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Chapter 45: Genitourinary Dysfunction
Terms in this set (93)
Renal System Assessment
-Observation of symptoms
-Laboratory, radiologic, or other evaluation methods.
-Uncontrolled or unintentional urination that occurs after a child is beyond an age at which bladder control is achieved.
-Inappropriate urination occur at least twice a week for at least 3 months.
-Child is at least 5 years of age before diagnosing enuresis.
-Rule out organic causes related to genitourinary dysfunction prior to diagnosis.
-Child has never been free of bedwetting for any extended periods of time.
-Child who started bedwetting after development of urinary control.
Enuresis Risk Fx
-Has no clear etiology.
-Disorders associated with bladder dysfunction.
Enuresis Expected Findings
-History of alterations in toilet training, voiding behaviors, and bowel movement patterns.
-History of chronic or acute illness such as UTI, diabetes mellitus, sickle cell disease, neurologic deficits.
-History of family disruptions or other emotional stressors.
-Fluid intake, especially in evening.
Enuresis Nursing Care
-Educate family/child regarding management.
-Have child empty bladder prior to bedtime.
-Encourage fluids during day and restrict fluids in evening.
-Avoids fluids after 4 pm.
-Allow child to wear sleepwear, avoid diapers.
-Use positive reinforcement.
-Avoid punishing, scolding, or teasing child following an incident.
-Have child change bed linens and after incident.
-Use night light, clear path to bathroom.
-Antidiuretic hormone -Desmopressin acetate (DDAVP).
-Reduces the volume of urine.
-Prescribed orally or nasally.
-Instruct the family to administer the medication at bedtime.
-Store nasal preparation in refrigerator.
-Inform family of possible adverse effects.
Antidiuretic hormone - Desmopressin acetate (DDAVP) Adverse Effects
-N/V -Weakness -Loss of appetite
-Restless -Irritability -Confusion
-Hallucinations -Muscle spasms
-Cramps -Seizures -Syncope
-Severe headache -Blurred vision
-Chest pain -Weight gain
-Unusual tiredness -Dizziness
-Loss of consciousness
-Shortness of breath
-Slow or shallow breathing
Enuresis Medications -Tricyclic antidepressants
-Monitor children for an increase in suicidality.
-Length of treatment is for 6 to 8 weeks, then gradually withdrawal.
-Instruct the family to administer the medication 1 hr before bedtime.
-Instruct the family to avoid sun exposure.
-Instruct the family to avoid using with over-the-counter medications.
Enuresis Medications -Anticholinergics
-Reduces bladder contractions.
-Instruct family about possible adverse effects.
-Dry mouth -Blurry vision
Complications of Enuresis
-Emotional problems such as-
-Low self-esteem -Altered body image
-Social isolation -Fears
-Assist child/family to understand emotional aspects of disorder.
-Early intervention cam alleviate long term emotional issues.
Urinary Tract Infections (UTI)
-Infection in any portion of urinary tract.
-One of the most common conditions of childhood.
-High incidence of infection among uncircumcised boys younger than 3 months.
Urinary Tract Infections (UTI) Types
-Bacteriuria -Bacteria in the urine.
-Asymptomatic bacteriuria -No S/S present.
-Symptomatic bacteriuria -S/S present.
-Recurrent UTI -Multiple occurrences.
-Persistent UTI -Unresolved bacteriuria w/antibiotic therapy.
-Febrile UTI -Symptomatic bacteriuria w/fever.
-Cystitis -Inflammation of bladder
-Urethritis -Inflammation of urethra.
-Pyelonephritis -Inflammation of upper urinary tract and kidneys.
-Urosepsis -Bacterial illness, urinary pathogens in blood.
Causes of Urinary Tract Infections
-Escherichia coli (80%).
UTI S/S -Neonatal period (birth to 1 month)
-Poor feeding -Vomiting
-Failure to gain weight
-Rapid respirations (acidosis)
-Spontaneous pneumothorax or pneumomediastinum
-Screaming on urination
-Poor urine stream
-Jaundice*** -Seizures -Dehydration
-Enlarged kidneys or bladder.
UTI S/S -Infancy (1-24 months)
-Increase in irritability -Poor feeding
-Vomiting -Failure to gain weight
-Excessive thirst -Frequent urination
-Straining or screaming on urination
-Foul smelling urine
-Persistent diaper rash***
-Pallor -Fever*** -Seizures, w/ or w/o fever.
-Dehydration -Enlarged kidneys or bladder.
UTI S/S -Childhood (2-14 years)
-Poor appetite -Vomiting -Growth failure
-Excessive thirst -Enuresis
-Swelling of the face -Seizures
-Pallor -Fatigue -Blood in urine
-Abdominal or back pain***
-Edema -Hypertension -Tetany
-Any child who exhibits the following should be evaluated-
-Incontinence in a toilet-trained child.
-Strong or foul-smelling urine.
-Frequency or urgency.
Urinary Tract Infections Lab Tests
-Urinalysis -Urine culture and sensitivity (C&S)
-Catheterization or suprapubic -children less than 2 years.
-If suprapubic aspiration, need informed consent.
-Clean-catch urine -if able to perform.
-pH, weak acid or neutral alkaline.
-Protein is positive
-Glucose is positive
-Ketones are positive
-Leukocytes are positive
-Nitrates are positive
Urinary Tract Infections Lab Tests -Bacterias
Urinary Tract Infections Dx Procedures
-Percutaneous kidney tap.
-Bladder wash outs.
-Voiding cystourethrogram (VCUG)
-IV pyelogram (IVP)
-Dimercaptosuccinic acid (DMSA) scan
Urinary Tract Infections Dx Procedures Nursing Actions
-Assess for allergy to iodine or shellfish if contrast medium is used.
-Sedate infants/young children if needed.
-Maintain the child on NPO status after midnight in preparation for a cystoscopy and IVP, requires bowel preparation.
Therapeutic Management of Urinary Tract Infections
-Antibiotics based on findings of urine culture and sensitivity testing.
Prevention of Urinary Tract Infections
-Wipe perineal area from front to back in females.
-Retract and clean foreskin of male infants.
-Instruct to wear cotton underwear and keep them dry.
-Avoid bubble baths.
-Encourage frequent voiding and complete emptying of bladder using double voiding.
-Encourage sexually active adolescents to void immediately after intercourse.
-Progressive kidney injury.
Nephrotic Syndrome (Nephrosis)
-Alterations in glomerular membrane allow proteins,*** especially albumin, to pass into urine, resulting in decreased serum osmotic pressure.
Nephrotic Syndrome (Nephrosis) Pathophysiology
-Normally impermeable to large proteins.
-Becomes permeable to proteins, especially albumin.
-Hyperalbuminuria, albumin loss in urine.
-Hypoalbuminemia, serum albumin decreased.
Nephrotic Syndrome (Nephrosis) Risk Fx
-Peak incidence is between 2 and 7 years of age.
-Cause is unknown
-Secondary nephrotic syndrome, glomerular damage occurs after known cause.
-Congenital nephrotic syndrome, an inherited disorder.
Nephrotic Syndrome (Nephrosis) S/S
-Weight gain over days or weeks.
-Facial and periorbital edema decreases throughout day.
-Ascites -Edema in legs or ankles.
-Anorexia -Diarrhea -Irritability
-Lethargy -Easily fatigued
-Decreased volume of urine and frothy urine, proteinuria.
-Dark and frothy.
-No gross hematuria***
-Blood pressure normal or decreased.***
Nephrotic Syndrome (Nephrosis) Dx
-Suspected based on clinical manifestations.
-Massive urinary protein loss
Nephrotic Syndrome (Nephrosis) Dx -Lab Tests
-Urinalysis/24-hr urine collection
-Proteinuria -protein greater than 2+ on dipstick.
-Hyaline casts -Few RBCs
-Oval fat bodies -Serum chemistry
-Hypoalbuminemia -reduced serum protein and albumin.
-Hyperlipidemia -elevated serum lipid levels.
-Hemoconcentration -elevated Hgb, Hct, and platelets.
-Possible hyponatremia -reduced sodium level.
-Glomerular filtration rate -normal or high.
Nephrotic Syndrome (Nephrosis) Dx Procedures
-Kidney biopsy, indicated only if unresponsive to steroid therapy.
-Biopsy will show damage to epithelial cells lining basement membrane of kidney.
Nephrotic Syndrome (Nephrosis) Nursing Care
-Activity adjustment -provide rest.
-Monitor I&O, urine for protein.
-Monitor daily weights, edema and measure abdominal girth daily.
-Assess skin for breakdown areas.
-Elevate edematous body parts.
Nephrotic Syndrome -Nursing Care High Risk/Susceptibility of Infection
-In edematous children and those receiving corticosteroids.
-Assist the client to turn, cough, and deep breathe to prevent pulmonary involvement.
-Monitor vital signs, for changes secondary
-Maintain good hand hygiene.
-Administer antibiotic therapy as ordered.
Nephrotic Syndrome -Nursing Care Diet
-Encourage nutritional intake within restriction guidelines.
-Salt and fluids restricted during the edematous phase.
-Loss of appetite is common.
Nephrotic Syndrome (Nephrosis) Medications -Corticosteroid
-First line of therapy
-Response is usually seen in 7-21 days.
Nephrotic Syndrome -Corticosteroid Nursing Considerations
-Monitor for adverse effects such as hirsutism, slowed linear growth, hypertension, GI bleeding, infection, and hyperglycemia.
-Administer with meals.
-Avoid large crowds, risk of infection.
-Inform of increased appetite, weight gain, especially in the face, and mood swings.
Nephrotic Syndrome -Diuretic Nursing Considerations
-Eliminates excess fluid from the body.
-Encourage child to eat foods high in potassium.
-Monitor serum electrolyte levels.
Nephrotic Syndrome - 25% Albumin Nursing Considerations
-Increases plasma volume and decreases edema.
-Monitor I&O and anaphylaxis.
Nephrotic Syndrome -Cyclophosphamide Nursing Considerations
-For children who cannot tolerate prednisone or who have repeated relapses of MCNS.
Nephrotic Syndrome (Nephrosis) Complications
-Steroid therapy increases risk for infection.
-Common infections seen in children with nephrotic syndrome include pneumonia, peritonitis, and cellulitis.
Acute Glomerulonephritis (AGN)
-Glomeruli are inflamed, which impairs kidney's ability to filter urine properly.
Acute Poststreptococcal Glomerulonephritis (APSGN)
-An antibody-antigen disease that occurs as a result of certain strains of the Group A ß-hemolytic streptococcal infection.***
-Most commonly seen in children between ages 2-7 years.
-Latent period of 10-21 days.
Acute Glomerulonephritis (AGN) Risk Fx
-Recent APSGN: streptococcal infection with specific strain of group A ß-hemolytic streptococcus.
Acute Glomerulonephritis S/S
-Cloudy (tea colored) urine, smoky brown.
-Gross hematuria*** -Bleeding in upper urinary tract causes urine to appear smoky.
-Proteinuria -Decreased urine output (oliguria)
-Irritability -Ill appearance
-Vague reports of discomfort -headache, abdominal pain, dysuria.
-Facial edema that is worse in the morning but then spreads to extremities and abdomen with progression of day.
-Mild to severe hypertension***
Acute Glomerulonephritis (AGN) Dx Lab Tests
-Throat culture to identify possible streptococcus infection -usually negative by the time of diagnosis.
-Urinalysis -acute phase, proteinuria, smoky or tea-colored urine, hematuria, increased specific gravity.
-Renal function -elevated BUN and creatinine
-Antistreptolysin O (ASO) titer -positive indicator for presence of streptococcal antibodies.
-Antideoxyribonuclease B (ADNase-B)
-Antideoxyribonuclease B (ADNase-B)
-Serum complement (C3) -decreased initially; increases as recovery takes place; returns to normal at 8 weeks post-glomerulonephritis.
Acute Glomerulonephritis Dx Procedures
-Chest x-ray to identify pulmonary edema, cardiac enlargement, or pleural effusion.
Acute Glomerulonephritis Nursing Care
-If child's BP and urine output are normal, can be managed at home.
-Monitor neurologic status and observe for behavior changes, especially in children who have edema, HTN, and gross hematuria.
-Implement seizure precautions if the condition indicates.
-Monitor and prevent infection.
-Assess tolerance for activity.
-Provide frequent rest periods.***
-Cluster care to facilitate rest and tolerance of activity.
Acute Glomerulonephritis Nursing Care Diet Considerations
-Monitor daily weights
-Monitor I&O -Daily abdominal girth.
-Low sodium diet***
-Fluids restriction during w/edema and HTN.
-Restrict foods high in potassium w/ oliguria.
-Provide small, frequent meals of favorite foods due to decrease in appetite.
Acute Glomerulonephritis Medications
-Diuretics and antihypertensives to remove accumulated fluid and manage HTN.
-Monitor blood pressure and I&O.
-Monitor for electrolyte imbalances such as hypokalemia.
-Inform dizziness can occur with antihypertensives.
Prognosis of Glomerulonephritis
-Almost all children with diagnosis of acute poststreptococcal glomerulonephritis recover completely.
-Recurrences are uncommon.
-Some children have been reported to develop chronic disease.
Structural Disorders of Genitourinary Tract
-Various structural disorders can be evident at birth and can affect normal genitourinary and reproductive function.
Structural Disorders -Obstructive Uropathy
-Structural or functional obstruction.
-Surgical procedures to divert flow of urine to bypass obstruction.
-Surgical repair with insertion of percutaneous nephrostomy or cutaneous ureterostomy tubes.
Structural Disorders -Chordee
-Ventral curvature of penis
-Surgical release of fibrous band.
Structural Disorders -Bladder Exstrophy
-Eversion of posterior bladder through anterior bladder wall and lower abdominal wall.
-Exposed bladder, urethra, and ureteral orifices through suprapubic area.
-Epispadias is present.
-Cover exposed bladder with sterile, nonadherent dressing.
-Prepare for immediate surgery.
Structural Disorders -Hypospadias
-Urethra opening located just below glans penis, behind glans penis, or on ventral surface of penile shaft.
-Meatus opening below glans penis.
-Meatus opening along ventral surface of penis, scrotum, or perineum.
-Possible chordee present.
Structural Disorders -Epispadias -Male
-Widened pubic symphysis.
-Urethra opening on dorsal surface of penis.
-Possible exstrophy of bladder.
-Surgery performed during first year of life.
-Traditionally male circumcision not performed, newer surgical techniques do not require an intact foreskin.
Structural Disorders -Epispadias -Female
-Bifid clitoris (double)
-Possible exstrophy of bladder
-Surgery performed during first year of life.
Structural Disorders -Phimosis
-Narrowing of pubital opening of foreskin.
-Inability to retract foreskin of penis.
-Normal finding in infants and young boys and usually disappears as child grows.
-Proper hygiene for phimosis foreskin is external cleansing during routine bathing, the foreskin should not be forcibly retracted.
Structural Disorders -Cryptorchidism
-Undescended testes -inability to palpate testes within scrotum.
-Surgery performed 6-24 months of age.
-Older children have administration of human chorionic gonadotropin.
Structural Disorders -Hydrocele
-Fluid in the scrotum.
-Enlarged scrotal sac.
-Can resolve spontaneously.
-Surgical repair if not resolved in 1 year.
Structural Disorders -Varicocele
-Elongation, dilation, and tortuosity of the veins of the spermatic cord superior to the testicle.
Structural Disorders -Testicular Torsion
-Testes hang free from its vascular structures.
-Pain is either acute or insidious in onset and radiates to the groin area.
Urinary Structural Defects Therapeutic Procedures
-Repair of structural defects should be done between 6-15 months, but before 3 years of age, to minimize impact on body image and to promote healthy development.•The goal of most structural defect repairs is to preserve or create normal urinary and sexual function. •Early intervention will minimize emotional trauma
Urinary Structural Defect Complications Medications
-Repair of structural defects should be done between 6-15 months, but before 3 years of age, to minimize impact on body image and to promote healthy development.
-The goal of most structural defect repairs is to preserve or create normal urinary and sexual function.
-Early intervention will minimize emotional trauma.
Postoperative Care of Structural Defects
-Assess pain using an appropriate pain assessment tool.
-Administer pain medication and/or antispasmodic, oxybutynin (Ditropan) as prescribed to treat painful bladder spasms.
-Provide wound and dressing care.
-Monitor for signs of infection at surgical site.
-Monitor for fever, lethargy, and foul-smelling urine.
-Do not provide tub baths for at least 1 week or as prescribed.
-Limit activity as prescribed.
Urinary Structural Defect Complications
-Emotional problems, poor self-esteem, altered body image, social isolation, fears.
-Hemolytic uremic syndrome (HUS)
-Diarrhea-positive (D+) HUS
-Diarrhea-negative (D-) or atypical HUS
-Occurs after prodromal period of diarrhea and vomiting.
Hemolytic Uremic Syndrome (HUS)
-HUS is acute renal failure, hemolytic anemia and thrombocytopenia.
-One of the main causes of acute renal failure in early childhood.
-Peak incidence 6 months to 3 years.
Urinary Structural Defect Complications Nursing Care
-Monitor hydration status.
-Implement seizures precautions.
-For child anuric for 24 hours or having oliguria with uremia or hypertension and seizures.
-Hemodialysis -Peritoneal dialysis
Acute Renal Failure (ARF)
-Inability of kidneys to excrete waste material, concentrate urine, and conserve electrolytes.
-Can be acute or chronic and affects most systems of body.
Acute Renal Failure Risk Fx
-Dehydration secondary to diarrheal disease or persistent vomiting.
-Surgical shock and trauma, including burns.
Acute Renal Failure Dx
-Assess kidney function related to preexisting renal disease.
-Metabolic acidosis -Hypocalcemia
-Anemia -Azotemia -high levels of nitrogen.
-Elevated plasma creatinine
-ECG for cardiac arrhythmias
Acute Renal Failure S/S
-Abrupt diuresis with return to normal urine volumes.
-Cardiac arrhythmia from hyperkalemia
-Seizures from hypotnatremia or hypocalcemia
-Tachypnea from metabolic acidosis
-CNS manifestations from continued oliguria
Acute Renal Failure Nursing Care
-Treat underlying causes.
-Admit to pediatric intensive care unit.
-Monitor strict I&O.
-Monitor vital signs for HTN complications.
-Maintain urinary catheterization.
-Assess for behavior changes or seizure activity.
-Implement seizure precautions if indicated.
-Assess for infection.
Acute Renal Failure Medications
-Mannitol and furosemide
-Glucose 50% and insulin 1 unit/kg IV
-Less urgent medications for hypertension
-Antiepileptic drugs if seizures present.
Acute Renal Failure Complications -Hyperkalemia
-Normal potassium (K 3.5-5)
-High potassium causes arrhythmias.
-Give Kay exulate to reduce potassium.
-Causes diarrhea, only way to remove excess potassium.
Acute Renal Failure Complications
-Cardiac failure with pulmonary edema
Chronic Renal Failure (CRF)
-Begins when diseased kidneys can no longer maintain normal chemical structure of body fluids under normal conditions.
Chronic Renal Failure Risk Fx
-Most common causes before 5 years of age are congenital renal and urinary tract malformations, and vesicoureteral reflux.
-Glomerular and hereditary renal disease 5-15 years of age.
Chronic Renal Failure S/S
-Loss of energy -Pallor -Delayed growth
-Occasional elevated blood pressure
-Anorexia -Nausea and vomiting
-Decrease interest in activities
-Decreased or increased urinary output and compensatory increase in fluid intake.
-Anemia -Headache -Muscle cramps
-Weight loss -Amenorrhea in adolescent girls.
-Puffiness of face -Bone or joint pain
-Itchy, bruised skin -Hypertension
-CHF -Pulmonary edema, circulatory overload
-Confusion -Dulling of sensorium
-Muscle twitching -Seizures
Chronic Renal Failure Dx
-Assess extent of kidney damage.
-Assess biochemical disturbances
-CBC -Serum creatinine
Chronic Renal Failure Nursing Care
-Provide rest -Monitor I&O
-Vital signs -Daily weights
-Monitor for infection and manage HTN.
-Maintain sodium restriction.
-Initiate fluid restriction if edema present.
-Dietary phosphorus can need to be restricted.
-Potassium is restricted if oliguria or anuria.
Acute Renal Failure Nursing Care Medications
-Mannitol and furosemide -Calcium gluconate
-Sodium bicarbonate -Glucose 50%
-Insulin 1 unit/kg IV
-Less urgent medications for HTN.
-Hydralazine IV -Clonidine IV -Verapamil IV
-Antiepileptic drugs if seizures present.
-Thiazides or furosemide -Beta-blockers
-Vasodilators -Phosphorus binding agent
-Calcium -Vitamin D active form
-Sodium bicarbonate -Potassium citrate
-Folic acid -Recombinant human erythropoietin
-Recombinant growth hormone -Antimicrobials -Antiepileptic medications -Diphenhydramine
Chronic Renal Failure Medications -Phosphorus Binding Agent
-Dietary phosphorus is controlled through reduction of protein and milk intake to prevent or correct calcium-phosphorus imbalance.
Chronic Renal Failure Medications -Calcium
-Oral calcium preparation (Tums) combines with phosphorus to decrease GI absorption and serum phosphate levels.
Chronic Renal Failure Interprofessional Care
-Obtain a dietary consult
-Encourage dental care
Chronic Renal Failure Client Education
-Encourage follow-up care
Chronic Renal Failure Complications
-End-stage renal disease
-Irreversible progress of renal insufficiency
-Process of separating colloid and crystalline substances through a semipermeable membrane.
-Peritoneal dialysis -Hemodialysis
-Preferred method of dialysis for children/adolescents.
-Abdominal cavity acts as semipermeable membrane for filtration.
-Warmed solution enters peritoneal cavity by gravity, remains for period of time before removal.
-Requires creation of vascular access and special dialysis equipment.
-Best suited for children who can be brought to facility three times/week for 4-6 hours.
-Achieves rapid correction of fluid and electrolyte abnormalities.
-From living related donor.
-Usually a parent or sibling.
-Primary goal -Long-term survival of grafted tissue.
-Role of immunosuppressant therapy.
-Taken for the rest of life.
-High susceptibility to infection.
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