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The Child With a Genitourinary Alteration

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Presentation on theme: "The Child With a Genitourinary Alteration"— Presentation transcript:

1 The Child With a Genitourinary Alteration
Chapter 20 The Child With a Genitourinary Alteration

2 Anatomy of the Genitourinary System

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 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 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 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 Serum Blood Tests Hemoglobin and hematocrit Blood urea nitrogen
Creatinine Serum electrolytes

8 Genitourinary Tract Disorders
Urinary tract infections Vesicoureteral reflux

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 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 P. 597

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 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 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 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 P. 598

15 International Classification of Reflux

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 Vesicoureteral Reflux
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 V: massive reflux of urine up the ureter with marked tortuosity and dilation of the ureter and calyces

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 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 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 Congenital Anomalies Epispadias Hypospadias Cryptorchidism

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 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 A previously descended testis that ascends into an extrascrotal position

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 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 Epispadias and Hypospadias
Clinical manifestations Ventral or dorsal placement of the urethral opening Altered urinary stream Chordee Diagnostic evaluation Based on physical examination

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 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 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 Glomerular Disease Acute glomerulonephritis Nephrotic syndrome

31 Pathophysiology of Acute Poststreptococcal Glomerulonephritis and Nephrotic Syndrome

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 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 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 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 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 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 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 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 Child with Nephrotic Syndrome

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 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 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 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 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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