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GENITO-URINARY SYSTEM

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Presentation on theme: "GENITO-URINARY SYSTEM"— Presentation transcript:

1 GENITO-URINARY SYSTEM
DISORDERS OF THE GENITO-URINARY SYSTEM IN CHILDREN

2 Aim To show an in-depth understanding of the
genito-urinary disorders in children and the process of care in the nursing management

3 Learning Objectives By the end of this session, the student
should be able to: Understand the anatomy and physiology of the renal system and structure and function Identify the differences between adult and children GU system Describe the most common diagnostic investigations and procedures for GU disorders

4 Learning Objectives…con’t
Understand the general assessment of children with genitourinary disorders Understand the common genitourinary disorders in children Plan the nursing management for children with GU disorders

5 PAEDIATRIC DIFFERENCES OF KIDNEY DEVELOPMENT
Begins during 1st week of gestation Completed by end of 1st year after birth Excretion less than adult By the age of 6 to 12 months, filtration and absorption is nearly like adults For healthy infant, the kidneys operate at a functional level appropriate for the size of the body.

6 Function of Kidney Nephron
Glomeruli – filter water and solutes from blood Tubules – reabsorb needed substances (water, protein, electrolytes, glucose, amino acids) from filtrate and allow unneeded substances to leave the body in urine Urine formed in the nephron, passes into renal pelvis, through ureter into bladder and out of body through urethra

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8 Urine formed in the nephron, passes into renal pelvis, through
ureter into bladder and out of body through urethra

9 filter water and solutes from blood
Glomeruli : filter water and solutes from blood Tubules : reabsorb needed substances (water, protein, electrolytes, glucose, amino acids) from filtrate and allow unneeded substances to leave the body in urine

10 Function of Kidney Maintaining body fluid volume and composition
Secretes hormones:- Renin – helps with the regulation of blood pressure Erythropoietin – stimulates red blood cell production by the bone marrow Metabolised Vitamin D – responsible for calcium metabolism

11 Diagnostic Investigations
Urinalysis CT Scan- an x-ray procedure that combines many x-ray images with the aid of a computer to generate cross-sectional views and, if needed, three-dimensional images of the internal organs and structures of the body. 

12 Blood urea nitrogen (B.U.N) and creatinine -
gross indicator of renal function (BUN) test measures the amount of nitrogen in blood that comes from the waste product urea. Urea is made when protein is broken down in body. Blood urea nitrogen (BUN) and creatinine tests can be used together to find the BUN-to- creatinine ratio (BUN:creatinine). body in the urine.   A blood urea nitrogen (BUN) test is done to determine : kidneys are working normally. kidney disease is getting worse. See if treatment of kidney disease is working. See if severe dehydration is present. Dehydration generally causes BUN levels to rise more than creatinine levels. This causes a high BUN-to-creatinine ratio. Kidney disease or blockage of the flow of urine from kidney causes both BUN and creatinine levels to go up.

13 Cystoscopy – bladder and urethra are examined with cystoscope (fibre optic technology)

14 KUB (Kidney, Ureter, Bladder) x-ray Renal Biopsy
Renal Ultrasound

15 Intravenous pyelogram (IVP)
An injection of x-ray contrast media via a needle or cannula into the vein, typically in the arm. The contrast is excreted or removed from the bloodstream via the kidneys, and the contrast media becomes visible on x-rays almost immediately after injection

16 Retrograde Pyelogram a urologic procedure where the physician injects contrast into the ureter in order to visualize the ureter and kidney.  Micturating Cystourethrography (MCUG) – serial x-ray of the bladder and urethra after IV infusion of iodine-bound contrast medium ( to detect blockage)

17 COMMON DISORDERS OF THE GENITOURINARY SYSTEM
Urinary tract infection (UTI) Nephrotic syndrome Acute Post-Streptococcal Glomerulonephritis (APSGN) Vesicoureteral reflux Hypospadias

18 URINARY TRACT INFECTIONS
Definition UTI is the presence of bacteria in the urine Infection usually occur at the upper urinary tract or at the lower urinary tract Incidence Common age of onset for UTI is 2-6 years Girl>Boy - Female has shorter urethra Uncircumcised male prone to develop UTI

19 Causes Causative organisms – E. Coli
Route of entry -bacteria ascending from the area outside of the urethra. Vesico-ureteral reflux Infections – URTI, GE Poor perineal hygiene - fecal organisms are the most common infecting organisms due to the proximity of the rectum to the urethra. Short female urethra Vesicoureteral reflux (VUR) is the abnormal flow of urine from the bladder back into the ureters. VUR is most commonly diagnosed in infancy and childhood after the patient has a urinary tract infection (UTI). About one-third of children with a UTI are found to have VUR. VUR can lead to infection because urine that remains in the child’s urinary tract provides a place for bacteria to grow. But sometimes the infection itself is the cause of VUR. here are two types of VUR. Primary VUR occurs when a child is born with an impaired valve where the ureter joins the bladder. This happens if the ureter did not grow long enough during the child's development in the womb. The valve does not close properly, so urine backs up (refluxes) from the bladder to the ureters, and eventually to the kidneys. This type of VUR can get better or disappear as the child gets older. The ureter gets longer as the child grows, and the function of the valve improves. Secondary VUR occurs when there is a blockage anywhere in the urinary system. The blockage may be caused by an infection in the bladder that leads to swelling of the ureter. This also causes a reflux of urine to the kidneys.

20 Urethritis – infection of the urethra
Types of UTI Urethritis – infection of the urethra Cystitis – an infection in the bladder that has moved up from the urethra Pyelonephritis – a urinary infection of the kidney as a result of an infection in the urinary tract

21 Diagram of cystitis

22 Signs & Symptoms of UTI in babies
Unexplained fever (febrile fits) Poor growth Abdominal pain Foul-smelling urine Signs & Symptoms of UTI in babies Irritability Poor feeding Weight loss (failure to weight gain) Vomiting

23 Signs & Symptoms of UTI in older children
Urinary frequency/urgency Dysuria Foul-smelling urine Cloudy urine Incontinence during day and/or night Increased irritability Nausea and vomiting Low abdominal or flank pain Fever and chills Fatigue Small amount of urine while micturating despite feeling of urgency

24 Signs of serious infections
Central pyrexia but peripherally cold Poor colour Pale, grey mottled skin Quiet and lethargic child Poor tone Tachycardic and hypertensive

25 Diagnostic investigations
Obtaining a urine specimen:- - Urine bag - Clean catch urine - Mid-stream urine - Catheterisation - Supra-pubic aspiration-draining the bladder by inserting a sterile needle through the skin above the pubic arch and into the bladder.

26 Diagnostic investigations
Ultrasound Plain x-ray Micturating Cystourethrogram (MCUG)

27 Nursing care Obtain urine specimen before antibiotics started, sent for ME/CS Blood tests Strict I/O chart Monitor vital signs esp. body temperature Administer antibiotics as prescribed (5 days course) Administer anti-pyretic drugs to reduce fever and pain Advised to take plenty of fluids to prevent dehydration and to flush the urinary tract If the child is unable (vomiting) or refuse to take fluids, administer IV fluids as prescribed

28 Nursing Problems Fever due to increased body temperature related to urinary tract infection. Alteration in urination (frequency, pain, burning, dribbling and enuresis) related to infection. Pain related to inflammatory changes in the urinary tract. Lack of knowledge about UTI and health prevention

29 Nursing interventions
Problem 1: Fever due to increased body temperature related to urinary tract infection Goal: to reduce fever and maintain normal body temperature Nursing interventions Rationales monitor body temperature every 4º encourage plenty of fluid intake administer anti-pyrexial medications as prescribed maintain bed rest wear thin loose clothing give tepid-sponging with luke-warm water baseline obs. to maintain hydration to maintain an optimum body temp. to reduce the body heat to reduce body heat

30 Nursing interventions
Problem 2: Alteration in urination (frequency, pain, burning, dribbling and enuresis) related to infection Goal: to ensure that the child is comfortable during urination Nursing interventions Rationales assess the urinary frequency, pain or burning sensation during micturation assess the colour & odour of urine strict I/O chart administer antibiotics as prescribed observe for signs & symptoms of serious infection as baseline obs. to observe urinary frequency to prevent spread of infection to prevent complications

31 Health teaching to prevent UTI
Ensure the child to pass urine regularly (every 2-3 hours) and take the time to completely empty the bladder Avoid holding urine for prolonged period of time Perineal hygiene - wipe from front to back Avoid tight fitting clothing or diapers; wear cotton panties Avoid constipation Encourage fluid intake Avoid bubble baths

32 Student’s Activity You are required to do the nursing care plan for problem no. 3 & 4, including nursing interventions and rationales

33 Nephrotic Syndrome Nephrotic Syndrome

34 What is Nephrotic Syndrome?
Alteration of glomerular membrane permeability with massive proteinuria, hypoalbuminaemia, hyperlipidaemia and oedema

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36 Causes It occurs when the filters in the kidney leak an excessive amount of protein. The level of protein in the blood ↓ and this allows fluid to leak across the blood vessels into the tissues – causing oedema Nephrotic syndrome are caused by changes in the immune system

37 Pathophysiology For unknown reason, the glomerular membrane, usually impermeable to large proteins becomes permeable. Protein, especially albumin, leaks through the membrane and is lost in the urine. Plasma proteins decrease as proteinuria increase.

38 The colloidal osmotic pressure which holds water in the vascular compartments is reduced owing to decrease amount of serum albumin. This allows fluid to flow from the capillaries into the extracellular space, producing oedema. Accumulation of fluid in the interstitial spaces and peritoneal cavity is also increased by an overproduction of aldosterone, which causes retention of sodium. There is increased susceptibility to infection due to decreased gamma-globulin. Causing generalised oedema

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41 Incidence 1 : 50 000 children Males > females
Common age of onset is between 2 to 6 years, but can occur at any age

42 Signs & Symptoms Oedema - initially noted in the periorbital area
- ascites - intense scrotal oedema - striae may appear due to skin overstretching - pitting oedema ↑ weight ↓ urine output Proteinuria (foamy urine indicates proteinuria) Fatigue Irritable and depression Severe recurrent infections Anorexia Wasting of skeletal muscles

43 Diagnostic investigations
Urinalysis - protein on dipstick - haematuria may be absent or microscopic

44 Diagnostic investigations…con’t
Blood test - total serum protein – low - serum albumin – low - cholesterol and lipoproteins – high Renal function test – often normal Blood pressure – often normal but 25% hypertension Renal biopsy

45 Renal biopsy

46 Nursing problems Generalised oedema due to fluid volume excess related to glomerular dysfunction Impaired skin integrity related to oedema Altered urinary pattern related to glomerular dysfunction Increased susceptibility to infection related to disease process and steroid therapy

47 Nursing problems…con’t
Altered body image (round face) due to side- effects of medication Inadequate nutritional intake related to large loss of protein from the urine Knowledge deficit of the disease process and treatment Anxiety and depression due to the up and down of the course of disease

48 Nursing problem 1 :Generalised oedema due to fluid volume excess related to glomerular dysfunction
Goal : to relieve oedema Nursing interventions Administer steroids – prednisolone 2-4mg/kg to control oedema Observe for side-effects of steroids – Cushing’s syndrome (moon face, abdominal distension, striae, ↑ appetite, ↑ weight, aggravation of adolescent acne)

49 Administer diuretic – frusemide
Administer diuretic – frusemide. Diuretics can cause loss of electrolytes esp. potassium, encourage ↑ potassium food e.g. citrus fruits, date, apricot, banana Keep the child CRIB during periods of severe oedema Strict I/O chart – restrict intake of fluid – offer small amount of measured fluid during severe oedema, for infant measure the diaper’s wt. Measure daily weight and abdominal girth – to check any weight gain due to water retention

50 Nursing problem 2 :Impaired skin integrity related to oedema
Goal : to protect the child from skin breakdown Nursing intervention Position the child comfortably in bed so that oedematous skin is well-support with a pillow Elevate the child’s head to reduce peri- orbital oedema Provide good skin care – give bath and maintain hygiene esp. genitals and moist area Change bedding daily and free from creases and sharp objects – to avoid cut

51 Student’s activity For problems 3 – 9, you are required to look for the nursing interventions yourself.

52 Nursing Management Admission to ward
Explain to parents nature of illness Blood for FBC/DC, U +E, Creat., Serum lipid, C&S, LFT, serum albumin For CXR and Echo Daily urine dipstick for protein, ME and C&S – every morning Daily BP, weight and abdominal girth Start on IV infusion

53 Nursing Management…con’t
Administration of IV albumin Start on steroid therapy – prednisolone given at a dose of 2mg/kg/day divided into 2-3 doses. This regimen is continued until remission is achieved Remission is achieved when the urine is 0 or trace for protein for 5 to 7 consecutive days Administer prophylactic antibiotics to reduce infections

54 Nursing Management…con’t
Start on diuretic therapy – frusemide (lasix) Dietary restriction – provide ↑ protein, high carbohydrate, ↑ potassium diet & no salt diet Strict I/O chart Provide careful skin care Good hygiene CRIB

55 THE END Question and Answer

56 VESICO-URETERAL REFLUX
DEFINITION The backflow or reflux of urine from the bladder into the ureters and possibly the kidneys. The urine returns to the bladder after passing urine.

57 Signs & symptoms for infants
Fever >39ºC Irritability Poor feeding Vomiting Dysuria as evidenced by crying when passing urine Change in urine colour or odor

58 Signs & symptoms for children
Abdominal or suprapubic pain Frequency in passing urine Urgency in passing urine Dysuria New or increased incidence of enuresis

59 Pathophysiology In normal functioning urinary tract, there is a valve-like mechanism at the junction of the ureter and bladder that prevents urine from refluxing in the ureters As urine fills the bladder or the bladder contracts during micturating, pressure in the bladder occludes the opening to the ureter When a defect occur at the vesioco-ureteral junction, VUR occur

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61 Diagnostic investigations
MCUG – to visualise the urethra, evaluate degree of reflux and define any abnormalities Renal scan – to assess renal scarring and function Urodynamic studies – this is done when there is micturating dysfunction (frequency, urgency, or incontinence) is present Cystograms Urine culture Blood test – serum creatinine

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63 International Classification of Reflux
GRADE I: reflux into ureter only – no dilatation GRADE II: reflux into ureter, pelvis and calyces with no dilaltation and normal calyceal fornices GRADE III: mild dilatation of ureter and renal pelvis GRADE IV: moderate dilatation of ureter, pelvis and calyces GRADE V: gross dilatation of ureter, pelvis and calyces

64 GRADE IV: moderate dilatation of ureter,
pelvis and calyces

65 GRADE V: gross dilatation of ureter, pelvis and calyces

66 - occurs as a result of acquired bladder dysfunction
Reflux can be divided into 2 categories :- PRIMARY REFLUX - caused by abnormal position of the ureteral bud on the wolffian duct during development of the urinary tract, resulting in smaller, tunneled segment of the ureter SECONDARY REFLUX - occurs as a result of acquired bladder dysfunction

67 Medical management Daily low dose of prophylactic antibiotic to prevent UTI Urinalysis and urine ME/CS – every 3 to 4 months to evaluate for UTI Monitor ↑BP

68 Surgical Management Surgery – reimplantation of the ureter into the bladder Indicated due to recurrent UTI despite antibiotics, Grade 5 reflux or progressive renal injury

69 HYPOSPADIAS Definition
Hypospadias is a congenital anomaly in which the actual opening of the urethral meatus is “below” the normal placement on the glans of penis

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74 Causes Occurs from incomplete development of the urethra in utero
Exact causes unknown – may be genetic, environmental or hormonal factor

75 Complications Stenosis of the opening could occur – may lead to UTI or hydronephrosis May interfere with fertility if left uncorrected The location of the meatus may make it difficult for the child to urinate standing up

76 Surgical management The choice of surgical correction is affected primarily by the severity of the defect Surgery is done when the child’s age is less than 18 months Reconstruction of the meatal opening is done – Meatal advancement granuloplasty (MAGPI)

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78 The goal for surgical correction:-
To enhance the child’s ability to pass urine in the standing position with a straight stream To improve the physical appearance of the genitalia for psychological reasons To preserve a sexually adequate organ

79 References Ashwill, J.W. and Droske, S. C Nursing Care of Children. Principles and Practice. USA: W.B. Saunders. Brunner, L.S. and Suddarth, D.S The Lippincott Manual of Peadiatric Nursing. (3rd ed.) UK: Chapman & Hall.

80 Question and Answer The End


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