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Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Chapter 20 The Child With a Genitourinary Alteration.

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Presentation on theme: "Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Chapter 20 The Child With a Genitourinary Alteration."— Presentation transcript:

1 Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Chapter 20 The Child With a Genitourinary Alteration

2 Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 2 Anatomy of the Genitourinary System

3 Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 3 Pediatric Differences in the Genitourinary System  Complete maturity of the kidney occurs between 6 and 12 months of age  Before this time, the filtration capacity of the glomeruli is reduced; urine is voided frequently and has a low specific gravity

4 Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 4 Pediatric Differences in the Genitourinary System  Fluid constitutes a larger fraction of an infant’s and small child’s total body weight  The kidneys are less efficient at regulating electrolyte and acid-base balance and eliminating some drugs from the body  The immaturity of the renal structures predisposes the infant to dehydration and fluid volume excess  Bladder capacity increases from 20 to 50 mL at birth to 700 mL in adulthood

5 Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 5 Pediatric Differences in the Genitourinary System  Innervation of stretch receptors in the bladder wall does not occur before the age of 2 years  The urethra is shorter in children than in adults and may contribute to the frequency of urinary tract infections in children  Kidneys are more susceptible to trauma in children because they do not have as much fat padding

6 Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 6 Diagnostic Tests and Assessments of the Renal System  Urine specimen (for urinalysis; may be clean catch or sterile)  Intravenous pyelogram  Radiographs of kidneys, ureters, and bladder  Renal/bladder ultrasound  Cystogram  Computed tomography  Voiding cystourethrogram  Magnetic resonance imaging

7 Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 7 Serum Blood Tests  Hemoglobin and hematocrit  Blood urea nitrogen  Creatinine  Serum electrolytes

8 Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 8 Genitourinary Tract Disorders  Urinary tract infections  Vesicoureteral reflux

9 Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 9 Urinary Tract Infections  Caused by bacteria ascending from outside the urethra into the bladder  From the bladder, bacteria may continue to ascend into the upper urinary tract  Fecal bacteria most common cause of urinary tract infections (approximately 80%)

10 Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 10 Urinary Tract Infections Anatomic and physical factors that predispose to urinary tract infections include:  Females: short urethra, which provides a ready pathway for invasion of organisms  Males: increased incidence in uncircumcised infants younger than 1 year  Urinary stasis  Vesicoureteral reflux  Sexual activity in adolescent girls  Urinary tract obstructions  Constipation

11 Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 11 Urinary Tract Infections Clinical manifestations in the infant:  Fever or hypothermia in the neonate  Irritability  Dysuria  Change in urine odor or color  Poor weight gain  Feeding difficulties Clinical manifestations in the child:  Abdominal or suprapubic pain  Voiding frequency  Voiding urgency  Dysuria  New or increased incidence of enuresis  Fever

12 Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 12 Urinary Tract Infections Diagnostic evaluation  History  Physical examination  Urinalysis  Urine culture and sensitivity Therapeutic management  Eliminate current infection  Identify contributing factor  Prevent urosepsis  Preserve renal function

13 Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 13 Urinary Tract Infections Nursing considerations  Monitor intake and output  Observe for signs of dehydration in the infant and child  Administer antibiotics as ordered  Obtain daily weights  Encourage frequent voiding in toilet-trained child  Encourage increased fluid intake  Child and family education

14 Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 14 Vesicoureteral Reflux  Retrograde flow of bladder urine into the ureters  Primary reflux: results from a congenital anomaly that affects the ureterovesical junction  Secondary reflux: result of an acquired condition  Reflux with infection is the most common cause of pyelonephritis in children Clinical manifestations  See urinary tract infection  May see clinical manifestations of pyelonephritis

15 Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 15 International Classification of Reflux

16 Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 16 Vesicoureteral Reflux  Divided into categories based on the degree of reflux from the bladder into the upper genitourinary tract structures  Grade I: urine refluxes partway up the ureter  Grade II: urine refluxes all the way up the ureter

17 Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 17 Vesicoureteral Reflux Grade III: urine refluxes all the way up the ureter with dilation of the ureter and calyces Grade III: urine refluxes all the way up the ureter with dilation of the ureter and calyces Grade IV: urine refluxes all the way up the ureter with marked dilation of the ureter and calyces Grade IV: urine refluxes all the way up the ureter with marked dilation of the ureter and calyces Grade V: massive reflux of urine up the ureter with marked tortuosity and dilation of the ureter and calyces Grade V: massive reflux of urine up the ureter with marked tortuosity and dilation of the ureter and calyces

18 Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 18 Vesicoureteral Reflux Diagnostic evaluation  Laboratory studies  Urinalysis  Urine cultures  Electrolytes  Blood urea nitrogen  Imaging studies  Plan 3 to 6 weeks after the infection to allow for infectious inflammation to subside  Ultrasound  Voiding cystourethrogram

19 Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 19 Vesicoureteral Reflux Therapeutic management  Grades I and II: continuous low-dose antibacterial therapy with frequent urine cultures  Grade III: managed with antibiotic therapy unless complications present  Grade IV and V: may require surgical intervention

20 Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 20 Vesicoureteral Reflux Nursing considerations  Explain treatment plan  Explain that medical management may last for years and that adherence to antibiotic therapy and follow-up is important  If surgical intervention is necessary, educate regarding preoperative and postoperative repair

21 Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 21 Congenital Anomalies  Epispadias  Hypospadias  Cryptorchidism

22 Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 22 Cryptorchidism  Testes fail to descend through the inguinal canal into the scrotal sac  Exposes the testes to the heat of the body, leading to low sperm counts at sexual maturity

23 Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 23 Cryptorchidism  Greater risk for torsion and trauma  Frequently associated with an inguinal hernia Clinical manifestations  Testes that are not palpable or not easily guided into the scrotum or or  A previously descended testis that ascends into an extrascrotal position

24 Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 24 Cryptorchidism Diagnostic evaluation  Ultrasound, computed tomographic scan, or magnetic resonance image to determine location Therapeutic management  Human chorionic gonadotropin hormone is given to induce descent  If testes remain undescended, an orchiopexy is performed in the toddler years

25 Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 25 Epispadias and Hypospadias  Hypospadias: congenital defect in which the urinary meatus is located on the lower or underside of the shaft  Epispadias: congenital defect in which the urinary meatus is located on the upper side of the penile shaft; less common than hypospadias

26 Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 26 Epispadias and Hypospadias Clinical manifestations  Ventral or dorsal placement of the urethral opening  Altered urinary stream  Chordee Diagnostic evaluation  Based on physical examination

27 Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 27 Epispadias and Hypospadias Therapeutic management is surgical intervention usually done in one stage  Release of chordee and lengthening of the urethra  Repositioning of the meatus at the penile tip  Reconstruction of the penis  Usually done between 6 and 12 months of age  No circumcision of infant with hypospadias  Urinary diversion is used after surgery to allow healing (stents or catheters)  Goal of surgery: to make urinary and sexual function as normal as possible and to improve the cosmetic appearance of the penis

28 Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 28 Nursing Considerations for Children Undergoing Renal Surgery  Provide surgical tour, especially the “wake-up” room  Determine child’s words for penis, urination, etc.  Encourage parents to remain with child as appropriate  Provide support and reassurance  Assist child to turn, cough, and breathe deeply; frequently reposition infants  Perform frequent vital signs monitoring  Teach splinting of incision and incentive spirometry preoperatively

29 Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 29 Nursing Considerations for Children Undergoing Renal Surgery  Assess and monitor for bladder spasms and incisional pain  Provide analgesics as ordered  Regulate intravenous fluids  Keep accurate intake and output records  Measure daily weights  Teach need to keep skin dry and odor free  Provide written instructions to parents  Provide contact number if problems occur

30 Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 30 Glomerular Disease  Acute glomerulonephritis  Nephrotic syndrome

31 Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 31 Pathophysiology of Acute Poststreptococcal Glomerulonephritis and Nephrotic Syndrome

32 Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 32 Acute Glomerulonephritis vs. Nephrotic Syndrome  Acute glomerulonephritis: disorder that occurs suddenly and are characterized by hematuria, proteinuria, edema, and renal insufficiency  Occurs most frequently in young school-age children, most commonly after a streptococcal infection  Nephrotic syndrome: a kidney disorder characterized by proteinuria, hypoalbuminemia, and edema  Occurs most frequently in children between ages 2 and 6 years

33 Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 33 Acute Glomerulonephritis vs. Nephrotic Syndrome Pathophysiology  Streptococcal infection  Formation of antibodies in response to streptococcal bacteria  Antibodies combine with bacterial antigens to form immune complexes  Antigen-antibody complexes become trapped in the glomerulus and activate an inflammatory response in the glomerular basement membrane Pathophysiology  Insult occurs to the glomerular basement membrane  Damage causes increased permeability and loss of substances that would normally prevent negatively charged proteins from crossing the membrane  Leads to increased clearance rate for albumin (negatively charged protein)  This causes a loss of plasma proteins and proteinuria

34 Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 34 Acute Glomerulonephritis vs. Nephrotic Syndrome  Inflammation causes damage to the glomerular capillaries and reduces the size of the capillary lumen  Leads to decreased glomerular filtration rate  Leads to renal insufficiency  Causes sodium and fluid retention  Leads to edema and oliguria  Hypoalbuminemia reduces the plasma oncotic pressure  This causes a shifting of fluid from intravascular space to interstitial spaces  Fluid shifts reduce intravascular volume, causing hypovolemia and decreased renal blood flow  In response, renin production is stimulated, causing increased excretion of aldosterone  Renal tubular reabsorption of sodium occurs, which causes water retention and in turn leads to edema

35 Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 35 Acute Glomerulonephritis vs. Nephrotic Syndrome Clinical manifestations  Hematuria: tea- or cola- colored urine  Hypertension  Edema (worse in morning)  Usually young school-age child Clinical manifestations  Proteinuria: frothy urine  Edema  Abdominal pain  Weight gain  Hypovolemia  Normotension  Pallor  Fatigue  Toddler or preschool- age child

36 Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 36 Acute Glomerulonephritis vs. Nephrotic Syndrome Diagnostic evaluation  History  Presenting symptoms  Renal ultrasound  Urinalysis Laboratory results  Elevated blood urea nitrogen  Elevated erythrocyte sedimentation rate  Elevated ASO titer  Elevated creatinine  Electrolyte imbalance Diagnostic evaluation  History  Clinical manifestations Laboratory results  Urinalysis (3 to 4+ protein)  Possible microscopic hematuria  Hypoalbuminemia  Elevated cholesterol  Elevated triglycerides  Elevated hemoglobin and hematocrit  Elevated platelets

37 Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 37 Acute Glomerulonephritis vs. Nephrotic Syndrome Therapeutic management  Supportive  Antihypertensives  Diuretics  Low-salt diet Therapeutic management  Prednisone to initiate remission  Diuretics  Possible administration of albumin  Antibiotics to prevent infection  No added salt diet

38 Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 38 Acute Glomerulonephritis vs. Nephrotic Syndrome Nursing considerations  Intake and output every shift  Daily weights  Monitor cardiopulmonary status every shift  Fluid restrictions as ordered  Low-salt diet  Cluster care to promote rest  Frequent position changes to decrease pressure on bony prominences (every 2 hours) Nursing considerations  Position changes every 2 hours  Good daily hygiene  Support and elevate edematous body parts with pillows  Physical activity as tolerated  Antibiotics as ordered  Vital signs every shift  Intake and output every shift

39 Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 39 Acute Glomerulonephritis vs. Nephrotic Syndrome Nursing considerations  Good daily hygiene  Monitor for signs of dehydration  Vital signs every shift  Parental education Nursing considerations  Monitor laboratory values  Observe for signs of dehydration  Daily weights  No added salt diet  Measure abdominal girth daily  Administer diuretics as ordered  Monitor cardiopulmonary status every shift  Parental education

40 Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 40 Child with Nephrotic Syndrome

41 Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 41 Hemolytic Uremic Syndrome  An acute renal disease characterized by a triad of manifestations: acute renal failure, hemolytic anemia, thrombocytopenia  Occurs primarily in infants and small children between 6 months and 3 years of age  An important cause of chronic renal failure  Disease usually follows an acute gastrointestinal or upper respiratory infection

42 Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 42 Hemolytic Uremic Syndrome Clinical manifestations  Presence of gastrointestinal, urinary tract, or upper respiratory tract infection with diarrhea and/or vomiting  Hemolytic anemia  Edema and ascites  Hypertension  Neurologic involvement (irritability, seizures, lethargy, stupor, coma, cerebral edema)  Rectal bleeding  Purpura  hematuria/proteinuria  Oliguria or anuria

43 Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 43 Hemolytic Uremic Syndrome Diagnostic evaluation  Triad of anemia, thrombocytopenia, and renal failure is sufficient for diagnosis  Renal involvement is evidenced by proteinuria, hematuria, and presence of urinary casts  Blood urea nitrogen and serum creatinine levels are elevated  Hemoglobin and hematocrit counts are low  Reticulocyte counts are high

44 Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 44 Hemolytic Uremic Syndrome Therapeutic management  Focuses on the complications of acute renal failure and includes the following:  Fluid restriction  Antihypertensive medications  High-calorie, high-carbohydrate diet low in protein, sodium, potassium, and phosphorus  Most consistently effective treatment is early dialysis or continuous hemofiltration  Transfusion of fresh packed red blood cells may be needed to treat severe anemia

45 Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 45 Hemolytic Uremic Syndrome Nursing considerations  Parenteral or enteral nutrition as ordered  Dialysis may be required during the acute period to correct electrolyte and fluid balances while eliminating wastes  Monitor intake and output  Daily weights  Maintain fluid restrictions as ordered  Blood pressure as ordered (report changes to prevent complications)  Thorough handwashing  Provide emotional support for child and address parental anxiety  Family education


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