Genitourinary lecture nurs 3341 slideshare

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Genitourinary lecture nurs 3341 slideshare

  1. 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. 2 Learning Outcomes 1. Describeanatomy&physiologyof thegenitourinarysystemandpediatric differences 2. Discussnursingmanagementofchildwithgenitourinarystructuraldefect 3. Developnursingcareplanforchildwithurinarytractinfection 4. Outlineaplantomeetfluidanddietaryrestrictionsofchildwithrenaldisorder 5. Summarizepsychosocialissuesforchildrequiringgenitourinarysurgery 6. Plannursingcareforchildwithacute&chronicrenalfailure 7. Identifygrowth&developmentissuesforchildwithchronicrenalfailure 22
  3. 3. 33 3 Comprised of: Kidneys Ureters Bladder Urethra Review: Anatomy Urinary System
  4. 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. 5 Review: Anatomy of the Kidney  Outercortex  Composedoftheglomeruliandconvoluted tubulesofthenephronandbloodvessels  Innermedulla  Composedoftherenalpyramid 5
  6. 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. 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. 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. 9. 99 9
  10. 10. 10 Children are not just small adults…. 1010
  11. 11. 1111 11 Development of the Genitourinary System
  12. 12. 12 Pediatric Differences – Urinary System 12
  13. 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. 14 Pediatric Differences: Urinary System  Allnephronspresentatbirth  Renalgrowth  Mostduringfirst5yrs  Fullsizebyadolescence  Renalefficiencyincreasesaschildmatures  Kidneyfunctionisimmatureuntilafter2yearsofage  Glomerularfiltration&absorptionimmature  Infantsmorepronetofluidvolumeexcess&dehydration  Lessefficientregulatingelectrolyte&acid-basebalance 1414
  15. 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. 16 Bladder  Bladdercapacityincreaseswithage  15to50mLatbirth  700mLinadolescence  Estimatebladdercapacity (inounces)–add2tochild’sage 1616
  17. 17. 17 Pediatric Differences – Reproductive System 17
  18. 18. 18 Pediatric Differences: Reproductive System  Infemaleinfants,theexternalgenitaliamaybeprominentduetomaternal estrogen  Labiaminoramayprotrudebeyondlabiamajora  Testiclesmayappearlargeatbirthinproportiontosizeofinfant  Mayfailtomoveintothescrotum,causingundescendedtestes  Theforeskinmaybetightatbirth,causingphimosis  Thesexorgansdonotmatureuntilonsetofpuberty  Secondarysexcharacteristicsoccurwithonsetofpuberty 18
  19. 19. 19 History & Physical 19
  20. 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. 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. 22 Urinary Symptoms  Enuresis(bedwetting)  Newonsetincontinence  Frequency,urgency,quantity  Dysuriaanditstimingduringvoiding(atbeginningorend,throughout)  Changeincolorandodorofurine  Hematuria  Presenceofstonesorsedimentintheurine  Toilettrainingproblems 22
  23. 23. 23 Toilet Training Readiness  Children<2yrsgenerallycannotmaintainbladdercontrol  12months:nocontroloverbladder  18to24months:somechildrenshowsignsofreadiness  Somechildrenmaynotbereadyuntilaround30months  Thepotty-trainingyearsareespeciallyriskyfordevelopingUTI  Remindchildtovoidoftenevenifhe/sheisnothavingaccidents  Remindfemalechildrentowipefromfronttoback  Achildwhoisuncircumcisedshouldbetaughtatpottytraininghowto graduallyandgentlyretracttheprepuceforvoidingandhygiene 2323
  24. 24. 2424
  25. 25. 25 Review Question  Amotherisinquiringaboutherchild'sabilitytopotty train.Whichofthefollowingfactors isthemost importantaspectoftoilettraining? A. Theageofthechild B. Thechild’sabilitytounderstandinstructions. C. Theoverallmentalandphysicalabilitiesofthechild. D. Frequentattemptswithpositivereinforcement. 25
  26. 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. 27 Single Umbilical Artery Associated with increased incidence of urogenital abnormalities 27
  28. 28. 28 Low-Set Ears & Urinary Tract Anomalies 28 Suspect urinary tract/ kidney anomalies
  29. 29. 29 Skin Tags/ Preauricular Sinus 29
  30. 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. 31. 3131 31
  32. 32. 32 Nursing Diagnoses  UrinaryIncontinence  ImpairedUrinaryElimination  UrinaryRetention  ExcessFluidVolume  RiskforDeficientFluidVolume  RiskforImbalancedFluidVolume  RiskforElectrolyteImbalance  ToiletingSelf-CareDeficit 3232
  33. 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. 34 Diagnostic Tests 3434
  35. 35. 35 Laboratory Tests  Urinalysis  Urineculture  Bloodureanitrogen(BUN)  Serumcreatinine  Creatinineclearancetest/glomerularfiltrationrate(GFR)  Urinealbumin(proteinuria)  Urineproteintocreatinineratio  Basicmetabolicpanel/CBC  Serumalbumin 35
  36. 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. 37 Urine Specific Gravity  Reliableassessmentofpatient’shydrationstatus  1.001–1.035 Normalvalue  IncreasedUrineSG Dehydration–diarrhea–excessivesweating-vomiting  DecreasedUrineSG Excessivefluidintake–pyelonephritis-glomerulonephritis 3737
  38. 38. 38 Urine Collection 38 Application of urine collection bag 38 See Videos: Urine Samples Collection Pediatric Urine Specimen Collection of Infant
  39. 39. 39 Review Question  Whichofthefollowinginterventionswillhelpobtain accurateurinalysisdata? A. Forcefluidsto1000mLpriortospecimencollection. B. Cleansethespecimencontainerwithpovidone-iodine(Betadine) priortocollectingthespecimen. C. Allowtheurinetocooltoroomtemperaturebeforetakingittothe lab. D. Provideclient/parenteducationforspecimencollectionbeforethe specimenisobtained. 3939
  40. 40. 40 Diagnostic Tests (p. 807)  ComputedTomography(CT)  Cystoscopy  FunctionalRadionucleotideRenalScan  IVP–IntravenousPyelogram  RenalBiopsy  RenalorBladderUltrasound  VCUG–VoidingCystourethrogram 4040
  41. 41. 41 Computerized Tomography (CT Scan) 4141 Abdomen CT Scan
  42. 42. 42 Cystoscopy 42 Invasive surgical procedure Visualizes bladder, urethra, and ureter placement 42
  43. 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. 44 Intravenous Pyelogram (IVP) 4444
  45. 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. 46 Review Question  Achildreturningtotheunitafteranintravenouspyelogram(IVP)hasan ordertodrinkextrafluids.Whenthemotherasksthepurposeofthese fluids,thenurserespondsthatincreasedfluidintakewill: A. Overhydratethechild. B. Increaseserumcreatininelevels. C. Make-upforfluidlossesfromNPOstatusbeforetests. D. Flushanyremainingdyefromtheurinarytract. 4646
  47. 47. 47 Renal Biopsy 4747
  48. 48. 48 Renal Bladder Ultrasound (RBUS) 4848
  49. 49. 49 Voiding Cystourethrogram (VCUG) 4949
  50. 50. 50 Treatment Modalities  Urinarydiversion  Stents  Drainagetubes  Intermittentcatheterization  Watchforlatexallergies  Pharmacologicalmanagement  Antibiotics  Anticholinergicforbladderspasm(oxybutynin[DitropanXL]) 5050
  51. 51. 51 Urinary Tract Infection 5151
  52. 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. 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. 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. 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. 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. 57 Uncircumcised Males  Instructparentstogentlyretractforeskinforcleansing  Donotforcetheforeskin  Donotleaveforeskinretractedoritmayactastourniquetandobstructthe headofthepenisresultinginemergencycircumcision 5757
  58. 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. 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. 60 Review Question UTI: What are the differences between older child/ adult S & S and infant-child S & S 60
  61. 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. 62 UTI: Nursing Education  Antibiotics–takefullcourse  Changediaperfrequently  Teachgirlstowipefronttoback  Encouragechildrentodrinkperiodicallyduringtheday  Nobubblebaths  Encouragefrequentvoiding  Discourage“holding”urine  Usecottonunderwear  Menstruatinggirl– changepadevery4hours  Whengirlsbecomesexuallyactive– urinateimmediatelyafterintercourse 6262
  63. 63. 63
  64. 64. 64 Review Question  Themostimportantnursingactivityinmanagingayoungchild diagnosedwithurinarytractinfection(UTI)isto: A. Provideadequatenutritiontopreventdehydration. B. Preventenuresis. C. Administerorderedantibioticsonschedule. D. Restrictfluidstoprovidekidneyrest. 6464
  65. 65. 65 Review Question  Theparentsofachilddiagnosedwithupperurinarytract infection(UTI)askthenursewhythechildneedsadailyweight. Informulatingaresponse,thenurseincludesthatitisimportant becauseadailyweightwill: A. Determineifthechild’scaloricintakeisadequate. B. Indicatetheneedfordietaryrestrictionsofsodiumandpotassium. C. Keeptrackofpossiblelossorgainoffluidretainedinbodytissues. D. Tracktheamountoffluidingestedorallyeachday. 6565
  66. 66. 66 BladderExstrophy Hypospadias&Epispadias Obstructive Uropathy Vesicoureteral Reflux Structural Defects of the Urinary System (usually hereditary) 6666
  67. 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. 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. 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. 70 Before and After Surgical Repair 70 Details: http://www.pediatricurologybook.com/bladder_exstrophy.html
  71. 71. 71 Goals of Treatment  Closebladder/abdominalwall  Preserverenalfunction  Attainurinarycontrol  Acceptableappearance/ functionofgenitals  Sexualfunction  Typical&normalchildhood 7171
  72. 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. 73 Review Question  Whichofthefollowingpositionswouldbestfacilitate healingfortheinfantafter bladderexstrophyrepair? A. Supine,legssuspendedverticallywithlegsclosetogether B. Leftside-lyingposition C. Rightside-lyingposition D. Low-Fowler’s,legsbentatkneeswithwedgebetweenlegs 73
  74. 74. 74 Long Term Complications  Urinaryincontinence  Infection  Bodyimage  Inadequatesexualfunction 7474
  75. 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. 76. 7676 76 Hypospadias  Ventral surface  Below glans penis Epispadias  Dorsal surface  Above glans penis Hypospadias & Epispadias
  77. 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. 78 Review Question  Shortlyafterbirth,thenewbornwasfoundtohaveepispadias.Priorto delivery,themotherhadsignedpermissionforacircumcision.The obstetricianisplanningtoperformthecircumcisionimmediatelyafter delivery.Thenurseexplainstothemotherthatthecircumcisionwillnotbe doneatthistimebecause: A. Themothershouldnothavesignedconsentbeforedelivery. B. Thefatheralsoneedstosignpermissionforsurgery. C. Theprepucewillbeusedforthesurgicalcorrection. D. Theriskofinfectionisgreaterwithachildwithepispadias. 7878
  79. 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. 80 Review Question  Aninfanthasbeenadmittedfortreatmentofhypospadias.Nursing managementofthechildandfamilyincludes: A. Parenteducationregardingsteroidtherapy. B. Addressingparentalanxietyrelatedtofunctioningandappearanceof thepenis. C. Homehealthteachingofproperstraightcatheterizationtechniques. D. Monitoringforsignsandsymptomsofnephroticsyndrome. 8080
  81. 81. 81 Double-Diapering Technique After Surgery for Hypospadias/Epispadias Repair 81
  82. 82. 82 Review Question  Themotherofaninfantwhounderwentsurgerytorepair hypospadiasasksthenursewhytheinfantisdouble-diapered. Thenursewouldrespondthatthismethodofdiapering: A. Protectstheurinarystentthathasbeenputinplace. B. Adequatelymeasurestheurinaryoutput. C. Providesformaximumabsorptionofurine. D. Providesoptimalprotectionofperinealskinfrominfectedurine. 8282
  83. 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. 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. 85 Prune-Belly Syndrome (Rare): Another Congenital Cause of Hydronephrosis 85
  86. 86. 86 Review Question  Aparentasksthenursewhatwilleventuallyhappeniftheinfantdoesnot havehiscongenitalhydronephrosistreated.Themostaccurateanswerby thenursewillbewhichofthefollowing? A. “Ifthehydronephrosisisnottreated,thechildcandevelopbladdercancer.” B. “Theinfantcanbecomedangerouslyhypotensivebecauseoftheobstructiontourine flow.” C. “Smallcalciumstonescanoccurasaresultofuntreatedhydronephrosis,causing furtherobstruction.” D. “Untreatedhydronephrosiscanleadtoirreversiblekidneydamageandeventual kidneyfailure.” 86
  87. 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. 88 Review Question  Anurseisreviewingapatient’schartandnoticesthatthechildsuffersfrom hydronephrosis.Whichofthefollowingwouldthenurseexpecttoseewith thispatient?  A.Swollenkidneyduetourinenotdrainingfromkidney  B.Dehydrationfromspittingupandseveralloosestools  C.Profuseurinationandurinaryfrequency  D.Spinalcorddefectcausinginabilitytoemptybladder 88
  89. 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. 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. 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. 92 Ureteral Reflux 9292
  93. 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. 94 Enuresis Disorders of Continence 9494
  95. 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. 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. 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. 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. 99. 9999 99 99
  100. 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. 101. 101101101
  102. 102. 102102 102 102
  103. 103. 103 NephroticSyndrome AcutePoststreptococcal Glomerulonephritis RenalFailure RenalReplacement Therapy Renal Disorders: Acute, Chronic, & Structural Causes 103103
  104. 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. 105
  106. 106. Review Question 106 Nephrotic syndrome is caused by damage to which part of the nephron????? MinimalChangeNephroticSyndrome/ Effacement of foot processes
  107. 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. 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. 109. Nephrotic Syndrome: Anasarca 109 Describe the fluid shifts in Anasarca…. What sorts of health complications do you anticipate?
  110. 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. 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. 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. 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. 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. 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. 116. Corticosteroids: Side Effects 116  Immunodeficiency  Hirsutism  Moonfacewithruddycheeks  Acne  Dorsocervicalfatpads  Ecchymosis(easybruising)  Truncalobesity  Moodswings–inabilitytosleep 116116
  117. 117. 117 Moon Face 117 High-dose corticosteroid therapy produces a characteristic “moon face” appearance 117
  118. 118. 118 Before and After 118118
  119. 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. 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. 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. 122. Group A Streptococcal Infection Manifestations 122
  123. 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. 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. 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. 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. 127. 127127 127
  128. 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. 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. 130 Review Question  Whenreviewingaurinalysisreportofaclientwithacute glomerulonephritis,thenursewouldexpecttonote: A. Decreasedcreatinineclearance. B. Decreasedspecificgravity. C. Hematuria. D. Decreasederythrocyte sedimentationrate(ESR). 130130
  131. 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. 132
  133. 133. 133 Review Question  Thenurseadmitschildrenwiththefollowingdiseasesto theunit.Whichdiseaseplacesthechildatriskforthe developmentofacuterenalfailure(ARF)? A. Leukemia. B. Cryptorchidism. C. Nephroticsyndrome. D. Phenylketonuria. 133133
  134. 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. 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. 136. Newborn Causes Childhood Causes  Congenitalanomalies  Hypotension  Complicationofopenheart surgery  Dehydration  Glomerulornephritis/ NephroticSyndrome  Nephro-toxicity/drug toxicity Acute Renal Failure 136
  137. 137. 137 Review Question  Achildisadmittedtothenursingunitwithacuterenalfailure (ARF).Whenreviewingthenursinghistory,thenursenotesa historyofallofthefollowingmedicalconditions.Whichismost likelytohaveprecipitatedtheonsetofARF? A. Chickenpox. B. Influenza. C. Dehydration. D. Hypervolemia. 137137
  138. 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. 139 Diagnostic Tests  BasicMetabolicPanel(BMP)  BUNandCreatinineelevated  SerumPotassiumelevated  DecreasedCO2  CBC  DecreasedRBCs,H&Hduetodeficienterythropoietin  ABG  DecreasedpH  DecreasedBicarbonate(HCO3−)  GFR(glomerularfiltrationrate)decreased–mostsensitiveindicatorof glomerularfunction 139139
  140. 140. 140140 140
  141. 141. The Most Deadly Electrolyte Imbalance… 141
  142. 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. 143
  144. 144. 144 Review Question  Thepriorityconcernforthenurseinassessingachild withacuterenalfailure(ARF) shouldbetolookfor whichelectrolyteimbalance? A. Potassium. B. Sodium. C. Calcium. D. Phosphorous. 144144
  145. 145. 145 Urea or BUN  Ureaisnormallyfreelyfilteredthroughtherenalglomeruli, withasmallamountreabsorbedinthetubulesandthe remainderexcretedintheurine  Decreaseorincreaseinthevaluedoesnottellthecause:pre- renal,post-renalorrenal  ElevatedBUNjusttellsyoutheureaisnotbeingexcretedby thekidney,notwhy 145145
  146. 146. 146 Creatinine  Creatinineisaveryspecificindicatorofrenalfunction  Ifkidneyfunctionisdecreased/creatininelevelwillbe increased  Conditionsthatincreaselevels:glomerulonephritis, pyelonephritisorurinaryblockage 146146
  147. 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. 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. 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. 150. 150150
  151. 151. 151 Review Question  Afour-year-oldchildhasbeendiagnosedwithrenalfailure.The nursewouldensurethatthedietforthischildwouldcontain: A. Foodshighinpotassiumandsodium. B. Adequatecaloriestooptimizegrowth. C. Foodshighincalciumcontenttopromotebonegrowth. D. Increasedfluidintaketoflushtheurinarysystem. 151151
  152. 152. 152 Review Question  Ateenagerinacuterenalfailurehasanorderforfluidrestriction. Whatassessmentcriteriawouldindicatethatinsufficientfluids arebeingadministeredtothischild? A. Increasedweightwithdecreasedserumpotassiumlevels. B. Proteinuria. C. Hypernatremiawithweightloss. D. Decreasedpulse. 152152
  153. 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. 154 Effects of Chronic Renal Failure  Growthdelays  Duetoanemia,metabolismdisturbances,decreasedcaloricintake, metabolicacidosis  Cognitivedelays  Duetodecreasedalertness,fatigue,poorschoolattendance  Socialdevelopmentimpairment  Duetoalterationofbodyimage,delayedonsetofpuberty,sideeffectsof medications 154154
  155. 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. 156. 156156 156
  157. 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. 158
  159. 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. 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. 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. 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. 163 Renal Replacement Therapy: Peritoneal Dialysis  Peritonealdialysis-child’sownperitonealcavityactsasthesemi-permeable membraneacrosswhichwaterandsolutesdiffuse 163 •SeevideoPeritonealDialysis(NursingConsiderations,Risks,PatientTeaching)
  164. 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. 165. 165165 165
  166. 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. 167 Review Question  Anappropriatenursingdiagnosisforachildreceivingperitoneal dialysisis: A. Fluidvolumedeficitrelatedtosodiumandwaterretention. B. Imbalancednutrition,greaterthanbodyrequirementsrelated toincreasedhunger. C. Riskforinfectionrelatedtoinvasiveproceduresand diminishedimmunefunctioning. D. Alteredrenaltissueperfusionrelatedtohypervolemia. 167167
  168. 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. 169 Hemodialysis: Types of Access 169169
  170. 170. Hemodialysis uses a special filter called a dialyzer to remove wastes and extra fluid from the blood 170
  171. 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. 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. 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. 174. 174174 174
  175. 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. 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. 177 Phimosis Cryptorchidism Testicular Torsion Structural Defects of the Reproductive System 177177
  178. 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. 179 Review Question  Thepediatricnurseisteachingparentsofnewbornmalesaboutphimosis. Aparentasks,"Whatisphimosis?"Thebestanswerbythenursewould bewhichofthefollowing? A. Urinaryopeningoropeningsonthesideofthepenis B. Congenitalmalformationoftheshapeofthepenis C. Swellingofthepeniscausedbyacuteinflammationandinfection D. Constrictionoftheforeskinsoitcannotbepushedbackovertheglans penis 179
  180. 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. 181 Review Question  Whyisitimportantthatthetestesareinthescrotalsac? 181
  182. 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. 183 Review Question  Thenewbornhasbeendiagnosedwithcryptorchidism.The physicianhasorderedhumanchorionicgonadotropin(hCG)to beadministeredtothebaby.Themotherasksthenursewhy thebabyisreceivingthisdrug.Thenurse’sbestexplanation wouldbethedrugwill: A. Maintainanadequatetemperaturearoundthetestes. B. Preventinfectionsintheundescendedtestes. C. Preventthedevelopmentofcancer. D. Promotedescentofthetestes. 183183
  184. 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. 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. 186 Review Question  Ababyisborn6weeksprematurely.Onadmissiontothe nursery,thenurseisunabletolocateanytesticlesinthe scrotum.Thenurseshould: A. Immediatelynotifythephysicianasthechildisatriskforrenalfailure. B. Notethefindingsinthechild’srecordandtakenofurtheractionatthis time. C. Discusswiththefathertheneedforsurgicalcorrectionofcryptorchidism. D. Catheterizethechildtodetermineifurineispresentinthebladder. 186186
  187. 187. 187 Review Question  Whentalkingwiththeparentsofachildoradolescentwhohasahistoryof cryptorchidism,thenursewillmoststresstheimportanceofthechilddoing whichofthefollowingthings? A. Gettingamumpsvaccineboosterevery5years B. Complying100%withhormonetherapybeginningatage15 C. Wearingatesticularsupport(jockstrap)whileparticipatinginsports D. Doingmonthlyself-testicularexaminationsbeginningatage13 187
  188. 188. 188 Testicular Torsion  Painfulconditionthatoccurswhenthespermaticcordattachedtotheaffected testiisbecomestwisted,cuttingoffthebloodsupplytothetestis  Lefttesticleaffectedmore,sincethereisalongercordontheleftside  Surgicalemergency!  Excruciatingone-sidedtesticularpain,withsuddenswelling  Mostcommon:malesbetweenagesof12-18  Etiology:Bellclapperdeformity(congenitalanomaly) 188
  189. 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. 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. 191 Testicular Torsion: Nursing Care  Providesupport&reassuranceforchild/family  Teachchild/family:  Careofincision  Painmanagement  Donotparticipateinstrenuousactivityfor2wks  Donotlifeheavyobjectsfor4wks  Teachadolescentmonthlytesticularself-examination 191191
  192. 192. 192 Review Question  Thenurseadmittingandassessinga12-year-oldwithsuspectednew- onsettesticulartorsionwillmostlikelyfindwhichofthefollowing manifestationsinadditiontopossiblenauseaandvomitingandacute testicularpain? A. Atestesthatisdarkredtoblackincolor B. Atesticleswollenmanytimesitsnormalsize C. Palpablesausage-shapedmassinlowerabdomen D. Cremastericreflexdepressedorabsent 192

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