/19502.htm
• http://www.rnceus.com/course_frame.asp?
exam_id=23&directory=ua
– This site is a great education resource for
CMEs
Nephrotic Syndrome
• Increased glomerular permeability to
plasma protein
• Leads to massive urinary protein loss
• Increased albumin in urine
• Decreased albumin in blood
• Decreased colloidal osmotic pressure in
capillaries causes pull of fluid to the
interstitial spaces
Nephrotic Syndrome cont.
• Hypovolemia due to the fluid shift to the
interstitial spaces
• Renin/angiotensin system stimulated for
the increase secretion of ADH and
aldosterone
• Usually the blood pressure does not
increase
Nephrotic Syndrome
Nephrotic Syndrome DX
• Proteinuria
• Hypoalbuminemia
• hypercholesterolemia
Nephrotic Syndrome
Management
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Avoid adding salt but not necessarily low sodium
Fluid restriction only when massive edema is present
Diuretics not usually useful
Albumin transfusion
Prednisone 2 mg/kg/day
– Response in 7-21 days
– Dose tapered off over several weeks
• Those that do not respond to prednisone are offered other
immunosuppressive therapy: Cytoxan
• Close observation for relapse
Nephrotic Syndrome
Nursing Care Issue
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Related to the side effects of steroids
Skin breakdown related to edema
Poor appetite accompanying nephrosis
Possible fluid restriction and sodium restriction
Decreased level of energy and appropriate
developmental stimulation and play.
• High risk for infection
Nephrotic syndrome
Ongoing nursing assessment
• Urinary output,
• Vigorous monitoring
concentration, protein.
for infection
• Daily weight
• Monitoring level of
• Abdominal girth
activity and energy
• Edema
• Continued monitoring
• Vital signs
of diet/intake
– Shock
• No vaccines while
– Infection
disease is active and
– Respiratory distress
during rx
Acute Glomerulonephritis
• Immune complex disease
• Occurs after a group A beta hemolytic
strep infection
• Immune complexes deposited in
glomerular basement membrane
• Results in decrease in plasma filtration
• Leads to fluid and sodium retention
Glomerulonephritis
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Manifestations of
Glomerulonephritis
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Edema: mild, periorbital
Anorexia
Tea colored urine
Oliguria
Pallor, irritability, lethargy
Mildly elevated blood pressure
Diagnostic Evaluation
• Hematuria
• Proteinuria
• Positive leukocytes, epithelial cells and
casts
• Increased BUN and Creatinine
• Positive Antistreptolysin O Titer
Management of
Glomerulonephritis
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Moderate sodium restriction
Possible fluid restriction
VS, wt, I/O
Fluid and electrolyte assessment
– Hyperkalemia, acidosis, hypocalcemia,
hyperphosphatemia
• Possible Antihypertensives
• Possible Antibiotics
Glomerulophritis complications
• Hypertensive encephalopathy
– headache,
– vomiting,
– depressed sensorium, confusion,
– visual disturbances,
– aphasia,
– memory loss,
– coma, and convulsions.
Glomerulonephritis complications
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Dyspnea,
orthopnea,
cough.
Pulmonary rales are often audible.
Cardiac failure is rare
References
• http://www.emedicine.com/ped/topic27.ht
m
• http://courses.vetmed.wsu.edu/vm552/urog
enital/gn.htm
Wilm’s Tumor
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Nephroblastoma
Peak age up to 3 years, familial origins
Avoid abdominal palpation: could cause tumor to spread
Treatment: surgery followed by radiation therapy and/or
chemotherapy
Wilm’s Tumor Manifestations
• Firm non tender mass confined to one side
of the abdomen
• Weight loss and fever
• Occasional hematuria
• Occasional hypertension
Hydorocele
• Excessive amount of fluid in the sac that
surrounds the testicle due to a minor defect
that allows peritoneal fluid to enter the
scrotum
• Surgical treatment IF the problem persists
beyond one year
Cryptorchidism
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Congenital undescended testes
Warmer in abdomen
Sperm cells begin to deteriorate
Often accompanied by inguinal hernia
Treatment orchidopexy
Testicular Torsion
• Small ligament at its base,
becomes loose.
• The testicle can then twist
on itself, cutting off its flow
of blood.
• Testicular torsion is
considered an emergency.
• Surgery performed within
about 5 hours from the
onset of symptoms to save
the testicle