Presentation on theme: "Renal Disorders in Children. Hypospadias Urethral opening of male is located below the glans or underneath the penile shaft Incidence 1 out of 300 live."— Presentation transcript:
Renal Disorders in Children
Hypospadias Urethral opening of male is located below the glans or underneath the penile shaft Incidence 1 out of 300 live births Cause unknown Familial tendency Website1 and Website 2 with hypospadias repair Website
Chordee Ventral curvature of the penis Often accompanies more severe forms of hypospadias Foreskin may be absent ventrally Hooded or crooked appearance of penis Surgical repair
Surgical Repair Objectives of repair ◦ Enhance ability to void standing up w/straight stream ◦ Improve physical appearance of genitalia for psychological reasons ◦ Preserve sexually adequate organ Repair best done between 6-18 mos ◦ Before develops body image and castration anxiety Nursing care: ◦ Prepare parents w/simple explanations ◦ Stent may be placed, but Catheter care essential– discharge instructions ◦ Increase PO fluids ◦ Loose clothing, no straddle toys, swimming, tub baths, rough play or sandboxes
Renal Development in Peds Fluid larger % of total body wt. GFR not adult level til 1-2 yrs. Short loop of Henle in newborn Less efficient first 2 yrs. No bladder control first 2 yrs. Smaller bladder capacity ◦ Newborn production about 1 to 2 mL/kg/hr ◦ Child production about 1 mL/kg/hr Shorter urethra
Lab & Diagnostic Tests Routine UA Specific gravity pH BUN and Cr IVP VCUG Ultrasounds Angiography
Normal Urinalysis pH 5 to 9 Sp gr to Protein <20 mg/dL Urobilinogen up to 1 mg/dL WBC’s: 0—5 NONE OF THE FOLLOWING: ◦ Glucose– RBCs ◦ Ketones– Casts ◦ Hgb– Nitrites
UTI Classification Upper Tract: Pyelonephritis, VUR, Glomerulonephritis ◦ Typically causes fever, chills, flank pain Lower Tract: Urethritis, Cystitis ◦ No systemic manifestations E. coli causes about 80%
Upper and Lower Tract UTIs
Urinary Tract Infections Typical Symptoms: (box 30-1, p th ed. Hockenberry) ◦ Dysuria ◦ Frequent urination (>q2h), foul-smelling urine ◦ Urgency ◦ Suprapubic discomfort or pressure ◦ Urine 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)
Pediatric Manifestations Pediatric patients with significant bacteriuria may have no symptoms or nonspecific symptoms like fatigue or anorexia Frequency Fever in some cases Odiferous urine Blood or blood-tinged urine Sometimes no symptoms except generalized sepsis Dx: Hx, PE, UA & culture
UTI Collaborative Care: Drug Therapy—Antibiotics Uncomplicated cystitis: short-term course of antibiotics Complicated UTIs: long-term treatment ◦ Trimethoprim-sulfamethoxazole (TMP-SMX, Bactrim) or nitrofurantoin (Macrobid) ◦ Amoxicillin, Cephalexin, Gentamycin Eliminate cause, ID contributing factors
Teaching 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, whirlpools No tight panties or nylon Good hygiene; wipe front to back Void after sexual activity Avoid Constipation
Vesicoureteral 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 children Scarring by 5-6 yrs Dx: ultrasound; cystography; VCUG Tx: continuous low dose antibiotics w/freq urine cultures OR surgical repair with stent placement.
Acute Glomerulonephritis APSGN most common – days after strep infection (skin or throat) Inflammation of glomeruli; damage by antigen- antibody complex ↓ GFR & renal bld flow → HTN & edema Most common s/s: HTN— monitor regularly, edema (periorbital), hematuria/proteinuria Daily wt – IMPORTANT Maintain fluid balance & treat HTN ◦ Loop diuretics or anti-hypertensives may be used 1 st sign of improvement-- ↑ urine & ↓ wt.
Nephrotic Syndrome Glomerular injury → massive proteinuria, hypoalbuminemia, hyperlipemia, edema Other 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 old Compare APSGN with Nephrotic Syndrome—see chart at end of Ppt.
Types Most common in peds: MCNS ◦ Minimal-Change Nephrotic Syndrome ◦ 80% of cases – cause unknown ◦ Precipitated by viral URI Secondary: result of glomerular damage ◦ Acute Glomerulonephritis ◦ Collagen Diseases (Lupus) ◦ Drug toxins/poisons/venons ◦ AIDS, sickle cell, hepatitis & others
Nephrotic Syndrome (p. 1155, 9 th ed)
Diagnosis History of S/S Labs ◦ Urine Proteinurea >2 gm/day Specific gravity ↑ ◦ Blood ↓ serum protein Hgb/Hct – nl or slightly ↑ due to hemoconcentration Platelets ↑ and serum Na+ ↓ Cholesterol ↑
Treatment Goals: Must try to ↓ excretion of protein & ↓ inflammation Meds: Corticosteroids till urine is free from protein & normal days ◦ Immunosuppressants – Cytoxan ◦ Loop Diuretics – not always effective During massive edema → ↓ salt No restriction on water
Nursing Considerations Monitor for infection (esp. peritonitis) Monitor for side effects of steroids Monitor wt, I & O, abd. girth Urinalysis for albumin Protect skin from breakdown d/t edema VS for signs of complications Monitor diet restrictions Support and educate family
Prognosis If diuresis within 7-21 days – GOOD If not after 28 days → chance of response ↓ 80% OK 50% relapse after 5 yrs 20% relapse after 10 yrs Key: early ID and Tx If responds to steroids, relapse is less
Manifestations Acute Glomerular Nephritis Minimal Change Nephrosis ASO Titers Normal BP Normal or Edema Primarily peripheral or periorbital Generalized, severe Circulatory congestion Common Absent Proteinuria Mild –moderate Massive Hematuria Gross or microscopicMicroscopic or none RBC casts PresentAbsent Azotemia PresentAbsent Serum K+ levels Normal or Normal Serum Protein levels Minimal reduction Markedly Serum lipid levels NormalElevated Peak age at onset (Yr)