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Genitourinary lecture nurs 3341 slideshare
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  • 1. 11 JoyA.Shepard,PhD(c),RN-C,CNE JoyceBuck,MSN,RN-C,CNE 1 Alterations in Genitourinary Function (Urinary Tract, Renal, and Reproductive Conditions)
  • 2. 2 Learning Outcomes 1. Describeanatomy&physiologyof thegenitourinarysystemandpediatric differences 2. Discussnursingmanagementofchildwithgenitourinarystructuraldefect 3. Developnursingcareplanforchildwithurinarytractinfection 4. Outlineaplantomeetfluidanddietaryrestrictionsofchildwithrenaldisorder 5. Summarizepsychosocialissuesforchildrequiringgenitourinarysurgery 6. Plannursingcareforchildwithacute&chronicrenalfailure 7. Identifygrowth&developmentissuesforchildwithchronicrenalfailure 22
  • 3. 33 3 Comprised of: Kidneys Ureters Bladder Urethra Review: Anatomy Urinary System
  • 4. 44 4 A nephron holds: The Glomerulus Bowman’s capsule Proximal tubule Loop of Henle Distal tubule Collecting duct The Functional Unit of the Kidneys is the Nephron
  • 5. 5 Review: Anatomy of the Kidney  Outercortex  Composedoftheglomeruliandconvoluted tubulesofthenephronandbloodvessels  Innermedulla  Composedoftherenalpyramid 5
  • 6. Review: Function of the Kidney  Regulates total body water  Regulates blood pressure (renin-angiotensin-aldosterone)  Regulates acid-base status  Regulates electrolytes, calcium and phosphorus  Converts Vitamin D to the active hormone (calcitriol)  Produces Erythropoietin (EPO)  Removes nitrogenous wastes  Drug metabolism and removal 6
  • 7. 7 Review: Anatomy Reproductive System  Pelvic Cavity: contains urinary bladder, and reproductive organs  Malereproductivesystem  Testes,scrotum,penis,prostate,vasdeferens(drainsintourethra) Testesproducetestosterone(primarymalesexhormone);spermafterpuberty  Femalereproductivesystem  Ovaries,fallopiantubes,uterus,vagina Ovariesproduceestrogen(primaryfemalesexhormone);ovumafterpuberty 7
  • 8. 8 Review: Physiology Genitourinary System  Renal/ Urinary System  Main function – Regulates fluid and electrolyte balance  Filters blood plasma  Returns useful substances to blood  Eliminates waste  Regulates  Osmolarity of body fluids, blood volume, BP  Acid-base / electrolyte balance  Secretes Renin & erythropoietin  Detoxifies free radicals & drugs  Reproductive System  Main function – Provides for perpetuation of the species 88  See Kidney Function Part 1 and Kidney Function Part 2
  • 9. 99 9
  • 10. 10 Children are not just small adults…. 1010
  • 11. 1111 11 Development of the Genitourinary System
  • 12. 12 Pediatric Differences – Urinary System 12
  • 13. 13 Fluid & Electrolyte Balance Differences  Incomparisontoadults,childrenareatagreaterriskforfluid&electrolyte imbalance.Childrenhave:  A proportionatelygreateramountofbodywater  Requiremorefluidintakeandsubsequentlyexcretemorefluid  A greaterbodysurfaceareaandahigherpercentageoftotalbodywater  A greaterpotentialforfluidlossviathegastrointestinaltractandskin  Anincreasedincidenceoffever,upperrespiratoryinfections,andgastroenteritis  A greatermetabolicrate  Immaturekidneysthatareinefficientatexcretingwasteproducts  Kidneysthathaveadecreasedabilitytoconcentrateurine  Increasedriskfordevelopinghypernatremiabasedontheirinabilitytoverbalizethirst 13
  • 14. 14 Pediatric Differences: Urinary System  Allnephronspresentatbirth  Renalgrowth  Mostduringfirst5yrs  Fullsizebyadolescence  Renalefficiencyincreasesaschildmatures  Kidneyfunctionisimmatureuntilafter2yearsofage  Glomerularfiltration&absorptionimmature  Infantsmorepronetofluidvolumeexcess&dehydration  Lessefficientregulatingelectrolyte&acid-basebalance 1414
  • 15. 15 Urinary Output  Urinaryoutputperkilogramofbodyweightdecreases aschildagesbecausethekidneysbecomemore efficient  Infants 2-3mL/kg/hr  Toddler/Preschooler 2mL/kg/hr  SchoolAge 1-2mL/kg/hr  Adolescent 0.5-1mL/kg/hr 1515 1 gram diaper weight = 1 mL of urine
  • 16. 16 Bladder  Bladdercapacityincreaseswithage  15to50mLatbirth  700mLinadolescence  Estimatebladdercapacity (inounces)–add2tochild’sage 1616
  • 17. 17 Pediatric Differences – Reproductive System 17
  • 18. 18 Pediatric Differences: Reproductive System  Infemaleinfants,theexternalgenitaliamaybeprominentduetomaternal estrogen  Labiaminoramayprotrudebeyondlabiamajora  Testiclesmayappearlargeatbirthinproportiontosizeofinfant  Mayfailtomoveintothescrotum,causingundescendedtestes  Theforeskinmaybetightatbirth,causingphimosis  Thesexorgansdonotmatureuntilonsetofpuberty  Secondarysexcharacteristicsoccurwithonsetofpuberty 18
  • 19. 19 History & Physical 19
  • 20. 20 Terms Commonly Used to Describe Urinary Dysfunction  Dysuria:Difficultyinurination  Frequency:Abnormalnumberofvoidingsinashortperiod  Urgency:Urgetovoidbutinabilitytodoso  Nocturia:Awakeningduringthenighttovoid  Enuresis:Uncontrolledvoidingafterbladdercontrolhasbeenestablished  Polyuria:Increasedurineoutput  Oliguria:Decreasedurineoutput 20
  • 21. 21 Focused Health History  Mother’spregnancy/child’sbirthhistory  Familyhistory:GU-specificdisorders  Reviewoffluidintake(includingtypeoffluid)  Urinarytractinfections,feversofunknownorigin,dysuria  Toilettraininghistory,voidingandbowelhistory,voidinghabits(e.g.,positioningduringvoiding)  Anyproblemsorchangeswithvoiding(e.g.,nocturiaorenuresis)  Rectum/genitalia:anyrashes,sores,ordischarges  Malechildren:circumcisionstatus,prepuceissues,inguinalbulge/scrotalswelling,failureoftestestodescend  Females(ifappropriate):  MenstrualHistory–menarche,LMP,interval,regularity,duration,amountofflow,dysmenorrhea  ObstetricalHistory-Gravida,Term,Para,Abortion,Live,Stillbirth(GTPALS)  Foradolescents,askaboutsexualactivitywithparentsoutofroom 21
  • 22. 22 Urinary Symptoms  Enuresis(bedwetting)  Newonsetincontinence  Frequency,urgency,quantity  Dysuriaanditstimingduringvoiding(atbeginningorend,throughout)  Changeincolorandodorofurine  Hematuria  Presenceofstonesorsedimentintheurine  Toilettrainingproblems 22
  • 23. 23 Toilet Training Readiness  Children<2yrsgenerallycannotmaintainbladdercontrol  12months:nocontroloverbladder  18to24months:somechildrenshowsignsofreadiness  Somechildrenmaynotbereadyuntilaround30months  Thepotty-trainingyearsareespeciallyriskyfordevelopingUTI  Remindchildtovoidoftenevenifhe/sheisnothavingaccidents  Remindfemalechildrentowipefromfronttoback  Achildwhoisuncircumcisedshouldbetaughtatpottytraininghowto graduallyandgentlyretracttheprepuceforvoidingandhygiene 2323
  • 24. 2424
  • 25. 25 Review Question  Amotherisinquiringaboutherchild'sabilitytopotty train.Whichofthefollowingfactors isthemost importantaspectoftoilettraining? A. Theageofthechild B. Thechild’sabilitytounderstandinstructions. C. Theoverallmentalandphysicalabilitiesofthechild. D. Frequentattemptswithpositivereinforcement. 25
  • 26. 26 Anomalies & Diseases: Genitourinary  Congenital/chromosomalanomalies(e.g., single umbilicalartery, low-setears,eartags);ambiguous genitalia  Cystitis,pyelonephritis,renaldisease  GUsurgeryorprocedures  Male: Phimosis,cryptorchidism,hydrocele,testiculartorsion 26
  • 27. 27 Single Umbilical Artery Associated with increased incidence of urogenital abnormalities 27
  • 28. 28 Low-Set Ears & Urinary Tract Anomalies 28 Suspect urinary tract/ kidney anomalies
  • 29. 29 Skin Tags/ Preauricular Sinus 29
  • 30. 30 Assessment of the Genitourinary System  Review:AssessingtheAbdomenforShape,BowelSounds,and UnderlyingOrgans(pp.143-145)  Review:AssessingtheGenitalandPerinealAreasforExternalStructural Abnormalities(pp.145-149) 30 See video “Pediatric Assessment” 24:07 – 25:47 See video “Physical Exam & Health Assessment: Child” 17:08 – 18:49
  • 31. 3131 31
  • 32. 32 Nursing Diagnoses  UrinaryIncontinence  ImpairedUrinaryElimination  UrinaryRetention  ExcessFluidVolume  RiskforDeficientFluidVolume  RiskforImbalancedFluidVolume  RiskforElectrolyteImbalance  ToiletingSelf-CareDeficit 3232
  • 33. 33 GU Process Focus  Dailymonitoringofintake/outputandweightarevitalinassessingalterationsinfluid- electrolytebalanceinthepediatricpatient  Assessvitalsigns,notingthatbloodpressureisoftenelevatedwithglomerulonephritis andnephroticsyndrome  Monitorserumelectrolytes,creatinine,andBUNlevels(arisingcreatinineandBUN suggestspoorrenalfunctioning)  Measureheight,weight,andbodymassindex(failuretothrivecanbeassociatedwith urinarytractinfectionsininfancyandincreasedweightcanbeassociatedwithnephrotic syndrome)  Noteearpositionandformation(low-setorabnormalearsmaybeanindicationof congenitalrenalconditions) 33
  • 34. 34 Diagnostic Tests 3434
  • 35. 35 Laboratory Tests  Urinalysis  Urineculture  Bloodureanitrogen(BUN)  Serumcreatinine  Creatinineclearancetest/glomerularfiltrationrate(GFR)  Urinealbumin(proteinuria)  Urineproteintocreatinineratio  Basicmetabolicpanel/CBC  Serumalbumin 35
  • 36. 36 Urinalysis (UA)/ Urine Culture  Specificgravity:1.001 – 1.035  pH: 4.6 – 8.0  Urinecolor  Appearance  Leukocyteesterace  Protein  Glucose  Ketones  Occultblood  Bilirubin  Urobilinogen  Nitrite 3636 Which of these components (if positive) would indicate a urinary tract infection?
  • 37. 37 Urine Specific Gravity  Reliableassessmentofpatient’shydrationstatus  1.001–1.035 Normalvalue  IncreasedUrineSG Dehydration–diarrhea–excessivesweating-vomiting  DecreasedUrineSG Excessivefluidintake–pyelonephritis-glomerulonephritis 3737
  • 38. 38 Urine Collection 38 Application of urine collection bag 38 See Videos: Urine Samples Collection Pediatric Urine Specimen Collection of Infant
  • 39. 39 Review Question  Whichofthefollowinginterventionswillhelpobtain accurateurinalysisdata? A. Forcefluidsto1000mLpriortospecimencollection. B. Cleansethespecimencontainerwithpovidone-iodine(Betadine) priortocollectingthespecimen. C. Allowtheurinetocooltoroomtemperaturebeforetakingittothe lab. D. Provideclient/parenteducationforspecimencollectionbeforethe specimenisobtained. 3939
  • 40. 40 Diagnostic Tests (p. 807)  ComputedTomography(CT)  Cystoscopy  FunctionalRadionucleotideRenalScan  IVP–IntravenousPyelogram  RenalBiopsy  RenalorBladderUltrasound  VCUG–VoidingCystourethrogram 4040
  • 41. 41 Computerized Tomography (CT Scan) 4141 Abdomen CT Scan
  • 42. 42 Cystoscopy 42 Invasive surgical procedure Visualizes bladder, urethra, and ureter placement 42
  • 43. 43 Functional Radionucleotide Renal Scan  Evaluates function of entire urinary system, from kidneys through bladder  Nuclear medical imaging  Requires use of a radiopharmaceutical tracer through an IV catheter  Gamma camera takes images (scintigraphy) 43
  • 44. 44 Intravenous Pyelogram (IVP) 4444
  • 45. 45 Intravenous Pyelogram (IVP) 45 Kidney function analyzed Watch for allergic reaction to dye Dye can be toxic to kidneys Push fluids Monitor I & O 45
  • 46. 46 Review Question  Achildreturningtotheunitafteranintravenouspyelogram(IVP)hasan ordertodrinkextrafluids.Whenthemotherasksthepurposeofthese fluids,thenurserespondsthatincreasedfluidintakewill: A. Overhydratethechild. B. Increaseserumcreatininelevels. C. Make-upforfluidlossesfromNPOstatusbeforetests. D. Flushanyremainingdyefromtheurinarytract. 4646
  • 47. 47 Renal Biopsy 4747
  • 48. 48 Renal Bladder Ultrasound (RBUS) 4848
  • 49. 49 Voiding Cystourethrogram (VCUG) 4949
  • 50. 50 Treatment Modalities  Urinarydiversion  Stents  Drainagetubes  Intermittentcatheterization  Watchforlatexallergies  Pharmacologicalmanagement  Antibiotics  Anticholinergicforbladderspasm(oxybutynin[DitropanXL]) 5050
  • 51. 51 Urinary Tract Infection 5151
  • 52. 52 Urinary Tract Infection (UTI)  Infection in urinary system (urethra, bladder, ureters, or kidneys)  Cystitis: Lower UTI; urethra or bladder  Pyelonephritis: Upper UTI; ureters, renal pelvis, or kidneys  Usually of bacterial origin (e coli); characterized by inflammation  Common in childhood; highest frequency ≤ 2 yrs of age  Uncircumcised males: 10-fold incidence  Prompt diagnosis/ treatment essential  See video Urinary Tract Infection 5252  The male and female urinary tracts are similar except for length of urethra
  • 53. 53 UTI: Etiology/ Pathophysiology  Urethralexposuretoorganismsortrauma  Most commoncausativeorganism:Escherichiacoli  Occursmorefrequentlyingirlsbecausethe short urethraislocatedcloseto anus  Pathogensenterasanascendinginfection  Teenager:sexualintercourseduetofrictiontrauma  Urinarystasis  Anatomicabnormalities;scarring/strictures  Hydronephrosis;hypospadias,epispadias  Neurogenicbladder–incompleteemptyingofbladder  Intheolderchild:infrequentvoidingandincompleteemptyingofbladderorconstipation  Vesicoureteralreflux(VUR)  Urineflowsbackwardsintouretersandkidneys;providesmediumforbacteriatogrow 5353
  • 54. 54 Review Question Which of the following organisms is the most common causeof UTI inchildren? A. Staphylococcus B. Klebsiella C. Pseudomonas D. Escherichiacoli 54
  • 55. 55 UTI - Females  More common (generally) in females  Short urethra  Improper wiping  Bubble baths  Nylon under pants  Current guidelines – renal and bladder ultrasound with first febrile UTI followed by VCUG if indicated  Second febrile UTI – VCUG 5555
  • 56. 56 UTI – Males  UTIs in males tend to be complicated  More common in males than females during 1st 3 months of life  Males 2-24 months:  Febrile with first UTI  Renal & bladder ultrasound – hydronephrosis, scarring, obstructions, masses  2nd episode febrile UTI  VCUG – vesicoureteral reflux  Higher incidence of UTIs in uncircumcised males 5656
  • 57. 57 Uncircumcised Males  Instructparentstogentlyretractforeskinforcleansing  Donotforcetheforeskin  Donotleaveforeskinretractedoritmayactastourniquetandobstructthe headofthepenisresultinginemergencycircumcision 5757
  • 58. 58 UTI: Diagnostic Tests  Urineforcultureandsensitivity  Cleancatch  Catheterization  Suprapubicaspiration  APositiveTest  Bacteriacolony≥50,000permL  Positiveleukocyteesterace;positivenitritetests;whitebloodcell(WBC)casts  Ultrasound:structuralabnormalities,scarring  Voidingcystourethrogram(VCUG):vesicoureteralreflux 58
  • 59. 59 UTI: Clinical Manifestations  Signs&symptomsnotalwaysclear(atypicalpresentation)  TypicalS&Sofolderchildrenandadults–dysuria,frequency,urgency, burning,hematuria–maynotbepresent  Newborn/infant:unexplainedfever;failuretothrive;poorfeeding;vomiting;diarrhea; foul-smellingurine;irritability;lethargy  Feverofunknownorigin(child≤2yrs):testforUTI  Toilet-trainedchild:newonsetincontinence,wettingaccidents  UpperUTIS&S:highfever,chills,abdominalpain,flankpain, costovertebral-angletenderness,vomiting,malaise(i.e.,vaguefeelingof generaldiscomfort) 5959 See “Clinical Manifestations Urinary Tract Infection” – p. 808
  • 60. 60 Review Question UTI: What are the differences between older child/ adult S & S and infant-child S & S 60
  • 61. 61 UTI: Collaborative Care  Obtainurinespecimen(orbloodcultures)beforeantibiotics!  ComplicatedUTI/pyelonephritis:hospitalization,IVfluids,parenteralantibiotics  UncomplicatedUTI:oralantibiotictherapyfor10to14days  Escherichiacoli,Enterococcus,Proteus,&Klebsiellamostcommonorganisms  Amoxicillin/clavulanic(Augmentin),sulfamethoxazole/trimethoprim(Bactrim,Sulfa),cephalexin(Keflex), cefixime(Suprax)  Increasefluidintake  Acetaminophen/ibuprofenforpain  Repeaturinalysis–usuallyafter72hrsoftreatmenttomakesuretreatmentiseffective 6161 See “Prevention of Urinary Tract Infections” – p. 810
  • 62. 62 UTI: Nursing Education  Antibiotics–takefullcourse  Changediaperfrequently  Teachgirlstowipefronttoback  Encouragechildrentodrinkperiodicallyduringtheday  Nobubblebaths  Encouragefrequentvoiding  Discourage“holding”urine  Usecottonunderwear  Menstruatinggirl– changepadevery4hours  Whengirlsbecomesexuallyactive– urinateimmediatelyafterintercourse 6262
  • 63. 63
  • 64. 64 Review Question  Themostimportantnursingactivityinmanagingayoungchild diagnosedwithurinarytractinfection(UTI)isto: A. Provideadequatenutritiontopreventdehydration. B. Preventenuresis. C. Administerorderedantibioticsonschedule. D. Restrictfluidstoprovidekidneyrest. 6464
  • 65. 65 Review Question  Theparentsofachilddiagnosedwithupperurinarytract infection(UTI)askthenursewhythechildneedsadailyweight. Informulatingaresponse,thenurseincludesthatitisimportant becauseadailyweightwill: A. Determineifthechild’scaloricintakeisadequate. B. Indicatetheneedfordietaryrestrictionsofsodiumandpotassium. C. Keeptrackofpossiblelossorgainoffluidretainedinbodytissues. D. Tracktheamountoffluidingestedorallyeachday. 6565
  • 66. 66 BladderExstrophy Hypospadias&Epispadias Obstructive Uropathy Vesicoureteral Reflux Structural Defects of the Urinary System (usually hereditary) 6666
  • 67. 67 Bladder Exstrophy  Exstrophy: turning inside out  1 in 40,000 births  Twice as common in males  Congenital malformation in which the abdominal and anterior bladder walls do not fuse during fetal development 6767 •Inside-outbladder; •Mucosa(inside lining)ofbladder exposed
  • 68. 68 Bladder Exstrophy: Clinical Manifestations  Visible defect revealing bladder mucosa/ ureteral orifices through open abdominal wall  Constant drainage of urine; excoriated skin  Mass bright red tissue (bladder)  Numerous additional congenital anomalies: epispadias, short penis, upward chordee, split clitoris, forward- positioned anus, low umbilicus, wide pelvis, waddling gait 6868
  • 69. 69 Bladder Exstrophy: Collaborative Care  Multidisciplinary approach  Surgery within 48 hrs after birth to close the skin over bladder and reconstruct male urethra/ penis  Urethral stents/ suprapubic catheter to divert urine  Further reconstructive surgery between 6 mos to 5 yrs of age  Requires lifelong follow-up 6969
  • 70. 70 Before and After Surgical Repair 70 Details: http://www.pediatricurologybook.com/bladder_exstrophy.html
  • 71. 71 Goals of Treatment  Closebladder/abdominalwall  Preserverenalfunction  Attainurinarycontrol  Acceptableappearance/ functionofgenitals  Sexualfunction  Typical&normalchildhood 7171
  • 72. 72 Nursing Care  Pre-Op:Preventinfectionandtrauma  Umbilicalcordtiedwith2.0silksuture(notumbilicalcordclamp)  Bladdercoveredwithsterileplasticwrap;irrigatedwithwarmsaline  Skinprotectedwithointmentorsealant  Infantpositionedsupinewithdiaperunderneath  Post-Op:  Maintainproperalignment(noabduction);monitorperipheralcirculation;providemeticulouswound/skin care  Monitorrenalfunction;strictI&O;observeforsignsofobstruction;promotecomfort;administerantibiotics  Supportparents;promotebonding;guidance&dischargeteaching 72 ModifiedBryant’straction
  • 73. 73 Review Question  Whichofthefollowingpositionswouldbestfacilitate healingfortheinfantafter bladderexstrophyrepair? A. Supine,legssuspendedverticallywithlegsclosetogether B. Leftside-lyingposition C. Rightside-lyingposition D. Low-Fowler’s,legsbentatkneeswithwedgebetweenlegs 73
  • 74. 74 Long Term Complications  Urinaryincontinence  Infection  Bodyimage  Inadequatesexualfunction 7474
  • 75. 75 Hypospadias & Epispadias 75 Hypospadias EpispadiasEpispadias Hypospadias Recurrent UTIs are a complication of both conditions  Hypospadias: Abnormal opening of urethra on underside of penis rather than tip  Common congenital anomaly of penis  Ranges from mild to severe  Undescended testes may be present  Downward curvature of penis (chordee)  Might interfere with fertility  Epispadias: Abnormal opening of urethra above tip of penis or between clitoris and labia (girls)  Rare congenital anomaly (girls & boys)  Milder expression of bladder exstrophy  Short broad penis, upward curvature  Abnormal clitoris, labia, wide pelvis (girls)
  • 76. 7676 76 Hypospadias  Ventral surface  Below glans penis Epispadias  Dorsal surface  Above glans penis Hypospadias & Epispadias
  • 77. 77 Hypospadias & Epispadias: Collaborative Care  Diagnosis:PrenatalUS,examinationatbirth  Circumcisionnotrecommended(foreskinmaybeneededfor reconstructivesurgery)  Notreatment necessaryinmilddisorder  Hypospadiasrepair:4-18mos(earlyinterventionpreferred)  Epispadiasrepair:12-18mos(allowsbladdertimetoenlarge)  Post-op:Forcefluids,keepurinarystentpatent,leavebandageinplace, notubbathinguntilstentisremoved 7777 See “Caring for the Child After Hypospadias and Epispadias Repair” – p. 812
  • 78. 78 Review Question  Shortlyafterbirth,thenewbornwasfoundtohaveepispadias.Priorto delivery,themotherhadsignedpermissionforacircumcision.The obstetricianisplanningtoperformthecircumcisionimmediatelyafter delivery.Thenurseexplainstothemotherthatthecircumcisionwillnotbe doneatthistimebecause: A. Themothershouldnothavesignedconsentbeforedelivery. B. Thefatheralsoneedstosignpermissionforsurgery. C. Theprepucewillbeusedforthesurgicalcorrection. D. Theriskofinfectionisgreaterwithachildwithepispadias. 7878
  • 79. 79 Hypospadias & Epispadias: Nursing Care  Keeptheareacleantopreventinfection  Assessforpostsurgicalcomplications  Monitorforsignsofinfection  WatchforevidenceofUTI  Assesspain(oxybutyninrelievesbladderspasms)  Encouragetheparentstoexpresstheirfeelings/concernsandprovideemotionalsupport  Dischargeinstructions: Bandagedressingcare,careofstent,activityrestrictions,nutrition, paincontrol,andsigns/symptomsofcomplications 79 See “Caring for the Child After Hypospadias and Epispadias Repair” – p. 812
  • 80. 80 Review Question  Aninfanthasbeenadmittedfortreatmentofhypospadias.Nursing managementofthechildandfamilyincludes: A. Parenteducationregardingsteroidtherapy. B. Addressingparentalanxietyrelatedtofunctioningandappearanceof thepenis. C. Homehealthteachingofproperstraightcatheterizationtechniques. D. Monitoringforsignsandsymptomsofnephroticsyndrome. 8080
  • 81. 81 Double-Diapering Technique After Surgery for Hypospadias/Epispadias Repair 81
  • 82. 82 Review Question  Themotherofaninfantwhounderwentsurgerytorepair hypospadiasasksthenursewhytheinfantisdouble-diapered. Thenursewouldrespondthatthismethodofdiapering: A. Protectstheurinarystentthathasbeenputinplace. B. Adequatelymeasurestheurinaryoutput. C. Providesformaximumabsorptionofurine. D. Providesoptimalprotectionofperinealskinfrominfectedurine. 8282
  • 83. 83 Hydronephrosis/ Hydroureter (Obstructive Uropathy)  “Water on kidney” enlarges renal pelvis, damages nephrons  Mechanical blockage/ obstruction in urinary tract; most often unilateral  Congenital malformations: ureters, ureteral valves, bladder, urethra  Can lead to: nephron destruction, HTN, ↓ ability to conserve Na+, metabolic acidosis, recurrent UTIs, progressive irreversible renal failure  Goal: maintain integrity of kidney until normal urinary flow established  Early diagnosis essential (US) 8383
  • 84. 84 Common Sites of Obstruction in Upper/ Lower Urinary Tract (Congenital Malformations) 84 84  Why would damage from the posterior urethral valves be potentially worse than other obstructions?
  • 85. 85 Prune-Belly Syndrome (Rare): Another Congenital Cause of Hydronephrosis 85
  • 86. 86 Review Question  Aparentasksthenursewhatwilleventuallyhappeniftheinfantdoesnot havehiscongenitalhydronephrosistreated.Themostaccurateanswerby thenursewillbewhichofthefollowing? A. “Ifthehydronephrosisisnottreated,thechildcandevelopbladdercancer.” B. “Theinfantcanbecomedangerouslyhypotensivebecauseoftheobstructiontourine flow.” C. “Smallcalciumstonescanoccurasaresultofuntreatedhydronephrosis,causing furtherobstruction.” D. “Untreatedhydronephrosiscanleadtoirreversiblekidneydamageandeventual kidneyfailure.” 86
  • 87. 87 Hydronephrosis: Clinical Manifestations  Distendedbladder/abdomen  HistoryofUTI:flankpain,feverandchills  S&Srenalinsufficiency:decreaseinurinaryoutflow,swelling, hypertension,anemia,poorappetite;decreasedabilityofkidneyto conservesodiumandconcentratetheurine  NeonatemaypresentasUTI  Outerearabnormalities,singleumbilicalartery  AnolderchildmaybeasymptomaticexceptforFTT 8787
  • 88. 88 Review Question  Anurseisreviewingapatient’schartandnoticesthatthechildsuffersfrom hydronephrosis.Whichofthefollowingwouldthenurseexpecttoseewith thispatient?  A.Swollenkidneyduetourinenotdrainingfromkidney  B.Dehydrationfromspittingupandseveralloosestools  C.Profuseurinationandurinaryfrequency  D.Spinalcorddefectcausinginabilitytoemptybladder 88
  • 89. 89 Hydronephrosis: Diagnostics  Ultrasound of kidneys/bladder  VCUG: voiding cystourethrogram  Diuretic renography with radioisotope  Requires use of a radiopharmaceutical tracer & intravenous furosemide through IV 8989
  • 90. 90 Hydronephrosis: Collaborative Care  Goalsofcorrection:Preserverenalfunction,lowerpressure withincollectionsystem  Temporaryurinarydiversionmaybeneededtorelievethepressure  Surgicaltreatment:insertionofureteralstents,nephrostomy tube;pyeloplasty;valverepair/reconstruction  Nephrectomyifrenaldamageisnotreversible  Nursingcare:support/educateparents;monitorVS,I&O; observeforsignsofurinaryretention;administermedications 9090
  • 91. 91 Vesicoureteral Reflux (VUR)  Regurgitationofurinefromthebladderintotheuretersduetofaultyvalvemechanismat theureterovesicularjunction  Predisposeschildto:UTIs;pyelonephritis;hydronephrosis  Whitechildren,girls,children≤age2;tendstoruninfamilies  Assessmentfindings:sameasforUTIs/FTT  Diagnostictests:kidney/bladderUS,VCUG,nuclearscan  Goals:preventpyelonephritis,renalscarring,chronicrenalfailure  Tx:Long-termdailylow-doseantibioticprophylaxis;valverepairorreconstruction; endoscopicsurgery;surgerytore-implantureters 9191
  • 92. 92 Ureteral Reflux 9292
  • 93. 93 Vesicoureteral Reflux: Nursing Care  Assist with preoperative studies as needed  Provide postoperative care:  Observe for signs of infection  Monitor VS, I & O  Monitor drains; may have one from bladder and one from each ureter (ureteral stents)  Check output from all drains (expect bloody drainage initially) and record carefully  Observe drainage from abdominal dressing; note color, amount, frequency  Administer medication for bladder spasms as ordered  Support/ educate parents
  • 94. 94 Enuresis Disorders of Continence 9494
  • 95. 95 Enuresis  Uncontrolled or unintentional urination that occurs after a child is beyond an age at which bladder control is achieved, usually age 5-6 yrs  Nocturnal = at night  Diurnal = during the day  Nocturnal enuresis is further categorized as primary and secondary:  Primary = the child has never achieved complete bladder control  Secondary = relapse after some control  Primary nocturnal enuresis is the most common type  Usually occurs when the child is asleep  More frequent in boys than in girls  5-7 million children > 6 yrs 9595
  • 96. 96 Enuresis: Etiology & Pathophysiology • Genetic predisposition (family history of bed-wetting) • Structural disorders; small bladder capacity • Developmental delay; delayed neuromuscular maturation • Impaired arousability from sleep (child may sleep too soundly to recognize the cues of a full bladder) • Lack of normal circadian rhythm for diuresis • Chronic or acute illness (constipation, encopresis, UTI, diabetes mellitus, obstructive sleep apnea, neurogenic bladder) • Family disruptions, trauma, anxiety, or stress (e.g., birth of a sibling, hospitalization, abuse/ neglect, moving to a new home, or divorce)
  • 97. 97 Enuresis: Clinical Manifestations  Inappropriate urination must occur at least twice a week for at least 3 months and the child must be at least 5 yrs of age before a diagnosis of enuresis is considered  Repeated voiding of urine during the day or at night into bed or clothes  Frequency, urgency, constant dribbling, involuntary loss of control after voiding  Emotional problems (e.g., poor self-esteem, altered body image, social isolation, fears)  Rashes on the bottom and genital area 97
  • 98. 98 Enuresis: Collaborative Care  Fluid restriction  Monitor fluid requirements  Reduce fluids in evening  Caffeine-free diet  Bladder training  Have child urinate before going to bed  Wake child up to urinate  Praise and reward  Behavioral chart to keep track of dry nights  Moisture bedwetting alarm system  Medications  Desmopressin acetate (DDAVP), oxybutynin (Ditropan), imipramine (Tofranil) 9898 See “Nonpharmacological Treatment Approaches for Enuresis” – p. 816
  • 99. 9999 99 99
  • 100. 100 Enuresis: Nursing Care  Organic causes related to GU dysfunction must be ruled out  Detailed history and examination (Box 26-2, p. 816)  Diagnostic tests (p. 815)  Assess parental attitudes on toilet training  Educate parents: developmental stage, causes, treatments  Teach parents about avoidance of fluids close to bedtime  Discuss behavioral treatments (battery-operated bed-wetting alarm; reward charts)  Support children and their families by listening to concerns  Recommend resources (support groups, counseling)  Discuss pharmacologic treatments See “Questions to Ask When Taking an Enuresis History” – p. 816
  • 101. 101101101
  • 102. 102102 102 102
  • 103. 103 NephroticSyndrome AcutePoststreptococcal Glomerulonephritis RenalFailure RenalReplacement Therapy Renal Disorders: Acute, Chronic, & Structural Causes 103103
  • 104. Nephrotic Syndrome/ Nephrosis (Minimal Change Nephrotic Syndrome) 104  Clinical state characterized by massive proteinuria, edema, hyperlipidemia, and hypoalbuminemia  Alterations in the glomerular membrane allow proteins, especially albumin, to pass in urine resulting in decreased serum osmotic pressure contributing to edema  Most common presentation of glomerular injury in children  Constellation of clinical findings, not a disease (all a result of massive renal losses of protein)  Most common form: Minimal Change Nephrotic Syndrome (MCNS); accounts for 85% of all pediatric cases  Peak incidence 2-6 years old; twice as frequent in boys  Etiology unknown; autoimmune process suspected  See video Nephrosis (Nephrotic Syndrome)
  • 105. 105
  • 106. Review Question 106 Nephrotic syndrome is caused by damage to which part of the nephron????? MinimalChangeNephroticSyndrome/ Effacement of foot processes
  • 107. 107 Contrast Between Normal Glomerular Anatomy & Changes of Nephrotic Syndrome (p. 818) 107 Massiveamountsofproteinare excretedinurine Edemaresultsfromdecreasedoncotic plasmapressure,renin-angiotensin- aldosteroneactivation,&antidiuretic hormonesecretion Loweralbuminbloodlevelstimulates thelivertogeneratelipids&excessive clottingfactors Loss of podocyte foot processes = MASSIVE PROTEINURIA
  • 108. MCNS: Clinical Manifestations  Pitting edema (around the eyes, scrotum, abdominal ascites, dependent areas, lower extremities)  Weight gain over a short period (from fluid retention)  Pale, poor appetite, irritability, fatigue, abdominal discomfort, vomiting, diarrhea  Pulmonary edema, effusions  Malnutrition, growth failure  Foamy appearance of urine  Normal or slightly elevated BP 108 Periorbital, scrotal edema
  • 109. Nephrotic Syndrome: Anasarca 109 Describe the fluid shifts in Anasarca…. What sorts of health complications do you anticipate?
  • 110. 110 MCNS: Diagnostic Evaluation  Proteinuria(Firstmorningurinesample)  Urineprotein/creatinineratio>2  Hypoproteinemia  Serumalbumin<2.5g/dL  Hyperlipidemia/Lipiduria  ↑Cholesterol,triglycerides;lipidsintheurine  Hypercoagulability(PT/PTT/INR/antithrombinIII)  Basicmetabolicpanel(BMP)  BUN/Creatininenormalunlessrenaldamage  Hyponatremia(lowserumsodium)  Kidneybiopsy 110110 Monitor serum albumin and electrolytes, particularly potassium and sodium.
  • 111. Review Question Which of the following signs and symptoms are characteristic of Minimal Change Nephrotic Syndrome? A. Gross hematuria, proteinuria, fever B. Hypertension, edema, fatigue C. Poor appetite, proteinuria, edema D. Body image change, hypotension 111
  • 112. 112 MCNS: Collaborative Care  Goals of treatment: minimize edema; decrease urinary protein loss; prevent infection; & prevent toxic medication side effects  Trial of corticosteroids: 1st step in treatment  Oral prednisone minimum of 6 months  If responsive, urine protein levels fall  Relapse/ remission not obtained: immunosuppressive agents  Diuretic therapy  Intravenous albumin followed by furosemide  Metolazone 30 minutes before furosemide (for resistant edema)  Antihypertensive therapy: ACE – to help reduce proteinuria  Balanced nutrition, low-salt diet  Prevent or treat any infection 112
  • 113. MCNS: Nursing Care  Nursing goals: manage symptoms; prevent complications; meet nutritional needs; address emotional needs of child/ family  Provide rest, cluster care  Monitor I&O, specific gravity, proteinuria  Daily weights on same scale and amount of clothing  Monitor edema and measure abdominal girth  Promote pulmonary health through position changes, activity as tolerated, deep breathing & coughing exercises, spirometer use 113
  • 114. MCNS: Nursing Care 114  Monitor VS, especially temperature for signs of infection  Encourage small, frequent meals within restriction guidelines o Salt & fluids may be restricted during edematous stage  Prevent skin breakdown & pressure sores; turn frequently  Administer medications as ordered; carefully monitor side effects  Prevent infection: meticulous hand hygiene, vaccinations, prevent contact with infectious persons
  • 115. Review Question  A nurse is assigned to care for a client with nephrotic syndrome. The nurse assesses which important parameter on a daily basis? A. Weight B. Albumin levels C. Activity tolerance D. Blood urea nitrogen (BUN) level 115
  • 116. Corticosteroids: Side Effects 116  Immunodeficiency  Hirsutism  Moonfacewithruddycheeks  Acne  Dorsocervicalfatpads  Ecchymosis(easybruising)  Truncalobesity  Moodswings–inabilitytosleep 116116
  • 117. 117 Moon Face 117 High-dose corticosteroid therapy produces a characteristic “moon face” appearance 117
  • 118. 118 Before and After 118118
  • 119. 119 Review Question While a child isreceiving prednisone (Orapred) for treatment of nephrotic syndrome, itis important for the nurse to assess the childfor: A. Infection. B. Urinaryretention. C. Easybruising. D. Hypoglycemia. 119119
  • 120. 120 Review Question  Achildhasrecurrentnephroticsyndrome.Themotherreportstothenurse thatsheisoverwhelmedwiththecareofherchild.Afterthenurse discussesoptionswiththemother,whichstatementbythemother indicatescontinuedcopingdifficulties? A. “Ijoinedasupportgrouplikeyousuggested.Ihopeitdoessomegood.” B. “I’mgoingtoaskmymother-in-lawtocomeonaregularbasistoallowmean afternoonout.” C. “Myhusbandhasagreedtohelpmemanagemyson’smedication.” D. “We’regoingtoskiphisdietaryrestrictionsonedayaweektoallowusbothsome relaxation.” 120120
  • 121. Acute Poststreptococcal Glomerulonephritis 121  Glomerulonephritis = inflammation of the glomerulus  Autoimmune immune-complex disorder occurring 10-21 days after group A beta-hemolytic streptococcal infection (upper respiratory, pharyngitis, tonsillitis, impetigo)  Children ages 2-6 yrs; more common in boys than girls  Sudden appearance of hematuria,proteinuria, red blood cell casts in the urine, edema, and hypertension with or without oliguria  Immune complexes from recent strep infection become entrapped in glomerular membrane; immune activity targeted at the glomerulus  Inflammation, tissue injury, and obstruction of glomerular capillaries  Reduced glomerular filtration rate (↓GFR)  Sodium and water retained: edema and hypertension
  • 122. Group A Streptococcal Infection Manifestations 122
  • 123. Review Question  A client has been admitted to the hospital with a diagnosis of acute glomerulonephritis. During history- taking the nurse first asks the client about a recent history of: A. Bleeding ulcer B. Deep vein thrombosis C. Myocardial infarction D. Streptococcal infection 123
  • 124. 124 Infection from group A beta-hemolytic Streptococcus leads to an immune response that causes inflammation and damage to glomeruli 124 Protein&redbloodcells areallowedtopassthrough glomeruli Bloodflowtoglomeruliis reducedduetoobstruction withdamagedcells Renalinsufficiencyresults, leadingto retentionof sodium,water,&waste IMMUNE ACTIVITY targeted at GLOMERULUS Vessels clogged with cells
  • 125. Glomerular Capillaries Clogged With Cells 125  Immune complexes (mixtures of antibodies and antigens) are filtered out of the bloodstream and become trapped within the glomeruli  Body responds by activating its immune defenses, resulting in further damage to the glomeruli
  • 126. 126 Acute Poststreptococcal Glomerulonephritis: Clinical Manifestations  Gross hematuria/ RBC casts  ↓GFR  Oliguria  Azotemia (elevated nitrogenous wastes in blood)  Hypertension  Periorbital edema  Brown foamy frothy urine  Mild/moderate proteinuria 126126 Tea- or cola-colored urine The most common clinical sign of glomerulonephritis is blood in the urine
  • 127. 127127 127
  • 128. 128  Dx:streptozymetest;↓H&H;↑BUN,creatinine;hematuria,proteinuria,RBCcasts;↑ erythrocytesedimentationrate  Tx goals:reliefofsymptoms,supportivetherapy  Monitorurinaryoutput,dailyweights,bloodpressure,&serumelectrolytes  Limitedactivity,bedrest  Diuretics suchasfurosemide(Lasix)toreducefluidoverload  Antihypertensivedrugstotreatincreasedbloodpressure  Antibiotics(penicillin)ifastreptococcalinfectionisdocumentedordetected  Restrictionoffluidstoreplaceinsensiblelosses  Low-sodium,lowproteindiet(duringacutephase) 128128 Acute Poststreptococcal Glomerulonephritis: Collaborative Care
  • 129.  Nursing care: monitor fluid status, prevent infection, prevent skin breakdown, meet nutritional needs, and provide emotional support to the child/ family  Monitor: VS, I & O, daily weight; abdominal girth; watch for signs of renal failure, including decreased (less than 1 mg/kg/hour), or no urine output  Monitor: signs of infection, including fever, malaise, & elevated WBC  Enforce activity limitations, bed rest during acute phase; cluster care  Institute sodium restrictions for the child with hypertension or edema  Educate parents: dietary restrictions (sodium, potassium, & fluid intake)  Administer diuretics/ antihypertensive medications as needed  Provide emotional support 129 Acute PoststreptococcalGlomerulonephritis: Nursing Care
  • 130. 130 Review Question  Whenreviewingaurinalysisreportofaclientwithacute glomerulonephritis,thenursewouldexpecttonote: A. Decreasedcreatinineclearance. B. Decreasedspecificgravity. C. Hematuria. D. Decreasederythrocyte sedimentationrate(ESR). 130130
  • 131. 131 Acute Renal Failure/ Acute Kidney Injury  Life-threateningdisorder  Kidneysunableto  Clearwastes  Regulatefluidvolume,sodiumbalance, &acid-basehomeostasis  Pre-renal,resultingfromimpairedbloodflow to oroxygenationofthekidneys  Renal,resultingfrominjurytoormalformation ofkidneytissues  Post-renal,resultingfromobstructionof urinaryflowbetween kidney &meatus  Seevideo3MinuteAcuteRenalFailureforNursingStudents 131131 Suddenlossofrenalfunction
  • 132. 132
  • 133. 133 Review Question  Thenurseadmitschildrenwiththefollowingdiseasesto theunit.Whichdiseaseplacesthechildatriskforthe developmentofacuterenalfailure(ARF)? A. Leukemia. B. Cryptorchidism. C. Nephroticsyndrome. D. Phenylketonuria. 133133
  • 134. 134 The initial kidney injury is usually associated with an acute condition such as sepsis, trauma, and hypotension, or is result of treatment for an acute condition with nephrotoxic medication 134 Injurytothekidneycan occurbecauseofglomerular injury,vasoconstrictionof capillaries,ortubularinjury Allconsequencesofinjury leadtodecreasedglomerular filtration&oliguria Acute Renal Failure/ Acute Kidney Injury
  • 135. 135 Review Question Achild has been admitted in renal failure.The nurse would expect to find: A. Decreased BUN. B. Adequate glomerular filtration. C. Azotemia and oliguria. D. Polyuria and elevated creatinine clearance. 135135
  • 136. Newborn Causes Childhood Causes  Congenitalanomalies  Hypotension  Complicationofopenheart surgery  Dehydration  Glomerulornephritis/ NephroticSyndrome  Nephro-toxicity/drug toxicity Acute Renal Failure 136
  • 137. 137 Review Question  Achildisadmittedtothenursingunitwithacuterenalfailure (ARF).Whenreviewingthenursinghistory,thenursenotesa historyofallofthefollowingmedicalconditions.Whichismost likelytohaveprecipitatedtheonsetofARF? A. Chickenpox. B. Influenza. C. Dehydration. D. Hypervolemia. 137137
  • 138. 138 Acute Renal Failure: Clinical Manifestations  Suddenonset  Oliguria  Urineoutputlessthan0.5to1mL/kg/hour  Darkurine  Volumeoverloadduetoretainedfluid  Hypertension,edema,shortnessofbreath  ElectrolyteImbalances–seechart,p.827  Acidosis  Nonspecificsymptoms:nausea,vomiting,lethargy 138 See “Clinical Manifestations” – p. 826
  • 139. 139 Diagnostic Tests  BasicMetabolicPanel(BMP)  BUNandCreatinineelevated  SerumPotassiumelevated  DecreasedCO2  CBC  DecreasedRBCs,H&Hduetodeficienterythropoietin  ABG  DecreasedpH  DecreasedBicarbonate(HCO3−)  GFR(glomerularfiltrationrate)decreased–mostsensitiveindicatorof glomerularfunction 139139
  • 140. 140140 140
  • 141. The Most Deadly Electrolyte Imbalance… 141
  • 142. Review Question  The child with acute renal failure has a serum potassium of 6.0 mEq/L. The nurse would plan which of the following as a priority action? A. Check the sodium level B. Place the child on a cardiac monitor C. Encourage increased vegetables in the diet D. Allow an extra 250 mL of fluid intake to dilute the electrolyte concentration 142
  • 143. 143
  • 144. 144 Review Question  Thepriorityconcernforthenurseinassessingachild withacuterenalfailure(ARF) shouldbetolookfor whichelectrolyteimbalance? A. Potassium. B. Sodium. C. Calcium. D. Phosphorous. 144144
  • 145. 145 Urea or BUN  Ureaisnormallyfreelyfilteredthroughtherenalglomeruli, withasmallamountreabsorbedinthetubulesandthe remainderexcretedintheurine  Decreaseorincreaseinthevaluedoesnottellthecause:pre- renal,post-renalorrenal  ElevatedBUNjusttellsyoutheureaisnotbeingexcretedby thekidney,notwhy 145145
  • 146. 146 Creatinine  Creatinineisaveryspecificindicatorofrenalfunction  Ifkidneyfunctionisdecreased/creatininelevelwillbe increased  Conditionsthatincreaselevels:glomerulonephritis, pyelonephritisorurinaryblockage 146146
  • 147. 147 Creatinine Levels  Adultfemale:0.5-1.1mg/dL  Adultmale:0.6-1.2mg/dL  Adolescent:0.5-1.0mg/dL  Child:0.3-0.7mg/dL  Infant:0.2-0.4mg/dL  Newborn:0.3-1.2mg/dL. 147147
  • 148. 148 Acute Renal Failure: Collaborative care  Treatmentdependsontheunderlyingcause  Preventpermanentrenaldamage  Reducesymptoms  Supportivecareuntilrenalfunctionreturns  Medications– seechart,p.827  Avoidnephrotoxicmedications(NSAIDs.,radiocontrastagents, aminoglycoside abx)  Dietaryrestrictions–seeTable26-5,p.831  Dialysisifindicated  Seevideo4NursingInterventionsforAcuteRenalFailurePart1andPart2 148148
  • 149. 149 Acute Renal Failure: Nursing Care  Provideemotionalsupportforchildandfamily  MonitorVS,I&O,dailyweights,serumelectrolytes  Administermedicationsasordered  Monitornutritionalintake–sodium,potassium,andphosphorusmayneed toberestricted  Meetfluid,electrolyte,andnutritionalneeds  Preventinfectionsandcomplications  Dischargeplanning&homecareteaching 149
  • 150. 150150
  • 151. 151 Review Question  Afour-year-oldchildhasbeendiagnosedwithrenalfailure.The nursewouldensurethatthedietforthischildwouldcontain: A. Foodshighinpotassiumandsodium. B. Adequatecaloriestooptimizegrowth. C. Foodshighincalciumcontenttopromotebonegrowth. D. Increasedfluidintaketoflushtheurinarysystem. 151151
  • 152. 152 Review Question  Ateenagerinacuterenalfailurehasanorderforfluidrestriction. Whatassessmentcriteriawouldindicatethatinsufficientfluids arebeingadministeredtothischild? A. Increasedweightwithdecreasedserumpotassiumlevels. B. Proteinuria. C. Hypernatremiawithweightloss. D. Decreasedpulse. 152152
  • 153. 153 Chronic Renal Failure  Progressive,irreversibledeteriorationofrenalfunction, usuallyoveraperiodofmonthsoryears  Fivestages:ESRDfinalstage  Etiology:congenitalanomalies, hereditary diseases,infections,glomerulonephritis  Signsandsymptoms  Lethargy,fatigue,anorexia,nausea,vomiting,hypertension,growthretardation,edema,volume overload,hyperkalemia,metabolicacidosis,anemia,bonedisease (renalosteodystrophy), cardiovasculardisease,centralnervoussystemabnormalities, delayedsexualmaturation  Seevideo4StagesofChronicRenalFailure&ESRD 153
  • 154. 154 Effects of Chronic Renal Failure  Growthdelays  Duetoanemia,metabolismdisturbances,decreasedcaloricintake, metabolicacidosis  Cognitivedelays  Duetodecreasedalertness,fatigue,poorschoolattendance  Socialdevelopmentimpairment  Duetoalterationofbodyimage,delayedonsetofpuberty,sideeffectsof medications 154154
  • 155. Chronic Real Failure: Collaborative Care  Dx:BUN/serumcreatinine(mostimportanttests);serumelectrolytes,bicarbonate;CBC; urinalysis(proteinuria,hematuria,pyuria,sp.gravity,hyalinecasts);estimationofGFR; US/radionuclidestudies;renalbiopsy  Treatmentdependsoncourseofthedisease  Medications -seechart,p.830  Diettherapy–limit potassium,phosphorus,sodium(seeTable26-5,p.831)  Proteinrestrictedonlytotherecommendeddailyallowanceforchildren  Preventionandtreatmentofcomplicationsofdecreasedkidneyfunction(e.g.,anemia,bonedisease, cardiovascularmanifestations,hypertension,growthfailure)  Avoidnephrotoxicmedications(NSAIDs.,radiocontrastagents,aminoglycosideabx)  Renalreplacementtherapy,ifsigns/symptomsofuremiaarepresent  Regularlifelongfollow-up 155
  • 156. 156156 156
  • 157. 157 Review Question Achild has been diagnosed with chronic renal failure.The nurse would question the medical order for: A. Aqueous penicillin. B. Gentamicin (Garamycin). C. Antihypertensives. D. Corticosteroids. 157157
  • 158. 158
  • 159. Review Question  A 10-year-old child has just been diagnosed with end- stage renal disease. The nurse gives the child instructions in which foods to avoid, including: A. Eggs B. Carrots C. Rice D. Spinach 159
  • 160. Review Question  Which of the following should be considered in the diet of the child with end-stage-renal-disease (ESRD)? A. Limit fluid B. Limit vitamin D-rich food C. Limit calcium-rich food D. Limit carbohydrates 160
  • 161. Chronic Renal Failure: Nursing Care  Provideemotionalsupport tochildandfamily  Assesshydrationstatuscarefully:I&O,dailyweights  Fluidrestrictions&dietaryrestrictionson potassium,phosphorus,&sodium  Maintainstrictsteriletechnique&watchforsignsofinfection  Monitorserumelectrolytelevels;H&H  Givemedications&monitorforsideeffects  Providesmall,frequentfeedings;presentmealsattractively;developmealplans thatfitarestricteddiet  Dischargeplanningandhomecareteaching 161
  • 162. Review Question  An adolescent with renal failure is receiving epoetin alfa (Epogen) to support erythropoiesis. The nurse questions the teenager about compliance with taking which of the following medications that supports red blood cell (RBC) production? A. Iron supplement B. Zinc supplement C. Calcium supplement D. Magnesium supplement 162
  • 163. 163 Renal Replacement Therapy: Peritoneal Dialysis  Peritonealdialysis-child’sownperitonealcavityactsasthesemi-permeable membraneacrosswhichwaterandsolutesdiffuse 163 •SeevideoPeritonealDialysis(NursingConsiderations,Risks,PatientTeaching)
  • 164. Peritoneal Dialysis  Softcatheterisusedtofilltheabdomen withadialysissolution  Solutioncontainsdextrose(1.5,2.5,or 4.25%)thatpullswasteandextrafluid intotheabdominalcavity  Osmoticpressureofglucoseinsolution drawsfluidfromvascularspacesinto theperitoneum,makingavailablefor exchange/eliminationofexcessfluid& wastes  Dialysisfluidisthendrained 164164164
  • 165. 165165 165
  • 166. Peritoneal Dialysis: Nursing Care  Assistparentsinlearningperitonealdialysis  Makesurestrictsteriletechniqueisusedatalltimesduringcatheterplacement andperitonealdialysis(handhygiene,gloves,masks)  Monitorthechild’sresponsetothetherapy  Assessforcomplications:bleedingfromthecathetersite,signsofinfectionatthe cathetersite,peritonitis,abdominalhernia  Maintainpatencyoftheperitonealdialysiscatheter:keepitinplace,withoutkinks orpulling,andwiththefluidbagsatthecorrectlevel  Noteifreturningdialysatesolutionhasunusualcolororiscloudy 166 See “Nursing Care Plan: Child Receiving Home Peritoneal Dialysis” – p. 835
  • 167. 167 Review Question  Anappropriatenursingdiagnosisforachildreceivingperitoneal dialysisis: A. Fluidvolumedeficitrelatedtosodiumandwaterretention. B. Imbalancednutrition,greaterthanbodyrequirementsrelated toincreasedhunger. C. Riskforinfectionrelatedtoinvasiveproceduresand diminishedimmunefunctioning. D. Alteredrenaltissueperfusionrelatedtohypervolemia. 167167
  • 168. 168 Renal Replacement Therapy: Hemodialysis  Inhemodialysis,amachinefilterswastes,saltsandextrafluidfromtheblood;the cleanbloodisthenreturnedtothebody  Requiresstricttreatmentschedule;adherencetomedications/dietrestrictions  Done3timesaweekfor3to4hoursatadialysiscenter  Attheonset,achildmayexperienceseveralsideeffects(disequilibrium syndrome)—hypotension,dizziness,weakness,nausea,ormusclecramps  SeevideosHemodialysis(Labs,H&H,Cautions)  WhatDoesaKidneyDialysisAccessLookLike?  HemodialysisandHowItWorks 168
  • 169. 169 Hemodialysis: Types of Access 169169
  • 170. Hemodialysis uses a special filter called a dialyzer to remove wastes and extra fluid from the blood 170
  • 171. Hemodialysis: Nursing Care  Weigh child before/ after hemodialysis  Check patency of AV fistula/ graft site by palpating thrill, auscultating bruit  No BP or blood draws on arm with access site  During hemodialysis:  Use strict aseptic technique, standard precautions  Monitor VS, fluid balance, clotting times, blood flow, patency of access site  After dialysis: monitor VS, access site for bleeding, S/S of disequilibrium syndrome  Educate parents:  Daily care of access site  S/S complications (infection, bleeding)  Promote lifelong coping skills 171
  • 172. Review Question  A client has an arteriovenous (AV) fistula in place in the right upper extremity for hemodialysis treatments. When planning care for this client, which of the following measures should the nurse implement to promote client safely? A. Take blood pressures only on the right arm to ensure accuracy B. Use the fistula for all venipunctures and intravenous infusions C. Ensure that small clamps are attached to the AV fistula dressing D. Assess the fistula for the presence of a bruit and thrill 172
  • 173. Renal Replacement Therapy: Kidney Transplantation  Healthy donor kidney surgically placed in lower abdomen  Preferred method of renal replacement therapy in the pediatric population  Blood type compatibility, HLA match; living relative donor preferred  Lifelong immunosuppressive therapy  Complications: opportunistic infection, lymphomas and skin cancer, and hypertension 173 • Rejection – major cause of transplanted kidney loss o S/S rejection: Fever; ↑ BUN & creatinine; pain & tenderness; irritability; weight gain
  • 174. 174174 174
  • 175. Review Question  The home care nurse is making follow-up visits to a pediatric patient following renal transplant. The nurse assesses the child for which signs of acute graft rejection? A. Hypotension, graft tenderness, and anemia B. Hypertension, oliguria, thirst, and hypothermia C. Fever, hypertension, graft tenderness, and malaise D. Fever, vomiting, hypotension, and copious amounts of dilute urine 175
  • 176. Kidney Transplantation: Nursing Care  Teach child/ parents about transplantation process  Provide emotional support & guidance to the child/ parents  Prepare the child/ parents for the possibility of continuing to need hemodialysis temporarily after the transplant because the transplanted kidney might not work effectively right away  Administer immunosuppressive medications as ordered  Monitor for S/S infection; keep child away from anyone with an infection  Teach child/ parents about follow-up appointments, medications, health promotion, when to call the physician  Teach child/ parents about signs of rejection and infection 176
  • 177. 177 Phimosis Cryptorchidism Testicular Torsion Structural Defects of the Reproductive System 177177
  • 178. 178 Phimosis  Tightening(constriction)offoreskinoverheadofpenis  Preventsforeskinfrombeingretractedoverpenis  Normalinnewborns;usuallyresolvesby3yrs  Insomechildren,obstructsflowofurine  Canbecorrectedbycircumcision  Balantis–Inflammation/infectionofglanspenis  Paraphimosis–Tightforeskinpulledbackofftheheadof peniscannotbereturnedtonormalposition(becomes stuck)  Medicalemergency;requiresimmediateintervention  Tx:surgicalremovalofforeskin;circumcision 178 Phimosis Balantis Paraphimosis
  • 179. 179 Review Question  Thepediatricnurseisteachingparentsofnewbornmalesaboutphimosis. Aparentasks,"Whatisphimosis?"Thebestanswerbythenursewould bewhichofthefollowing? A. Urinaryopeningoropeningsonthesideofthepenis B. Congenitalmalformationoftheshapeofthepenis C. Swellingofthepeniscausedbyacuteinflammationandinfection D. Constrictionoftheforeskinsoitcannotbepushedbackovertheglans penis 179
  • 180. 180 Cryptorchidism  Failure of one or both testes to descend through inguinal canal; hidden testis  3-6% term; 20-30% preterm infants  Testosterone deficiency, defective testis, structural problem, early gestational age  Complications: infertility, testicular CA  Usually detected newborn exam  Goals of treatment:  Preserve testicular function  Normal scrotal appearance 180 Bilateral Cryptorchidism
  • 181. 181 Review Question  Whyisitimportantthatthetestesareinthescrotalsac? 181
  • 182. Cryptorchidism: Collaborative Care  Mosttestesspontaneouslydescend  Hormonetherapy–humanchorionic gondadotropin (hCG)  Surgicalprocedure(orchiopexy)iftestes donotdescendintoscrotalsacby6-12 months  Riskoftesticularcancerifuntreated  Monthlytesticularself-examinationis recommendedforallmalesbeginningin puberty,butisessentialinmaleswith historyofundescendedtestis 182 Orchiopexy
  • 183. 183 Review Question  Thenewbornhasbeendiagnosedwithcryptorchidism.The physicianhasorderedhumanchorionicgonadotropin(hCG)to beadministeredtothebaby.Themotherasksthenursewhy thebabyisreceivingthisdrug.Thenurse’sbestexplanation wouldbethedrugwill: A. Maintainanadequatetemperaturearoundthetestes. B. Preventinfectionsintheundescendedtestes. C. Preventthedevelopmentofcancer. D. Promotedescentofthetestes. 183183
  • 184. Cryptorchidism: Nursing Care  Surgical repair: orchiopexy is done between 6-12 months of age  Postoperatively, keep the surgical area dry for 1-2 days  Encourage bed rest  Monitor voiding  Apply ice to surgical area  Administer prescribed analgesics (acetaminophen or ibuprofen) 184
  • 185. Cryptorchidism: Discharge Instructions  Incision care:  Diaper area should be cleaned well with each diaper change  Sponge baths only for 2 days after surgery  No medicine/ ointment placed over incision  Prevent pulling on the thigh suture postoperatively because the testis could reascend into the abdomen through the inguinal canal if the suture disconnects  Child should avoid straddling activities or strenuous activity for 2-3 weeks  Have the child wear loose clothing  Use analgesics as needed (acetaminophen or ibuprofen)  Observe for redness, warmth, swelling, purulent discharge, fever, increased pain at the incision site (indicative of infection) 185
  • 186. 186 Review Question  Ababyisborn6weeksprematurely.Onadmissiontothe nursery,thenurseisunabletolocateanytesticlesinthe scrotum.Thenurseshould: A. Immediatelynotifythephysicianasthechildisatriskforrenalfailure. B. Notethefindingsinthechild’srecordandtakenofurtheractionatthis time. C. Discusswiththefathertheneedforsurgicalcorrectionofcryptorchidism. D. Catheterizethechildtodetermineifurineispresentinthebladder. 186186
  • 187. 187 Review Question  Whentalkingwiththeparentsofachildoradolescentwhohasahistoryof cryptorchidism,thenursewillmoststresstheimportanceofthechilddoing whichofthefollowingthings? A. Gettingamumpsvaccineboosterevery5years B. Complying100%withhormonetherapybeginningatage15 C. Wearingatesticularsupport(jockstrap)whileparticipatinginsports D. Doingmonthlyself-testicularexaminationsbeginningatage13 187
  • 188. 188 Testicular Torsion  Painfulconditionthatoccurswhenthespermaticcordattachedtotheaffected testiisbecomestwisted,cuttingoffthebloodsupplytothetestis  Lefttesticleaffectedmore,sincethereisalongercordontheleftside  Surgicalemergency!  Excruciatingone-sidedtesticularpain,withsuddenswelling  Mostcommon:malesbetweenagesof12-18  Etiology:Bellclapperdeformity(congenitalanomaly) 188
  • 189. 189 Testicular Torsion: Clinical Manifestations  Suddenseverepainanderythemainthescrotalarea,nauseaandvomiting, abdominalpain,andscrotalswellingthatisnotrelievedbyrestorscrotalsupport  Painfulscrotum(especiallyonpalpation)withone-sidedtesticularswellingand elevation  Neonate—scrotumappearsduskycolored,asolidmassispalpated,scrotal edema,andminimalpain  Oldermales—severeandpersistentpain  Cremastericreflexabsent  Highestincidenceonleftsideduetolongercordonthatside 189189
  • 190. 190 Testicular Torsion: Collaborative Care  Dx:Physicalexam;imagingviaDopplerultrasound;nuclearscanoftesticlestoassess thedegreeofbloodflow  Painmedication:morphineorhydromorphone  Surgicalintervention(orchiopexy)within6hrs  Topreservethetesticularfunction  Securetesticletoavoidfurthertwisting  Usuallyperformedbilaterally  Ifthetesticlecannotbesalvaged,thetesticleisremoved(aprocedureknownas orchiectomy). 190190
  • 191. 191 Testicular Torsion: Nursing Care  Providesupport&reassuranceforchild/family  Teachchild/family:  Careofincision  Painmanagement  Donotparticipateinstrenuousactivityfor2wks  Donotlifeheavyobjectsfor4wks  Teachadolescentmonthlytesticularself-examination 191191
  • 192. 192 Review Question  Thenurseadmittingandassessinga12-year-oldwithsuspectednew- onsettesticulartorsionwillmostlikelyfindwhichofthefollowing manifestationsinadditiontopossiblenauseaandvomitingandacute testicularpain? A. Atestesthatisdarkredtoblackincolor B. Atesticleswollenmanytimesitsnormalsize C. Palpablesausage-shapedmassinlowerabdomen D. Cremastericreflexdepressedorabsent 192

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