Chapter 15 Fluid Balance, Renal, and Reproductive Disorders Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.

Fluid Imbalance Dehydration: Infants Subject to greater evaporation of water from skin Rapid respirations increase fluid loss When diarrhea is present, additional fluid is lost Immature infant kidneys = poor water conservation Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.15-2

Fluid Imbalance Classification of dehydration is based on serum sodium levels –Isotonic –Hypotonic –Hypertonic Maintenance therapy vs. deficit therapy –Adjusted continually for patient’s condition Oral fluids Parenteral fluids –Given by route other than digestive tract Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.15-3

Fluid Imbalance Overhydration –Body receives more fluid than it can excrete –Can occur in patients with normal kidneys who receive intravenous fluids too rapidly –Can also occur in a patient receiving acceptable rates of fluid, especially when the patient’s illness is related to disorders of fluid mechanism –Edema: presence of excess fluid in the interstitial spaces Edema in infants may first be seen about the eyes and in the presacral, occipital, or genital areas Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.15-4

Urinary Tract Infection Description –Bacterial invasion of the upper urinary tract (kidney and ureters) or lower urinary tract (bladder and urethra) Vesicoureteral reflux –Primary contributing factor to upper UTIs Rated I-V –Malfunctioning valve at the junction of the ureter and bladder lets urine reflux up the ureters toward the kidney –Bacteria from urine can cause pyelonephritis and renal damage –Diagnosed via ultrasound and voiding cystourethrogram Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.15-5

Urinary Tract Infection Signs and symptoms –Poor feeding, fussiness, delayed growth, foul- smelling urine, and incontinence (in a child who has been previously trained) –Many adolescent girls exhibit classic signs of UTI (frequency, urgency, pain on urination, blood in the urine) after the first episode of sexual intercourse –High fever, chills, flank pain, and abdominal pain can indicate kidney infection (pyelonephritis) Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.15-6

Urinary Tract Infection Treatment and nursing care –7- to 14-day course of an appropriate antibiotic, generally sulfamethoxazole-trimethoprim (Bactrim, Septra) Penicillins and cephalosporins may also be ordered –Nurses need to teach proper hygiene No bubble baths or irritating diaper wipes Wiping from front to back –Other preventive measures include wearing cotton underwear, adequate fluid intake, encouraging children to not put off going to the bathroom when the urge is felt, investigating and treating signs of intestinal parasites (pinworms) Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.15-7

Acute (Post-streptococcal) Glomerulonephritis Description –Occurs as an immune reaction (antigen- antibody) to an infection in the body –Generally caused by a Group A beta- hemolytic streptococci infecting the throat or the skin –Oliguria: Decreased urine output, often caused by sodium/fluid retention Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.15-8

Acute (Poststreptococcal) Glomerulonephritis Signs and symptoms –Urine is smoky brown in color or bloody –Periorbital edema may also be present in the morning, and the edema spreads to the abdomen and extremities as the day progresses due to gravity –The child may have fatigue, headache, abdominal discomfort, and vomiting –Anuria: body’s suppression of urine formation; may necessitate dialysis Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.15-9

Acute (Poststreptococcal) Glomerulonephritis Treatment and nursing care –Every effort is made to prevent the child from becoming overtired, chilled, or exposed to infection –A low-sodium diet may be ordered –Furosemide (Lasix) may be given if significant edema and fluid overload are present and renal failure is not severe –Penicillin is given if the streptococcal infection persists, but it usually does not alter the course of the disease –Persistent anuria may necessitate dialysis Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.15-10

Nephrotic Syndrome (Nephrosis) Description –Refers to a number of different types of kidney conditions that are distinguished by the presence of marked amounts of protein in the urine –Glomeruli: Filter blood in the kidneys; damage allows protein to enter the urine Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.15-11

Nephrotic Syndrome (Nephrosis) Signs and symptoms –The characteristic symptom of nephrosis is edema –The edema shifts with the position of the child during sleep –The urine appears dark and frothy –Urine output can be decreased –Vomiting and diarrhea may also be present Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.15-12

Nephrotic Syndrome (Nephrosis) Treatment and nursing care –Control of edema—steroids, diuretics, and albumin –Diet—should be well-balanced and high in protein; salt is restricted –Fluid balance—the patient’s urine must be carefully measured; weight daily –Care of the skin—good skin care is especially important during periods of marked edema Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.15-13

Nephrotic Syndrome (Nephrosis) Treatment and nursing care (continued) –Positioning—the child is repositioned frequently to prevent respiratory infection and skin breakdown –Infection prevention—assessment for and protection from infection is critical –Emotional support—parental guidance, education and support should be given by all members of the nursing team Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.15-14

Enuresis Bed-wetting –Primary: child has never been dry for an extended period of time –Secondary: bed-wetting after the child has been dry Child should never be punished Time is usually all that is needed; out grow it Therapy includes medications, fluid restriction after evening meal, waking a child to void, bladder training, alarms upon initiation of voiding Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.15-15

Hydrocele An excessive amount of fluid in the sac that surrounds the testicle; causes the scrotum to swell Common in the neonate, and in many cases, the condition corrects itself as the baby grows If a chronic hydrocele persists in the older child, it is corrected with surgery Routine postoperative nursing care is given Same-day or outpatient surgery may be arranged Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.15-16

Undescended Testes (Cryptorchidism) Description –One or both testes fail to descend into the scrotum –Because the testes are warmer in the abdomen than in the scrotum, the sperm cells begin to deteriorate Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.15-17

Undescended Testes (Cryptorchidism) Treatment and nursing care –Occasionally, spontaneous descent of the testis or testes occurs during the first 6 months of life –If this does not happen, treatment is recommended at 9 to 15 months –The testis or testes can be brought down to the scrotum with a surgical intervention called orchiopexy Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.15-18

Hypospadias and Epispadias Description –Hypospadias—the urinary meatus appears on the ventral or underside of the penis’ shaft –Epispadias—the urethral opening is on the dorsal or upper surface of the shaft Treatment and nursing care –Surgical repair is usually performed between 6 and 12 months of age using the foreskin Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.15-19

Dysmenorrhea (Primary) Description –Painful menstruation; denotes pain associated with the menstrual cycle in the absence of organic pelvic disease –Secondary dysmenorrhea: Patient may have an underlying condition such as endometriosis, PID, ovarian cysts, adhesions, congenital abnormalities –Mittelschmerz: Midcycle pain during ovulation Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.15-20

Dysmenorrhea (Primary) Signs and symptoms –Cramping, abdominal discomfort, and leg aches, all of which begin at the onset of menses –Systemic symptoms such as nausea, vomiting, dizziness, diarrhea, backache, and headache –Premenstrual syndrome: symptoms overlap with dysmenorrhea, but include weight gain, breast tenderness, irritability, and insomnia Treatment and nursing care –Ibuprofen or naproxen should be taken every 4 hours; usually 2 to 3 days of medications are required –Warm heating pad applied to the lower abdomen Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.15-21

Sexually Transmitted Disease Description –The general name given to infections that are spread through direct sexual activity Signs and symptoms –Table 15-3 describes the clinical manifestations of the major STDs in the United States Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.15-22

Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.15-23

Sexually Transmitted Diseases Chlamydia infection –Most common STD in the U.S. –Often asymptomatic Gonorrhea –Anaerobic bacterium –GC, clap, a dose, strain, the drip –Men: Symptoms within 2-7 days of contact Painful urination, pus discharge, inflamed scrotum –Women: 80-90% asymptomatic Mild burning in genital area, possible yellow discharge, swelling of Bartholin glands, abdominal discomfort. Can cause PID. –Minors can receive free, confidential treatment without parental consent from the city/state health department, or most physicians Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.15-24

Sexually Transmitted Diseases Syphilis –Caused by spirochete Treponema pallidum –Can be passed to unborn children –Incubation period: days Stages of syphilis symptoms –Primary: chancre sores where spirochete enters the body –Secondary: begins 4 weeks to 6 months after infection. Disease enters a latent period if left untreated –Tertiary: After the fourth year. Spirochetes attack heart, blood vessels, brain, spinal cord Insanity and blindness, crippling or paralysis, death Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.15-25

Sexually Transmitted Diseases Genital herpes –Herpes simplex virus (HSV) type II frequency among teenagers is increasing –Lesions can persist for 3-6 weeks –Fever, headache, malaise, anorexia –HSV Type II can be passed to infants via the birth canal Cesarean section is generally performed Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.15-26

Sexually Transmitted Diseases Treatment and nursing care –Table 15-4 describes treatment methods for frequently seen STDs –Hospitalization is uncommon –Nurses need to create a comfortable environment and approach teenagers without judgment –The reporting of sexual contacts, required by law, often prevents patients from seeking help; assuring confidentiality is important Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.15-27

Acquired Immunodeficiency Syndrome (AIDS) Description –A retrovirus identified as the human immunodeficiency virus attacks T-helper cells that support immune functioning Signs and symptoms –Failure to thrive, chronic diarrhea, repeated respiratory infections, oral candidiasis, and enlargement of the liver and spleen Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.15-28

Acquired Immunodeficiency Syndrome Treatment and nursing care –There is no cure for AIDS –Several antiviral drugs are being used for treatment in children –Assessment for signs of infection, including vital signs, and observation of the skin and general condition of the child should be done routinely –Psychological support of the child and family is critical Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.15-29