Transcript Genitourinary Dysfunction

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Enuresis
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Urinary Tract Infection
Pyelonephritis
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Vesicoureteral reflux (VUR)
Hydronephrosis
Cryptorchidism
Hypospadius
Exstrophy of Bladder
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Acute Glomerulonephritis
Nephrotic Syndrome
Acute Renal Failure
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Myelination of spinal
cord necessary before
child can control
bowel and bladder
function; occurs
between 12-18
months
However, child is
usually not ready
until 18-24 months
Waiting until 24-30
months makes the
job easier
Expected
Milestones
Age Developmental
Bladder
Control
1.5 years
2 Years
2.5 years
3 years
3.5 years
Urinates regularly
Aware of voiding
Can hold urine
Daytime control
Nighttime control
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Physical Readiness
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Child
Child
Child
Child
removes own clothes
is willing to let go of toy
is able to sit, squat, and walk well
has been walking for 1 year
Psychological Readiness
◦ Child notices wet diaper
◦ Child indicates need for diaper change
◦ Child communicates need to go to the bathroom and
can get there by self
◦ Child wants to stay dry
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Parent Readiness
◦ Requires many toileting sessions a day
◦ Need to be able to give child undivided attention
◦ Patience
◦ Personal choice on toilet or free standing potty
chair
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Primary
◦ Never achieved dryness for 3 months
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Secondary
◦ Dry for 3-6 months then resumes wetness
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Diurnal
◦ Wetting occurs only in daytime
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Nocturnal
◦ Wetting occurs only in nightime
 Neurological
 UTI
 Structural
delay
disorder
 Chronic renal failure
 Disease with polyuria (DM)
 Chronic constipation
 Sleep
arousal problem
 Sleep disorders from enlarged
tonsils, sleep apnea
 Psychological stress
 Family history
 Inappropriate toilet training
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May avoid activities
◦ Sports
◦ Sleepovers
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Great source of stress
Concealing wet clothing is difficult
Odor is a concern
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Situational Low Self-Esteem related to
bed- wetting or urinary incontinence
Impaired Social Interaction related to
bed- wetting or urinary incontinence
Compromised Family Coping related to
negative social stigma and increased
laundry load
Risk for Impaired Skin Integrity related
to prolonged contact with urine
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Organic- treat underlying cause
Nonorganic- most will outgrow by late
childhood
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Assess parent and child’s motivation and
readiness
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If willing to be active participant then
management includes:
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Alarms
Timed voiding
Bladder exercises
Elimination diets
Behavioral therapy
Medications
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DDAVP
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Ditropan
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Tofranil (Imipramine)
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Most common infection of GI tract
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Fecal bacteria (E. coli) cause most UTI’s
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Girls>boys after age 1
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In males uncircumcised>circumcised
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Can lead to renal scarring, high blood
pressure, End Stage Renal Disease
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Urinary tract obstructions
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Voiding dysfunction resulting in urinary stasis
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Anatomic differences in younger children
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Individual susceptibility to infection
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Urinary retention while toilet-training
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Bacterial colonization of the prepuce of uncircumcised infants
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Infrequent voiding
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Sexually active adolescent girls
◦ Nonspecific
◦ Fever
◦ Irritability
◦ Dysuria (crying when voiding)
◦ Change in urine odor or color
◦ Poor weight gain
◦ Feeding difficulties
◦ Abdominal or suprapubic pain
◦ Voiding frequency
◦ Voiding urgency
◦ Dysuria
◦ Fever
◦ Malodorus urine
◦ Hematuria
◦ New or increased incidence of enuresis
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Urinealysis (UA)
◦ Macro
◦ Micro
◦ 24 hour
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Culture and Sensitivity (C & S)
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Specimen collection
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Clean catch
Pediatric urine collector
Straight cath
Foley cath
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UA (Urinalysis)
◦ Bacteruria
◦ Pyuria
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Urine C&S: colony count = 100,000
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Pyelonephritis
◦ Above UA and C&S findings plus
 Elevated WBC
 Elevated ESR
 Increased CRP
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Infection travels to kidneys
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Same symptoms of UTI plus:
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Higher fever
Back or flank pain (CVAT)
Nausea & vomiting
Look sick
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7-10 day of antibiotics by mouth
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Dehydrated child and very young
often require IV antibiotics
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Increase PO fluids
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Analgesia
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Antipyretics
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7-10 days of IV antibiotics
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Increase PO fluids
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Analgesia
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Antipyretics
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Proper toilet training
Teach proper wiping
Avoid tight clothing
Wear cotton underwear
Encourage children to avoid “holding” urine
Avoid bubble baths
Don’t force cranberry-increases acidity
Adolescent: urinate immediately after
intercourse
Malformed
and bladder
valves at ureters
Allows
a backflow of urine
up the ureter into the kidney
Can
be congenital
abnormality, graded 1-5
Grade
Grade
1-3 frequent UTI
4- 5: massive
ureteral and renal pelvis
dilation
reflux
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Genetic origin
Girls>boys
Symptoms
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Frequent UTI’s (most common)
Enuresis
Flank pain
Abdominal pain
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Prophylactic antibiotics
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Teach child to double void
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Grades 1-3: will usually resolve on
own
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Grades 4-5: valve repair
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Urine C&S every 2-4 months
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Enlargement of the pelvis of the kidney
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Caused by
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Congenital narrowing of the ureteropelvic junction
Kidney stones
Tumors
Blood clots
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Usually free of symptoms initially
May have repeated UTI’s (urinary stasis)
Polyuria
Frequency
Flank pain
Increased BP
Abdominal palpation reveals a mass
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If untreated can destroy nephrons
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Surgical correction of the obstruction
One
or both testes fail to
descend through the inguinal
canal into the scrotal sac
In
85% right testis is affected
The
affected side or bilateral
scrotum appears flaccid or
smaller than normal
Unknown
why this fails
◦Increased abd pressure
◦Hormonal influences
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Common in the premature infant and LBW
infant
Incidence decreases with age
Many resolve spontaneously by 12 months
age
If still present at age 1, descent usually does
not occur
Associated with lower sperm production
Increased risk for malignant testicle turoms in
adulthood
 Observation
for first year
 HCG- stimulates testosterone
production and helps with
descent
 If testis fail to descend
between 1-2 years of age then
surgical treatment: Orchiopexy
 Post
op instructions
◦ Loose clothing
◦ Incision Care
◦ Monitor for infection
◦ Analgesia
◦ Ice
◦ Discuss future fertility & cancer
risk
◦ Congenital malformation
◦ Urethral opening is below normal
placement on glans of penis (ventral
surface-underside)
◦ May also have short chordee (fibrous
band of the penis, will cause it to
curve downward)
Epispadius
◦ dorsal placement of urethral opening
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Cause is unknown
Defects in testosterone is possible
Possible genetic origin
Symptoms
 Urinary stream deflected downward
 Prepuce is small-Penis appears to look
circumcised
 May have chordee, undescended testes and
inguinal hernia
 Out
patient surgery to
lengthens urethra (meatomy),
position meatus at penile tip,
release the chordee
 Performed
btw 12-18 mos of
age
 No circumcision
Post-op:
 Stent for urinary
drainage and patency
 Double Diapering
 Strict I&O
 Pain Management
 Monitor for Infection
 No Hip-Holding, rideon toys
 Possible fertility
problems
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Bladder lies open and exposed on
abdomen (defect in abdominal wall)
Bladder is bright red & unable to contain
urine
Surgical closure of abdominal wall,
reconstruction of bladder, urethra and
genitalia “continent urinary reservoir”
Prevent
infection
Protect skin integrity
Protect exposed bladder
Parental education
(straight catheterization)
Keep infant’s legs flexed
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Closure of the bladder and abdominal wall
Urinary continence, with preservation of renal
function
Creation of functional and normal-appearing
genitalia
Correction to promote later sexual
functioning
Suprapubic
catheter-if unable to restore
function
Immobilized Pelvis
Strict I&O
Antispasmotics: Probanthine (Pyridium)
Analgesics
Parental Emotional Support
Structural Disorders of GU System
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Many children are discharged with stents or
catheters.
Teach parents how to change dressings, double
diaper, care for catheters, assess pain and give
analgesics, and recognize signs of possible
obstruction or infection.
Parents should encourage the child to
participate in age-appropriate activities.
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Chemistry Panel
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Potassium: 3.5-5.8
Sodium: 135-148
Urea Nitrogen: 3.5-7.1
Creatinine: 0.2-0.9
Calcium: 2.2-2.7
Albumin: 3.2-4.7
Blood Gases
◦ Bicarbonate: 18-25
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Urinalysis
◦ Protein: None
◦ Specific Gravity: 1.001-1.030
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Sudden inflammation of the glomeruli of
the kidney resulting in acute renal failure
Peak age 5-10 years, boys>girls
Capillary walls of kidney become
permeable; allows red blood cells and
protein to pass into urine
Usually seen 7-10 days after a strep
infection (immune response to strep),
may be other organisism
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URI preceding symptoms
Sudden onset of hematuria (smokey or
tea-colored urine)
Proteinuria (+1 to +4)
Edema (worse in the morning) of eyelids
and ankles; sodium and fluid are retained
Oliguria: < 1 ml/kg/hr = impending renal
failure
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Hypertension (due to decreased
glomerular filtration rate) can be severe
HTN may lead to pulmonary edema
(listen for crackles)
Fever, malaise, abdominal pain, HA,
vomiting- feel sick
 Presenting
symptoms
 Urinalysis
◦ proteinuria +1 to +4,
◦ 24h urine 1 gram protein
◦ hematuria
 Increased
BUN, creatinine
• Electrolytes Imbalance (from inadequate
glomerular filtration)
◦ high serum potassium
◦ low serum bicarbonate
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BP may increase, if > 160/100 can lead to
encephalopathy
ASO Titer (antistreptolysin): indicates
presence of antibodies to streptococcal
bacteria
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No specific treatment- supportive
Manage S&S (adequate rest- main tx)
Monitor renal dysfunction
Anti-hypertensive therapy (limit sodium
& water or by diuretics & antihypertensive meds)
Prognosis is excellent
Daily weight, accurate I & O until fully
resolved (2 mos)
Diuresis signals the beginning of
resolution
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Monitoring fluid status- hypovolemia
◦ I&0, VS, Electrolytes
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Preventing infection-ARF risk for infection
◦ Hand hygiene, screen visitors, watch CBC
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Preventing skin breakdown
◦ Bed Rest is the Treatment
◦ Check dependent areas
◦ Sheets tight, free of crumbs, sm toys
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Meeting nutritional needs
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ARF anorexia is common
no added salt, low protein diet
Encourage food from home
Age appropriate quantity
Providing emotional support to the child and
family
◦ Guilt is common from untreated strep
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Immune response to systemic infection alters
the structure of the glomeruli to become
permeable to protein
resulting in:
◦ Massive urinary protein loss
◦ Generalized tissue edema
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Highest incidence
at age 3
Generalized Edema
◦ Periorbital edema
◦ Abdominal edema
◦ Scrotal edema
Poor nutrition
Growth retardation
Renal failure
 Proteinuria
(24h urine 15
grams)
 Hypoalbuminemia
 Hyperlipidemia
 Urine appears dark and
frothy
 Negative ASO titer
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Reduce edema
Protect skin from FVE
Protect from Infection
Prevent Hypovolemia
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Prednisone 2mg/kg/day for 4-8 weeks
◦ Long term steroid use is concern
◦ Treat until child is in remission (zero to trace
urine protein for 5-7 consecutive days)
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Diuretic therapy used only if poor response
to steroids
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May need IV albumin (helps restore normal
plasma osmotic pressure)
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Give parental support and education re:
urine protein checks
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Frequent position changes q2h
Loose clothing
Semifowler’s for sleeping, elevate
edematous body parts
Maintain good hygiene (daily baths, dry
completely)
Promote physical activity if able (promote
circulation)
 Screen
visitors for s/s of
infection
 Administer ABX as ordered
given for peritonitis prophylaxis
 Good handwashing for staff and
family
 Monitor child for s/s infection
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Monitor I & O
Obtain accurate daily weights
Adhere to no-added salt diet
Monitor BP at least once each shift
Administer diuretics (potassium intake)
Monitor pulmonary status (watch for
fluid overload, pulmonary edema)
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Watch for low BP & increased pulse =>
hypovolemia
Report if child has output of less than 1
ml/kg/hr of urine
Increased Hbg, Hct and platelets may indicate
hemoconcentration or low intravascular
volume
Observe for s/s dehydration r/t use of
diuretics
AGN
Nephrotic Syndroms
School age child
Dark Urine
Oliguria
Strep Infection
Mild proteinuria
Serum protein unaffected
Hyperkalemia
Increased BUN, Cr
Mild edema
HTN
TX- BP meds
Young child
Dark Urine
Oliguria
Negative Strep
Severe proteinuria
Hypoalbuminemia
Hyperlipidemia
Severe edema
Normal or low BP
Tx-prednisone, diuretics, IV
albumin
kidney is unable to excrete wastes and
concentrate urine
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Sudden onset of impaired renal function
Boys>girls
More common age < 5 years
Usually occurs secondary to infection
Most children regain renal function
Can be life threatening
◦ Dehydration
◦ Hypovolemia
◦ Antibiotic
◦ Contrast dye
◦ Infections of the kidney
◦ Structural abnormality
◦ Tumor or calculi
Oliguria
(< 1ml/kg of weight)
HTN may be malignant
Dehydration
Pallor, listlessness
Hyperkalemia
Hyponatremia
Hypocalcemia
Increased
Azotemia
BUN & creatinine
(increased serum nitrogen)
Uremia (azotemia plus cerebral irritation)
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Increase renal perfusion and restore
electrolyte balance
Depends on Cause
General Treatment Includes:
◦ Fluid restriction
◦ Daily weight
◦ TPN to minimize protein catabolism
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Kayexalate for hyperkalemia
◦ I & O (Foley)
The nurse is teaching the parents of a preschooler
information about urinary tract infections and ways
to reduce their recurrence. Statements from the
parents that indicate an understanding of ways to
prevent UTI’s include (select all that apply)
1.
2.
3.
4.
5.
“I
should try to get her to drink a lot of water”
“I will buy her cotton underwear”
“Soaking in a bubble bath will wash away the
bacteria”
“She should avoid urinating in public
restrooms ”
“I should give her cranberry juice daily”
The parent of a 2 ½ year old child asks the
nurse about potty training. Which assessment
question should the nurse ask to assess the
child’s developmental readiness?
1. “Can you child hold urine voluntarily?”
2. “Can you child urinate on command?”
3. “Is your child dry at night?”
4. “Does your child know when he is voiding?”
The nurse would include which of the
following in the care of a child with acute
glomerulonephritis?
(select all that apply)
1.
2.
3.
4.
5.
Careful handling of edematous extremities
Observing the child for evidence of HTN
Provide fun activities for the child on
bedrest
Monitor for hematuria
Encouraging salty foods
The newborn has been diagnosed with
cryptorchidism. The MD has ordered HCG
to be administered. The mother asks the
nurse why the baby is receiving the drug.
The nurse explains it will:
1.
2.
3.
4.
Maintain an adequate temperature around
the testes
Prevent infection in the undescended tests
Prevent the development of cancer
Promote descent of the testes
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View the diagram below. Where is the site
of malformation in a child with VUR?
A
B
C
D
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1.
2.
3.
4.
Am 18.4 kg child urinated 43.68ml. The last
void was 3 hrs ago. The nurse evaluates this
output to be:
Oliguria
Polyuria
Normal output
Anuria
The following results are from a chemistry
panel on a 5-year-old child. Which of the
following labs confirm the child is in AGN
(Select all that apply)
1. Potassium 5.9
2. Urea Nitrogen 7.4
3. Albumin 3.8
4. Creatinine 0.6
5. 15 g 24/hr proteinuria
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Answer 1,2,3
1. Potassium
5.9 (hyperkalemia)
2. Urea Nitrogen 7.4 (Inc BUN)
3. Albumin 3.8 (Normal)
4. Creatinine 0.6 (should be inc)
5. 15 g 14/hr proteinuria (way to high)
The nurse is treating a 33 lb child with
Nephrotic Syndrome. The nurse calculates the
appropriate dose of prednisone to be:
1. 10 mg qd
2. 20 mg qd
3. 30 mg qd
4.
40 mg qd
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