Transcript Genitourinary Dysfunction

Genitourinary
Dysfunction
Common Genitourinary Disorders
• Enuresis
• Urinary Tract Infection
• Pyelonephritis
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Vesicoureteral reflux (VUR)
Hydronephrosis
Cryptorchidism
Hypospadius
Exstrophy of Bladder
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Acute and chronic Glomerulonephritis
Nephrotic Syndrome
Wilm’s Tumor (Nephroblastoma)
Acute Renal Failure
Toilet Training
• Myelinization of spinal cord
necessary before child can
control bowel and bladder
function; occurs between
12-18 months
• Usually not ready until 18-24
months
• Waiting until 24-30 months
makes the job easier
Toilet Training
• Average of continence 3 years
• Order of control
1.Noctural bowel control
2.Daytime bowel control
3.Daytime urine control
4.Noctural urine control
Signs of Readiness for Toilet
Training
• Physical Readiness
– Child removes own clothes
– Child is willing to let go of toy
– Child is able to sit, squat, and walk well
– Child 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
Enuresis Involuntary voiding of urine > 6
yrs
• Primary
– Never achieved dryness for 3
months
• Secondary
– Dry for 3-6 months then resumes
wetness
• Diurnal
– Wetting occurs only in daytime
• Nocturnal
– Wetting occurs only in nightime
Etiology
Organic
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Neurological delay
UTI
Structural disorder
Chronic renal failure
Disease with polyuria (DM)
Chronic constipation
Etiology
Non-organic
• Sleep arousal problem
• Sleep disorders from
enlarged tonsils, sleep apnea
• Psychological stress
• Family history
• Inappropriate toilet training
Diagnosis
• Physical exam to r/o organic
cause
• Made by voiding diary
Impact on child
• May avoid activities
– Sports
– Sleepovers
• Great source of stress
• Concealing wet clothing is difficult
• Odor is a concern
Enuresis: Nursing Diagnosis
• 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
Management
• Elimination diets
• Behavioral therapy
• Motivational therapy
Medication
• DDAVP
• Ditropan
• Tofranil (Imipramine)
Urinary Tract Infection
(UTI) • Most common infection of GI tract
• Fecal bacteria (E. coli) cause most
UTI’s
• Girls>boys after age 1
• In males uncircumcised>circumcised
• Can lead to renal scarring, high
blood pressure, End Stage Renal
Disease
Conditions that Predispose
Infants and Children to UTIs
• Urinary tract obstructions
• Voiding dysfunction resulting in
urinary stasis
• Anatomic differences in younger
children
• Individual susceptibility to infection
• Urinary retention while toilet-training
• Bacterial colonization of the prepuce
of uncircumcised infants
• Infrequent voiding
• Sexually active adolescent girls
Symptoms
• Infants
– Nonspecific
– Fever or
hypothermia
(neonate)
– Irritability
– Dysuria (crying
when voiding)
– Change in urine
odor or color
– Poor weight gain
– Feeding difficulties
Symptoms
• Children
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Abdominal or suprapubic pain
Voiding frequency
Voiding urgency
Dysuria
New or increased incidence of enuresis
Fever
Malodorus urine
Hematuria
Pyelonephritis
Infection travels to kidneys
Symptoms
• Same s/s of UTI plus:
• Higher fever
• Back or flank pain (CVAT)
• Nausea & vomiting
• Look sick
Diagnostic tests
• Urinealysis (UA)
– Macro
– Micro
– 24 hour
• Culture and Sensitivity (C & S)
• Specimen collection
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Clean catch
Pediatric urine collector
Straight cath
Foley cath
Diagnosis
• UA (Urinealysis)
– Bacteriuria
– Pyuria
• Urine C&S: colony count > 100,000
• Pylonephritis
– Above plus
– Elevated WBC
– Elevated ESR
– Increased CRP
Management of Both
• 7-10 day course of ABX
• Dehydrated child and very
young often require IV and hosp
• Increase PO fluids
• Analgesia
• Antipyretics
• Repeat urine C&S 3-5 days
after tx
Prevention
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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
• Adolescent: urinate immediately
after intercourse
Structural Defects
Vesicoureteral reflux (VUR)
• Malformed valves at ureters and bladder
• Allows a backflow of urine up the ureter
into the kidney
• Can be congenital abnormality, graded 1-5
• Grade 5: massive ureteral and renal pelvis
dilation
• Diagnosed with cystourethrogram
Etiology and symptoms
• Genetic origin
• Girls>boys
• Symptoms
– Frequent UTI’s (most common)
– Enuresis
– Flank pain
– Abdominal pain
Vesicoureteral reflux (VUR)
Treatment:
• Grades 1-3: will usually resolve
on own
• Grades 4-5: valve repair, repeat
cystograms q12-18 months to
monitor progress
• Prophylactic ABX
• Teach child to double void
• Urine C&S q2-4 months until 3
negative
Hydronephrosis
• Enlargement of the pelvis of the
kidney secondary to a congenital
narrowing of the ureteropelvic
junction
• May also be acquired secondary to
kidney stones, tumors, blood clots
Symptoms
• Usually free of symptoms
• May have repeated UTI’s (urinary
stasis)
• Polyuria
• Frequency
• Flank pain
• Increased BP
• Abdominal palpation reveals a mass
Hydronephrosis
Diagnosis:
• If congenital, usually diagnosed in
utero
• IVP shows enlarged renal pelvis &
site of obstruction
Management:
• If untreated can destroy nephrons
• Surgical correction of the obstruction
Cryptorchidism (UDT)
• One or both testes fail to descend through
the inguinal canal into the scrotal sac
• Testis may be retractable
• 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
Cryptorchidism (UDT)
• 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
Management
• Observation for first year
• HCG- stimulates testosterone
production and helps with
descent
• If testis fail to descend
between 1-2 years of age
Management
surgical treatment:
• Orchiopexy
• Post op:
–Loose clothing
–Analgesia
–Future fertility
Hypospadius
– 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
Hypospadius, epispadius,
chordee
Etiology and Symptoms
• 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
Management of both
• Out patient surgery to lengthens
urethra (meatomy), position
meatus at penile tip, release the
chordee
• Performed btw 12-18 mos of age
• No circumcision
• If untreated:
Post-op:
Prone to bladder spasms
Foley cath until edema is decreased
Possible fertility problems
Exstrophy of Bladder
• Bladder lies open and exposed on abdomen
(defect in abdominal wall)
• Pelvic bone defects (non-closure of pelvic
arch)
• Bladder is bright red & unable to contain
urine, may also have defects in urethra
(epispadius)
• Surgical closure of abdominal wall,
reconstruction of bladder, urethra and
genitalia “continent urinary reservoir”
Management
Preop:
•Prevent infection
•Protect skin integrity
•Protect exposed
bladder
•Parental education
(straight
catheterization)
•Keep infant’s legs
flexed
Postop:
•Suprapubic catheter
•Antispasmotics:
Probanthine
(Pyridium)
•Analgesics
Disorders of the Kidney
Pediatric Normal Value
• 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
• Urinalysis
– Protein: None
– Specific Gravity: 1.001-1.030
Acute Glomerulonephritis (AGN)
• 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)
– APSGN
• or other bacterial or viral infection
Signs & 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: < 1-2ml/kg/hr => impending
renal failure
• URI preceding symptoms
Signs & Symptoms
• Hypertension (due to decreased
glomerular filtration rate) can be
severe => pulmonary edema
• Fever, malaise, abdominal pain,
HA, vomiting
Diagnosis
History:
• Presenting symptoms
• Urinalysis
– proteinuria +1 to +4,
– 24h urine 1 gram protein
– hematuria
• BUN, creatinine increase
Diagnosis
• Electrolytes (high serum potassium, low
serum bicarbonate from inadequate
glomerular filtration
• BP may increase, if > 160/100 can lead
to encephalopathy
• ASO Titer (antistreptolysin): indicates
presence of antibodies to streptococcal
bacteria
• WBC may be increased
Management
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No specific treatment
Manage S&S (adequate rest)
Monitor renal dysfunction
Anti-hypertensive therapy (limit sodium &
water or by diuretics & anti-hypertensive
meds)
• Prognosis is excellent
• Daily weight, accurate I & O until fully
resolved (2 mos)
• Diuresis signals the beginning of resolution
Chronic Glomerulonephritis
• Permanent destruction of glomeruli
• Can result from untreated acute
glomerulonephritis or nephrotic
syndrome
• Chronic renal failure
• Poor prognosis
• Renal dialysis, kidney transplant
Nephrotic Syndrome
• Immune response to systemic
infection alters the structure of the
glomeruli to become permable to
protein
• resulting in:
– Massive urinary protein loss
– Tissue edema
Assessment
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Highest incidence at age 3
Proteinuria (24h urine 15 grams)
Hypoalbuminemia
Hyperlipidemia
Periorbital edema
Abdominal edema
Scrotal edema
Poor nutrition
Growth retardation
Renal failure
Diagnosis
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Presenting symptoms
Age of child
Lab results
Proteinuria
Urine appears dark and
frothy
• Serum albumin markedly
decreased
• Negative ASO titer
Reduce edema
• 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)
• Diuretic therapy used only if poor
response to steroids
• May need IV albumin (helps restore
normal plasma osmotic pressure)
• Give parental support and education re:
urine protein checks
Risk for impaired skin integrity
r/t edema & decreased
circulation.
• 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)
Risk for infection r/t urinary loss of
gamma-globulins and
immunosuppressive therapy.
• 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
Fluid volume excess r/t decreased
excretion of sodium and fluid
retention.
• 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)
Risk for fluid volume deficit r/t proteinuria, edema,
effects of diuretics.
• Watch for low BP & increased pulse
=> hypovolemia
• Report if child has output of less than
1-2ml/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
Wilm’s Tumor
(Nephroblastoma)
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Malignant tumor of the kidneys
Peak age 3-4 years
Girls > boys
Cause is unknown
Other GU problems
• Occurs in asymptomatic child
– May have genetic predisposition
– Is associated with congenital
anomalies
Nephroblastoma
• parents usually notice a large, mobile
abdominal mass while bathing or the
diaper doesn’t fit anymore
• DO NOT PALPATE ABDOMEN
– can rupture the tumor and cause
spreading of cancerous cells
Other Signs & Symptoms
• microscopic to gross
hematuria
• hypertension
• abdominal pain
• fatigue, anemia, fever
Diagnosis
• Suspected from a good history
• CT scan
• Definitive dx made at time of
surgery
• Staged 1-5
Staging 1 through 5
1. tumor confined to the kidney and completely
removed surgically
2. tumor extending beyond the kidney but
completely removed surgically
3. regional spread of disease beyond the
kidney with residual abdominal disease
postoperatively
4. metastases to lung (primary site), liver,
bone, distant lymph nodes
5. bilateral disease
Treatment
• State 1 and 2
–Nephrectomy
–Chemotherapy
• Stage 3-5
–Nephrectomy
–Radiation
–Chemotherapy
• Survival rates are good (up to 90%)
Acute Renal Failure (ARF)
• 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
Types of ARF
Prerenal
– Sudden decrease in renal blood flow result
from dehydration, hypovolemia, shock,
burns, CHF
Intrarenal
-damage to kidney tissue from
antibiotic use and other nephrotoxic
drugs, contrast dye, or infections of the
kidney
Postrenal
– Urine is obstructed between the kidney and
meatus causing back up of urine in kidney
and diminishes renal function. Structural
abnormality, tumor or calculi are the cause
Acute Renal Failure
Signs & symptoms:
•Oliguria (< 1ml/kg of
weight)
•HTN may be
malignant
•Respiratory distress
from metabolic
acidosis
•Dehydration
•Pallor, listlessness
•Hyperkalemia
•Hyponatremia
•Hypocalcemia
•Azotemia (increased
serum nitrogen)
•Uremia (azotemia plus
cerebral irritation)
•Increased BUN &
creatinine
Treatment: Mild ARF
• Increase renal perfusion and
restore electrolyte balance
– Fluid restriction
– Sodium restriction
– TPN
– Kayexalate PO or per rectum
– Daily weight
– I & O (Foley)
– Prevent infection
Indications for Dialysis in Acute
Renal Failure
• Severe fluid overload
• Pulmonary edema or congestive
heart failure secondary to fluid
overload
• Severe hypertension
• Metabolic acidosis or
hyperkalemia not responsive to
medications
• Blood urea nitrogen >120 mg/dl
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 and
juices”
“I will buy her cotton underwear”
“Soaking in a bubble bath will reduce meatal
irritation”
“If I notice her wetting the bed, I need to have her
checked for UTIs”
“I should avoid giving her cranberry juice as it has
been shown to make urine more acidic”
The nurse would include which of the
following in the care of a child with
acute glomerulonephritis? (select all
that apply)
1. Careful handling of edematous
extremities
2. Observing the child for evidence of
HTN
3. Provide fun activities for the child on
bedrest
4. Monitor for hematuria
5. Encouraging fluid intake
When reviewing a urinalysis report
of a child with AGN, the nurse
expects to find:
1.
2.
3.
4.
Decreased creatinine clearance
Decreased specific gravity
Proteinuria
Decreased ESR
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. Maintain an adequate temperature
around the testes
2. Prevent infection in the undescended
tests
3. Prevent the development of cancer
4. Promote descent of the tests
Parents ask the nurse how to toilet-train
their toddler. Which is NOT an
appropriate statement by the nurse?
1. Wanting to please the parent helps
motivate the toddler to use the toilet
2. Awareness of urge to defecate must
be developed
3. Practice sessions should be limited
to once or twice a day
4. Free-standing potty chairs help to
make the toddler feel more secure