1. The child with genitourinary dysfunction
2/17/2019
Mrs. Raghad Abdlkader

2. Genitourinary Dysfunction
Assessment and diagnosis of urinary tract disease are based on several evaluative tools.
History taking
Physical examination.
Laboratory
Radiology.
2/17/2019
Mrs. Raghad Abdlkader

3. Clinical manifestations
Depend on the age and maturation of the child.
In newborn urinary tract disorders are association with a number of malformation as low-set ears and urinary tract anomalies.
2/17/2019
Mrs. Raghad Abdlkader

4. Clinical manifestations
Neonatal period (birth to 1 month).
Poor feeding .
vomiting.
Failure to gain weight.
Rapid respiration (acidosis).
Respiratory distress.
Spontaneous pneumothorax.
Frequent urination.
2/17/2019
Mrs. Raghad Abdlkader

5. Clinical manifestations Neonatal period (birth to 1 month).
Screaming on urination.
Poor urine stream.
Jaundice.
Dehydration.
Other anomalies .
Enlarged kidneys or bladder.
2/17/2019
Mrs. Raghad Abdlkader

6. Clinical manifestations 1 - 24 months
- Poor feeding .
Vomiting.
Failure to gain weight
Excessive thirst
Frequent urination.
Straining or screaming on urination.
Foul-smelling urine.
2/17/2019
Mrs. Raghad Abdlkader

7. Clinical manifestations 1 - 24 months
Pallor.
Fever.
Persistent diaper rash.
Seizures ( with or without fever)
Dehydration.
Enlarge kidney or bladder.
2/17/2019
Mrs. Raghad Abdlkader

8. Clinical manifestations: childhood (2 -14 years)
Poor appetite.
Vomiting
Growth failure.
Excessive thirst.
Enuresis, incontinence, frequent urination.
Painful urination.
Swelling of face.
Seizures.
Pallor, fatigue, blood in urine.
Abdominal or back pain.
Edema, hypertension, tetany.
2/17/2019
Mrs. Raghad Abdlkader

9. Laboratory tests Urine culture and sensitivity
Physical tests: volume, specific gravity, appearance.
Chemical tests: pH, protein level, glucose level, ketone level.
Microscopic tests: WBCs and RBCs count, present of bacteria, present of cast.
BUN
Uric acid.
creatinine
2/17/2019
Mrs. Raghad Abdlkader

10. Radiographic studies Renal/bladder ultrasound.
Testicular (scrotal ultrasound).
Voiding cystourethrography.
Radionuclide cystogram
Radioisotope imaging studies( DTPA, DMSA,MAG3)
IVP,IVU
CT scan.
Cystoscopy.
Renal angiography.
Renal biopsy.
Urodynamics.
2/17/2019
Mrs. Raghad Abdlkader

11. Cystitis and Pyelonephritis
Description
Bacterial colonization of urine or bacterial invasion of any of the structural components of urinary tract.(Symptomatic, Asymptomatic).
Cystitis: the most common type of urinary tract infection(UTI) is infection to the bladder.
Urethritis: inflammation of the urethra
2/17/2019
Mrs. Raghad Abdlkader

12. Cystitis and Pyelonephritis
Pyelonephritis: inflammation of the upper urinary tract and kidneys
Bacteria reach the parenchyme either by the ascending route from the bladder hematogenous seeding from a bacteremia.
Urosepsis: febrile urinary tract infection coexisting with systemic signs of bacterial illness; blood culture reveals presence of urinary pathogen
2/17/2019
Mrs. Raghad Abdlkader

13. Etiology E-coli 80-90%. Gram positive organisms 10-15%.
Viruses infrequently may cause a UTI associated with hemorrhagic cystitis.
Candida species with immunocompromised patients
2/17/2019
Mrs. Raghad Abdlkader

14. Risk factors Female gender. Uncircumcised males.
Family history of VUR.
Neurogenic bladder.
Urinary tract malformations (strictures, posterior urethral valves, calculi).
Chronic constipation .
Poor hygiene .
Catheterization of urinary tract
2/17/2019
Mrs. Raghad Abdlkader

15. Assessment
History :
Newborns have non-specific symptoms: fever, anorexia, jaundice, frequently leading to sepsis.
Infants toddlers and preschoolers have specific symptoms as fever, vomiting diarrhea and abdominal pain.
2/17/2019
Mrs. Raghad Abdlkader

16. Assessment Children and adolescents have more classic adult symptoms:
Cystitis: dysuria, frequency and urgency
Pyelonephritis: fever flank pain, costovertebral angle (CVA) tenderness
History of prior UTI.
2/17/2019
Mrs. Raghad Abdlkader

17. Diagnostic studies Urinalysis and urine culture.
First morning specimen is preferable because bacterial count decrease with hydration during the day.
Suprapubic aspiration (in children younger than 2 years).
IVP, DMSA scan
2/17/2019
Mrs. Raghad Abdlkader

18. Therapeutic management
The objective are:
To eliminate current infection.
To identify contributing factors to reduce the risk of recurrence.
to prevent systematic spread of the infection.
To preserve renal function
2/17/2019
Mrs. Raghad Abdlkader

19. Management Nonpharmacologic treatment:
Increase fluids , void more frequently and completely empty the bladder.
Cranberry juice in large quantities may reduce bacterial adherence to bladder wall.
Improve hygiene: front to back wiping for females
2/17/2019
Mrs. Raghad Abdlkader

20. Pharmacologic treatment
For cystitis/uncomplicated UTI, treat for 10 days, for Pyelonephritis 14 days.
Oral third generation cephalosporin recommended .
Choice of antibiotic needs to be reviewed in hours with culture and sensitivity report.
Pyelonephritis usually need to hospitalization for IV AB
2/17/2019
Mrs. Raghad Abdlkader

21. Surgical treatment
If anatomic defect as primary reflux or bladder neck obstruction are present surgical correction of these abnormalities may be necessary to prevent recurrent infection.
2/17/2019
Mrs. Raghad Abdlkader

22. Vesicoureteral Reflux VUR
VUR refer to the abnormal retrograde flow of bladder urine into the ureters.
During voiding, urine is swept up the ureters and then flows back into empty bladder.
Primary reflux results from congenitally abnormal insertion of ureters into the bladder.
Secondary reflux occurs as a result of an acquired condition.
2/17/2019
Mrs. Raghad Abdlkader

23. Vesicoureteral Reflux VUR
In the presence of VUR, infected urine from the bladder has access to the kidney, resulting in kidney infection ( Pyelonephritis).
Symptoms : high fever, vomiting, and chills.
Reflux when associated with UTI is the most common cause of renal scarring in children
2/17/2019
Mrs. Raghad Abdlkader

24. Therapeutic management
The most important concepts in managing VUR is preventing bacteria from reaching the kidneys.
VUR is managed conservatively with daily low-dose antibiotic therapy.
Urine culture should be done every 2-3 months and any time the child has fever.
2/17/2019
Mrs. Raghad Abdlkader

25. Therapeutic management
Surgical treatment if there is:
Anatomical abnormality at the ureterovesical junction
Recurrent UTI.
Sever form of VUR.
Noncompliance with medical therapy.
Intolerance to antibiotics.
VUR after puberty in females.
2/17/2019
Mrs. Raghad Abdlkader

26. Nursing consideration
Nurses should instruct parents to observe regularly for clues suggesting UTI.
For infant and young children ,a carful history regarding voiding habits, stooling pattern and unexplained irritability may assist in detecting UTI
Obtain acceptable clean-voided specimens .
Prepare children for additional renal test as appropriate for their age.
2/17/2019
Mrs. Raghad Abdlkader

27. Nursing consideration
Advising parents about proper dosage and administration of antibiotics .
For all children an adequate or increased fluid intake is encouraged.
Measurement of prevention:
Perineal hygiene: wipe from front to back.
Avoid tight clothing or diapers, wear cotton panties rather than nylon.
2/17/2019
Mrs. Raghad Abdlkader

28. Measurement of prevention
Check for vaginitis or pinworms, especially if child scratches between legs.
Avoid “holding” urine; encourage child to void frequently, especially before long trip or other circumstances in which toilet facilities are not available.
Empty bladder completely with each void.
Sever cases may require clean, intermittent catheterization .
Encourage generous fluid intake.
Avoid constipation
2/17/2019
Mrs. Raghad Abdlkader

29. Defect of Genitourinary Tract
2/17/2019
Mrs. Raghad Abdlkader

30. Defect of Genitourinary Tract
Inguinal hernia
Protrusion of abdominal continents through inguinal canal into scrotum.
Therapeutic management:
Detected as painless inguinal swelling of variable size..
Surgical closure of inguinal defect.
2/17/2019
Mrs. Raghad Abdlkader

31. Defect of Genitourinary Tract…cont’d
Hydrocele
Fluid in scrotum
Therapeutic management:surgical repair indicated if spontaneous resolution not accomplished in 1 year.
2/17/2019
Mrs. Raghad Abdlkader

32. Defect of Genitourinary Tract…cont’d
Phimosis:
Narrowing or stenosis of preputial opening of foreskin
Therapeutic management:
Mild cases: manual retraction of foreskin and proper cleansing the area.
Sever cases: circumcision of foreskin.
2/17/2019
Mrs. Raghad Abdlkader

33. Defect of Genitourinary Tract…cont’d
Hypospadias
Urethral opining located behind glans penis or anywhere along ventral surface of penile shaft.
Therapeutic management:
Objectives of surgical correction: enable child to void in standing position and direct stream voluntarily in usual manner.
Improve physical appearance of genitalia.
Produce a sexually adequate organ.
2/17/2019
Mrs. Raghad Abdlkader

34. Defect of Genitourinary Tract…cont’d
Epispadias:
Meatal opining located on dorsal surface of penis.
Therapeutic management:surgical correction, usually including penile and urethral lengthening and bladder neck reconstruction( if necessary).
2/17/2019
Mrs. Raghad Abdlkader

35. Defect of Genitourinary Tract…cont’d
Cryptorchidism:
Failure of one or both testes to descend normally through inguinal canal
Therapeutic management:
Detected by inability to palpate testes within scrotum.
Medical: administration of human chorionic gonadotropin (older child).
Surgical: orchiopexy.
2/17/2019
Mrs. Raghad Abdlkader

36. Defect of Genitourinary Tract Cryptorchidism …cont’d
Objective of therapy:
Prevent damage to undescended testicale
Decrease incidence of malignant tumor formation.
Avoid trauma and torsion.
Close inguinal canal.
Prevent cosmetic and psychologic disability from empty scrotum.
2/17/2019
Mrs. Raghad Abdlkader

37. Defect of Genitourinary Tract…cont’d
Extrophy of bladder:
Eversion of posterior bladder through anterior bladder wall and lower abdominal wall associated with open pubic arch (a sever defect).
Therapeutic management:
Potential objectives of surgical correction:
Prevent renal function.
Attain urinary control.
Adequate reconstructive repair.
Improve sexual function (especially in male)
2/17/2019
Mrs. Raghad Abdlkader

38. Defect of Genitourinary Tract…cont’d
Ambiguous genitalia
Types:
Masculinized female (female pseudohermaphrodite).
Therapeutic management: gender assignment-female assign gender while avoiding irreversible surgery, realizing some children may change gender later in life.
2/17/2019
Mrs. Raghad Abdlkader

39. Defect of Genitourinary Tract…cont’d
Incompletely masculinized maleohermaphrodite).
Therapeutic management:
- Assugn gender while avoiding irreversible surgery. Realizing some children may change gender later in life.
2/17/2019
Mrs. Raghad Abdlkader

40. Defect of Genitourinary Tract…cont’d
True hermaphrodite (both ovaries and testes.
Therapeutic management:
Assign gender while avoiding irreversible surgery, realizing some children may change gender later in life, gender assignment depends on predominant cha-cha, family participation essential.
2/17/2019
Mrs. Raghad Abdlkader

41. Defect of Genitourinary Tract…cont’d
Mixed gonadal dysgenesis:
Assign gender while avoiding irreversible surgery, realizing some children may change gender later in life, gender assignment depends on predominant cha-cha; family participation essential.
2/17/2019
Mrs. Raghad Abdlkader

42. Wilms Tumor
Wilms Tumor or nepheroblastoma is the most common malignant renal and intraabdominal tumor of childhood.
The peak age at diagnosis is approximately 3 years.
It’s occurrence is slightly more frequent in boys than in girls.
1% - 2.5% having a familial origin.
Unfortunately, there is no method of identifying gene carriers at this time.
2/17/2019
Mrs. Raghad Abdlkader

43. Etiology
Wilms tumor probably arises from a malignant, undifferentiated cluster of primordial cells capable of initiating the regeneration of an abnormal structure.
Left kidney more than right affected.
10% of cases both kidneys are involved.
Study have shown that development of Wilms tumor is frequently associated with genitourinary anomalies.( kline & Sevier,2003)
2/17/2019
Mrs. Raghad Abdlkader

44. Diagnostic Evaluation
Emphasis is placed on history and physical examination for presence of congenital anomalies,
Family history of cancer.
Radiographic studies: abdominal U/S,CT scan,.
Hematologic studies.
Biochemical studies.
Urinanalysis .
Inferior venacavagram.
Bone marrow aspiration
2/17/2019
Mrs. Raghad Abdlkader

45. Clinical manifestations of Wilms Tumor
Abdominal swelling or mass: firm, nontender, confined to one side.
Hematuria (less than fourth case).
Hypertension (occasionally).
Fatigue/malaise.
Weight loss.
Fever
2/17/2019
Mrs. Raghad Abdlkader

46. Clinical manifestations of Wilms Tumor.
Manifestation resulting from compression of tumor mass.
Secondary metabolic alteration from tumor or metastasis.
If metastasis, symptoms of lung involvement: dyspnea ,cough, shortness of breath, chest pain (sometimes). .
2/17/2019
Mrs. Raghad Abdlkader

47. Stages of Wilms tumor
Stage I: tumor is limited to kidney and completely resects.
Stage II: Tumor extends beyond kidney but is completely respected.
Stage III: Residual nonhematogenous tumor is confined to abdomen.
Stage IV: hematogenous metastases deposits are beyond stage III; namely, to lung, liver, bone and brain.
Stage V: bilateral renal involvement is present at diagnosis.
2/17/2019
Mrs. Raghad Abdlkader

48. Therapeutic management
Combined treatment of surgery and chemotherapy with or without radiation is based on the histologic pattern and clinical stages.
Surgery is scheduled as soon as possible after confirmation of a renal mass.
Great care is taken to keep the encapsulated tumor intact.
Regional lymph nodes are inspected .
2/17/2019
Mrs. Raghad Abdlkader

49. Therapeutic management
Any involved structures such as part of the colon, or diaphragm are removed.
If both kidneys are involved ,the child may treated with radiotherapy or chemotherapy before surgery of partial nephrectomy on the less affected kidney, with a total nephrectomy on the opposite side.
Transplant from a twin, sibling or parent ,then bilateral nephrectomy.
2/17/2019
Mrs. Raghad Abdlkader

50. Therapeutic management
Post operative radiation therapy is indicated for children with large tumors, metastasis.
Chemotherapy is indicated for all stages. ranged from 6-15 months.
Prognosis: survival rates for Wilms tumor are the highest among all childhood cancer.
Stage I &II (localized ) have 90% chance for cure with multimodal therapy.
2/17/2019
Mrs. Raghad Abdlkader

51. Nursing consideration
Preoperative care:
Prepare child and the family for all laboratory and operation.
Monitored blood pressure (excess renin)
The tumor is not palpated unless absolutely necessary.
Explain to family about chemotherapy and radiotherapy.
2/17/2019
Mrs. Raghad Abdlkader

52. Nursing consideration
Postoperative care: the child postoperative abdominal surgery is risk for intestinal obstruction as bowel movement ,bowel sound, distention, vomiting and pain are carefully monitored
Monitor blood pressure, urine output, signs of infection.
2/17/2019
Mrs. Raghad Abdlkader

53. Glomerular disease Nephrotic syndrome
2/17/2019
Mrs. Raghad Abdlkader

54. Nephrotic syndrome
It is a clinical state that includes massive proteinuria, hypoalbuminemia, hyperlipedmia and edema
The disorder can occur as:
A primary disease known as idiopathic nephrosis, childhood nephrosis, minimal-change Nephrotic syndrome (MCNS).
A secondary disorder that occur as a clinical manifestation after or in association with Glomerular damage
2/17/2019
Mrs. Raghad Abdlkader

55. Nephrotic syndrome
3. Congenital form inherited as an autosomal recessive disorder.
Nephrotic syndrome occur in children between 2-7 years of age., it is rare in children younger than 6 months of age ,
Patients with (MCNS) are twice as likely to be male.
2/17/2019
Mrs. Raghad Abdlkader

56. Pathophysiology It is not understood.
There may be a metabolic, biochemical, physiochemical, or immune-mediated disturbance that causes the basement membrane of the glomeruli to become increasingly permeable to protein.
The sequence of events in Nephrotic syndrome is diagrammed in fig 27-2.
2/17/2019
Mrs. Raghad Abdlkader

57. Pathophysiology
Renal Glomerular damage proteinuria (massive)---- hypoproteinemia:
Hypoproteinemia –increased hepatic synthesis of proteins and lipids--- hyperlipidemia.
Hypoproteinemia –decreased oncotic pressure---1. edema 2. hypovolemia
a. decrease renal blood flow— Renin release—vasoconstriction.
b. increased secretion of ADH and aldosterone —Na+ and water reabsorption --- edema.
2/17/2019
Mrs. Raghad Abdlkader

58. Pathophysiology
2/17/2019
Mrs. Raghad Abdlkader

59. Diagnostic evaluation
Clinical manifestation:
Weight gain.
Puffiness of face (facial edema), especially around the eyes, apparent on arising in the morning, subsides during day.
Abdominal swelling (ascites).
Pleural effusion.
Labial or scrotal swelling.
Edema of intestinal mucosal may cause: diarrhea, anorexia, poor intestinal absorption.
Ankle/leg swelling.
Irritability, easily fatigued, lethargic.
2/17/2019
Mrs. Raghad Abdlkader

60. Diagnostic evaluation
Blood pressure normal or slightly decreased.
Susceptibility to infection.
Urine alterations: decreased volume, frothy
- The hallmark of NS is massive proteinuria (higher than 3+ on urine dipstick).
- Fat bodies, and few red blood cells can be found, seldom gross hematuria.
The Glomerular filtration rate (GFR) is usually normal or high.
2/17/2019
Mrs. Raghad Abdlkader

61. Diagnostic evaluation
Total serum protein concentration is low.
Serum albumin significantly reduced.
Plasma lipid elevated.
Serum sodium concentration may be low.
Renal biopsy may be needed if the patient dose not respond to a 4-8 weeks course of steroids .
The platelet count may be elevated.
2/17/2019
Mrs. Raghad Abdlkader

62. Therapeutic management
Objectives o therapeutic management includes:
Reducing excretion of urinary protein.
Reducing fluid retention in the tissues.
Preventing infection.
Minimizing complications related to therapies.
2/17/2019
Mrs. Raghad Abdlkader

63. Therapeutic management
Dietary restriction includes a low salt diet and fluid restriction.
Diuretic therapy.
Sometimes infusions of 25% albumin are used.
Acute infection are treated with appropriate antibiotics.
Corticosteroids are the first line of therapy for MCNS.
Relapses are treated with a repeated course of high-dose steroid therapy.
MCNS episodes, often happen in conjunction with a viral or bacterial infection.
Relapses in children may continue over many years.
2/17/2019
Mrs. Raghad Abdlkader

64. Complications Infection: peritonitis, cellulites, and pneumonia.
Circulatory insufficiency secondary to hypovolemia.
Thromboembolism.
2/17/2019
Mrs. Raghad Abdlkader

65. Prognosis The prognosis for ultimate recovery in most cases is good.
It is self-limited disease.
In children who respond to steroid therapy the tendency to relapse decreases with time.
2/17/2019
Mrs. Raghad Abdlkader

66. Nursing consideration
Continuous monitoring of fluid retention or excretion:
Strict intake &output.
Urine examination for albumin.
Daily wt.
Daily measurement of abdominal girth.
Assessment for edema.
Vital signs are monitor to detect any signs of shock or infections (respiratory).
They must be kept warm and dry.
Active, and protect from contact with infected individuals
2/17/2019
Mrs. Raghad Abdlkader

67. Nursing consideration
During Loss of appetite, the combined efforts of nurse, dietitian, parents, and the child are needed to formulate a nutritionally adequate and attractive diet.
Salt is usually restricted during the edema phase.
Fluid restriction
Children usually adjust activities according to their tolerance level.
- Suitable recreational and diversional activities are an important part of their care.
2/17/2019
Mrs. Raghad Abdlkader

68. Family support and home care
Parents are taught to detect signs of relapse and to call for changes in treatment at the earliest indications.
Parents are instructed in testing urine for albumin, administration of medications, and general care.
Parents are also instructed regarding avoiding contact with infected playmates, but the child should attend school.
Reassure with emphasis on the importance of long-term care needs to be provided to parents and children to gain their cooperation.
2/17/2019
Mrs. Raghad Abdlkader

69. Renal failure RF
2/17/2019
Mrs. Raghad Abdlkader

70. Renal failure RF
RF is the inability of the kidneys to excrete waste material, concentrate urine, and conserve electrolytes.
It can occur suddenly (acute renal failure {ARF}) in response to inadequate perfusion ,kidney disease, or urinary tract obstruction.
It can develop slowly,(chronic renal failure) as a result of long-standing kidney disease or an anomaly.
2/17/2019
Mrs. Raghad Abdlkader

71. Renal failure RF Azotemia & Uremia are terms used in relation to RF
Azotemia is the accumulation of nitrogenous waste within the blood.
Uremia is a more advanced condition in which retention of nitrogenous products produces toxic symptoms.
2/17/2019
Mrs. Raghad Abdlkader

72. Acute Renal Failure {ARF}
ARF :it exist when the kidneys suddenly are unable to regulate the volume and composition of urine appropriately in response to food and fluid intake and the needs of the organism.
the feature of ARF is oliguria associated with Azotemia, metabolic acidosis, and diverse electrolyte disturbances.
ARF is not common in childhood.
2/17/2019
Mrs. Raghad Abdlkader

73. Etiology of ARF Glemerunephriyis Poor renal perfusion.
Urinary tract obstruction.
Acute renal injury.
Irreversible renal disease.
Transient renal failure resulting from dehydration.
2/17/2019
Mrs. Raghad Abdlkader

74. Pathophysiology ARF is usually reversible.
The mortality in pediatric is high.
There is severe reduction in the Glomerular filtration rate, an elevation BUN level and significance reduction of renal blood flow.
The clinical course is variable depend on the cause .
In reversible ARF there is a period of oliguria followed by diuresis, and then gradually return to normal urine volume
2/17/2019
Mrs. Raghad Abdlkader

75. Diagnostic Evaluation
A careful history is taken .
Clinical manifestation:
Specific: oliguria, anuria uncommon(except in obstructive disorders).
Nonspecific(may develop): Nausea, vomiting, drowsiness, edema, hypertension.
Significant laboratory measurements BUN, serum creatinine, Ph, sodium, potassium, and calcium
2/17/2019
Mrs. Raghad Abdlkader

76. Therapeutic Management
Directed treatment toward:
treatment of underlying cause.
Management of complication of renal failure.
Provision of supportive therapy within the constraints imposed by the renal failure.
2/17/2019
Mrs. Raghad Abdlkader

77. Therapeutic Management
Treatment for dehydration.
Initially Foley catheter is inserted to role out of urine retention, to collect urine specimen and to monitor results of diuretic administration
When the output begin to increase the intake of fluid, potassium, and sodium must be monitored and adequate replacement provided to prevent depletion and its consequences.
2/17/2019
Mrs. Raghad Abdlkader

78. Complications:
ARF patient high tendency to develop water intoxication and hyponatremia:
Oral food, high concentrate of CHO, and fat low in protein ,K and Na may provided. or
Amino acid administered by the central venous route.
Accurate intake and output, body weight, electrolyte measurement,
No K, Cl, and Na is given during oliguric phase.
Regular measurement of plasma electrolyte ,pH, BUN, creatinine.
2/17/2019
Mrs. Raghad Abdlkader

79. Complications
Hyperkalemia is the most immediate threat to the life of the child with ARF.
- Avoided by eliminating K. from all food and fluid by oral or rectal a administration of kayexalate and peritoneal dialysis or hemodialysis.
Hypertension: to detect it early :BP measurements are made every 4-6 hours.
hypertension is controlled with antihypertensive drugs.
2/17/2019
Mrs. Raghad Abdlkader

80. Complications
Anemia: blood transfusion is not recommended unless the HB drops under 6 g/dl.
Seizures (uremia, decrease electrolytes):treatment is directed to the specific cause when known ,antiepileptic drugs.
Cardiac failure with pulmonary edema: treatment is directed toward reduction of fluid volume with water and sodium restriction and administration of diuretics.
2/17/2019
Mrs. Raghad Abdlkader

81. Prognosis
Children in whom ARF is a result of acute glomerulitis may recover completely.
Complete recovery is usually expected in children whose renal failure is a result of dehydration, nephrotoxins, or ischemia.
ARF following cardiac surgery is less favorable
2/17/2019
Mrs. Raghad Abdlkader

82. Nursing consideration
Attention to fluid intake and output is mandatory
Monitoring fluid balance and vital signs is a continuous process.
Intensive observation for dialysis.
Meeting nutritional needs ,IV nourishment
Maintaining optimal thermal environment, reducing any elevation of body temperature,
Reducing restlessness and anxiety.
The nurse must be continually alert for changes in behavior that indicate
2/17/2019
Mrs. Raghad Abdlkader

83. Family support
Parents need reassurance and a sympathetic listener especially if the cause of ARF is ingestion of a toxic substance, dehydration, or a genetic disease.
They also need to be kept informed of the child’s progress and provided explanation regarding the therapeutic regimen.
Nurses can do much to help parents comprehend and deal with the stresses of the situation.
2/17/2019
Mrs. Raghad Abdlkader

84. Chronic renal failure CRF
CRF begins when the disease kidneys can no longer maintain the normal chemical structure of body fluid under normal conditions.
Progressive deterioration over months or years produces a variety of clinical and biochemical disturbances that known as uremia
2/17/2019
Mrs. Raghad Abdlkader

85. Etiology Congenital renal and urinary tract malformations .
VUR associated with recurrent UTI.
Chronic Pyelonephritis.
Hereditary disorders.
Chronic glomerulonephritis.
2/17/2019
Mrs. Raghad Abdlkader

86. Pathophysiology
Early in the course of progressive Nephrotic destruction, the child remains asymptomatic with only minimal biochemical abnormalities.
Midway in the disease process few normal nephrones are able to make sufficient adjustment to maintain reasonable degree of fluid and electrolyte balance.
2/17/2019
Mrs. Raghad Abdlkader

87. Pathophysiology
The disease progress to end stage because of a sever reduction in the number of functioning nephrones, the kidneys are no longer able to maintain fluid and electrolyte balance and uremia appear
2/17/2019
Mrs. Raghad Abdlkader

88. Pathophysiology
The result from diminished renal function produces complication as:
Retention of waste products especially BUN and creatinine.
Water and sodium retention.
Hyperkalemia.
Metabolic acidosis
Calcium and phosphorus disturbances.
Anemia.
Growth disturbance
More susceptible to infection
2/17/2019
Mrs. Raghad Abdlkader

89. Diagnostic evaluation
History of prior renal disease and /or biochemical findings
Clinical manifestation:
Early signs:
Loss of normal energy.
Pallor
Increased fatigue on exertion.
Elevated blood pressure.
2/17/2019
Mrs. Raghad Abdlkader

90. Clinical manifestation
As the disease progress:
Decreased appetite (especially at breakfast)
Less interest in normal activities.
Increase or decreased urine output with compensatory intake of fluid.
Pallor more evident.
Child may complain of headache, muscle cramps, nausea.
Weight loss, facial edema
Malaise, bone or joint pain.
2/17/2019
Mrs. Raghad Abdlkader

91. Clinical manifestation
Growth retardation, dryness or itching of the skin.
Bruised skin, sensory or motor loss.
Amenorrhea.
Uremic syndrome(untreated):
Gastrointestinal symptoms.
Anorexia, nausea and vomiting.
Bleeding tendencies: bruises, bloody diarrhea stools, stomatitis, bleeding from lips and mouth
2/17/2019
Mrs. Raghad Abdlkader

92. Clinical manifestation
Uremic frost( deposits of urea crystals on skin.
Unpleasant “ uremic” breath odor.
Deep respirations, hypertension, congestive heart failure.
Pulmonary edema.
Neurologic involvement:
Progressive confusion,
dulled sensorium, coma,
tremors, muscular twitching, seizures
2/17/2019
Mrs. Raghad Abdlkader

93. Therapeutic management
The goal of medical treatment:
Promote maximum renal function
Maintain body fluid and electrolyte balance within safe biochemical limits.
Treat systematic complication.
Promote as active and normal a life as possible for the child.
2/17/2019
Mrs. Raghad Abdlkader

94. Therapeutic management
Diet regulation.
Metabolic acidosis is alleviated through administration of alkalizing agents as sodium bicarbonate..
Growth failure .
Anemia.
Intercurrent infection.
2/17/2019
Mrs. Raghad Abdlkader

95. Prognosis
Dialysis and transplantation are the only treatments currently for children with ESRD.
Children may survive on dialysis.
Complication include infection of access site, growth failure,
2/17/2019
Mrs. Raghad Abdlkader

96. Nursing care plan Nursing diagnosis:
Risk for injury R/to accumulated electrolytes and waste products.
Fluid volume excess r/to failure of renal regulatory mechanisms.
Altered nutrition: less than body requirements r/to restricted diet.
Body-image disturbance r/to chronic illness, impaired growth, and perception of being “different”.
Altered family process r/to a child with a chronic disease.
2/17/2019
Mrs. Raghad Abdlkader

97. Nursing care plan
The goals of care for the child with CRF especially one in ESRF, and the family are as follows:
Child will receive encouragement in his or her normal growth and development, minimizing the impact of the disease process.
Child will remain free of complication.
Child wand family will receive appropriate support, guidance, and education.
2/17/2019
Mrs. Raghad Abdlkader