2HypospadiasUrethral opening of male is located below the glans or underneath the penile shaftIncidence 1 out of 300 live birthsCause unknownFamilial tendencyWebsite1 and Website 2 with hypospadias repair
3Chordee Ventral curvature of the penis Often accompanies more severe forms of hypospadiasForeskin may be absent ventrallyHooded or crooked appearance of penisSurgical repair
4Surgical Repair Objectives of repair Enhance ability to void standing up w/straight streamImprove physical appearance of genitalia for psychological reasonsPreserve sexually adequate organRepair best done between 6-18 mosBefore develops body image and castration anxietyNursing care:Prepare parents w/simple explanationsStent may be placed, but Catheter care essential– discharge instructionsIncrease PO fluidsLoose clothing, no straddle toys, swimming, tub baths, rough play or sandboxes
5Renal Development in Peds Fluid larger % of total body wt.GFR not adult level til 1-2 yrs.Short loop of Henle in newbornLess efficient first 2 yrs.No bladder control first 2 yrs.Smaller bladder capacityNewborn production about 1 to 2 mL/kg/hrChild production about 1 mL/kg/hrShorter urethra
6Lab & Diagnostic Tests Routine UA Specific gravity pH BUN and Cr IVP VCUGUltrasoundsAngiography
7Normal Urinalysis pH 5 to 9 Sp gr 1.001 to 1.035 Protein <20 mg/dL Urobilinogen up to 1 mg/dLWBC’s: 0—5NONE OF THE FOLLOWING:Glucose – RBCsKetones – CastsHgb – Nitrites
10Urinary Tract Infections Typical Symptoms: (box 30-1, p th ed. Hockenberry)DysuriaFrequent urination (>q2h), foul-smelling urineUrgencySuprapubic discomfort or pressureUrine may contain visible blood or sediment (cloudy appearance)General malaise, poor feeding or appetite, vomiting, fussiness/irritability.Flank pain, chills, and fever indicate infection of upper tract (pyelonephritis)
11Pediatric Manifestations Pediatric patients with significant bacteriuria may have no symptoms or nonspecific symptoms like fatigue or anorexiaFrequencyFever in some casesOdiferous urineBlood or blood-tinged urineSometimes no symptoms except generalized sepsisDx: Hx, PE, UA & culture
12UTI Collaborative Care: Drug Therapy—Antibiotics Uncomplicated cystitis: short-term course of antibioticsComplicated UTIs: long-term treatmentTrimethoprim-sulfamethoxazole (TMP-SMX, Bactrim) or nitrofurantoin (Macrobid)Amoxicillin, Cephalexin, GentamycinEliminate cause, ID contributing factors
13Teaching Enc. freq. voiding & complete emptying ↑ fluid intake Acidify urine (cranberry juice, Vit. C)-present research does NOT support the efficacy of this. pH needs to be at 5.0 or < in order to have a significant impact on e.coli. (P. 1145)Avoid bubble baths, hot tubs, whirlpoolsNo tight panties or nylonGood hygiene; wipe front to backVoid after sexual activityAvoid Constipation
14Vesicoureteral Reflux (VUR) Urine swept up ureters w/each void then empties back into bladder (p. 1269)↑s chance for infections - most common cause of pyelonephritis in childrenScarring by 5-6 yrsDx: ultrasound; cystography; VCUGTx: continuous low dose antibiotics w/freq urine cultures OR surgical repair with stent placement.
15Acute Glomerulonephritis APSGN most common – days after strep infection (skin or throat)Inflammation of glomeruli; damage by antigen- antibody complex↓ GFR & renal bld flow → HTN & edemaMost common s/s: HTN—monitor regularly, edema (periorbital), hematuria/proteinuriaDaily wt – IMPORTANTMaintain fluid balance & treat HTNLoop diuretics or anti-hypertensives may be used1st sign of improvement-- ↑ urine & ↓ wt.
16Nephrotic SyndromeGlomerular injury → massive proteinuria, hypoalbuminemia, hyperlipemia, edemaOther s/s: wt. gain, periorbital edema early in day → ankle edema later in day, anorexia, pallor, fatigue, oliguria (dark & frothy)More common between 2-4 yrs oldCompare APSGN with Nephrotic Syndrome—see chart at end of Ppt.
17Types Most common in peds: MCNS Secondary: result of glomerular damage Minimal-Change Nephrotic Syndrome80% of cases – cause unknownPrecipitated by viral URISecondary: result of glomerular damageAcute GlomerulonephritisCollagen Diseases (Lupus)Drug toxins/poisons/venonsAIDS, sickle cell, hepatitis & others
18Nephrotic Syndrome (p. 1155, 9th ed) Wong 7th ed p. 1276; 6th ed p. 1386
19Diagnosis History of S/S Labs Urine Blood Proteinurea >2 gm/day Specific gravity ↑Blood↓ serum proteinHgb/Hct – nl or slightly ↑ due to hemoconcentrationPlatelets ↑ and serum Na+ ↓Cholesterol ↑
20Treatment Goals: Must try to ↓ excretion of protein & ↓ inflammation Meds: Corticosteroids till urine is free from protein & normal daysImmunosuppressants – CytoxanLoop Diuretics – not always effectiveDuring massive edema→ ↓saltNo restriction on water
21Nursing Considerations Monitor for infection (esp. peritonitis)Monitor for side effects of steroidsMonitor wt, I & O, abd. girthUrinalysis for albuminProtect skin from breakdown d/t edemaVS for signs of complicationsMonitor diet restrictionsSupport and educate family
22Prognosis If diuresis within 7-21 days – GOOD If not after 28 days → chance of response ↓80% OK50% relapse after 5 yrs20% relapse after 10 yrsKey: early ID and TxIf responds to steroids, relapse is less
23Minimal Change Nephrosis ManifestationsAcute GlomerularNephritisMinimal Change NephrosisASO TitersNormalBPNormal or EdemaPrimarily peripheral or periorbitalGeneralized, severeCirculatory congestionCommonAbsentProteinuriaMild –moderateMassiveHematuriaGross or microscopicMicroscopic or noneRBC castsPresentAzotemiaSerum K+ levelsNormal or Serum Protein levelsMinimal reductionMarkedly Serum lipid levelsElevatedPeak age at onset (Yr)5-72-3