• Share
  • Email
  • Embed
  • Like
  • Save
  • Private Content
Pediatric Renal Disorders
 

Pediatric Renal Disorders

on

  • 5,307 views

 

Statistics

Views

Total Views
5,307
Views on SlideShare
5,279
Embed Views
28

Actions

Likes
1
Downloads
255
Comments
0

3 Embeds 28

http://study.myllps.com 14
https://imperial.blackboard.com 13
http://www.slideshare.net 1

Accessibility

Categories

Upload Details

Uploaded via as Microsoft PowerPoint

Usage Rights

© All Rights Reserved

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Processing…
Post Comment
Edit your comment
  • NB will produce 1-2 ml/kg/hr; after 1 mo. Approx 1 ml/kg/hr
  • Second most common bacterial disease Account for more than 8 million office visits per year Results in >100, 000 people hospitalized annually >15% patients who develop gram-negative bacteria DIE 1/3 of gram-negative infections originate in urinary tract
  • Bladder and its contents are free of bacteria in majority of healthy patients Minority of healthy individuals have colonizing bacteria in bladder Called asymptomatic bacteria and does not justify treatment
  • Gram-negative bacilli from GI tract common cause Fungal generally after multiple antibiotic courses; Also more common w/ immunosuppressed or diabetics
  • Cystitis—Contained in bladder Urethritis—Irritation>>infection; potential for ascending Pyelonephritis—Inflam of upper urinary tract and may involve kidneys Role of vesicoureteral reflux VUR—w/ ea void, urine goes up into ureter and is opportunity for microbial proliferation Glomerulonephritis—Immunologic disorder in the kidney proper; did not begin in the bladder and ascend; Generally follows other bacterial illness, esp strep
  • Uncomplicated infection: occurs in otherwise normal urinary tract Complicated Infections: Stones Obstruction Catheters Diabetes or neurologic disease Recurrent infection
  • Recurrent is reinfection in person whose prior infection was successfully eradicated Recurrent occurs because original infection not adequately eradicated Unresolved bacteriuria: bacteria resistant or drug discontinued before bacteriuria is completely eradicated Bacterial persistence: resistance developed or foreign body in urinary system serves as harbor and anchor for bacteria to survive despite therapy
  • Explain what this means
  • This can also occur in adults as well This is why when a child is admitted with FUO urine culture is done as part of the septic workup.
  • Dipstick : to identify presence of nitrates, WBCs, and leukocyte esterase Confirm w/ micro ua Urine culture indicated in complicated or nosocomial, persistent bacteria, or frequently recurring (>2 episodes annually) May be cultured if infection is unresponsive to empiric therapy or diagnosis is questionable
  • Clean-catch is preferred Specimen obtained by catheterization or suprapubic needle aspiration has more accurate results May be necessary when clean-catch cannot be obtained
  • Antibiotic selected on empiric therapy or results of sensitivity testing
  • Sulfa : used to treat empiric uncomplicated or initial Inexpensive TMP-SMX taken bid Pyridium is OTC that provides soothing effect on urinary tract mucosa Stains urine reddish orange that can be mistaken for blood and may stain underclothing Effective in relieving discomfort
  • Suppressive therapy often effective on short-term basis Limited because of antibiotic resistance ultimately leading to breakthrough infections
  • Obstruction from BPH or from stone Stricture (narrowing)
  • Vary from mild fatigue to sudden onset of chills, fever, vomiting, malaise, flank pain, and lower urinary tract symptoms characteristic of cystitis Costovertebral tenderness usually present on affected side, kidney usually palpated as enlarged Acute Pyelonephritis Nausea, vomiting, anorexia, chills, nocturia, frequency, urgency Suprapubic or lower back pain, bladder spasms, dysuria, burning on urination Fever, Hematuria, foul-smelling urine, tender, enlarged kidney Leukocytosis, positive findings for bacteria, WBCs, RBCs, pyuria,
  • Urinalysis shows pyuria, bacteriuria, and varying degrees of hematuria WBC casts indicate involvement of renal parenchyma CBC will show leukocytosis with increase in immature bands If bacteremia is a possibility, close observation and vitals monitoring are essential Prompt recognition and treatment of septic shock may prevent irreversible damage or death
  • Hospitalization for patients with severe infections and complications such as nausea and vomiting with dehydration Parenteral antibiotics to establish high serum levels
  • Diagnostics: UA, CBC, BUN, Serum creatinine, and albumin Complement levels and ASO Titer Renal Bx prn
  • Most kids will normally restrict activity due to malaise
  • MCNS is most common of these Pathogenesis not known
  • Prognosis is usually good for ultimate recovery in most cases (80%) Self limiting If child responds to steroids, usually will do ok Early detection and treatment to decrease proteinuria, and permanent renal damage About 20% will have relapses for up to 5 yrs, some up to 10 yrs.

Pediatric Renal Disorders Pediatric Renal Disorders Presentation Transcript

  • The Child with Genitourinary Dysfunction Chapter 27
  • Renal System Assessment
    • Physical assessment
      • Palpation, percussion
    • Health history
      • Previous UTIs, calculi, stasis, retention, pregnancy, STDs, bladder cancer
      • Meds: antibiotics, anticholinergics, antispasmodics
      • Urologic instrumentation
      • Urinary hygiene
      • Patterns of elimination
  • Nursing Assessment of Urinary Tract Infection (UTI)
    • Nausea, vomiting, anorexia, chills, nocturia, frequency, urgency
    • Suprapubic or lower back pain, bladder spasms, dysuria, burning on urination
  • Nursing Assessment of UTI (cont’d)
    • Objective data
      • Fever
      • Hematuria, foul-smelling urine, tender, enlarged kidney
      • Leukocytosis, positive findings for bacteria, WBCs, RBCs, pyuria, ultrasound, CT scan, IVP
  • Diagnostic Studies
    • Renal scan
    • Cystogram
    • Retrograde Pyelogram
    • U/S
    • CT
    • MRI
    • Renal arteriogram
    • UA
    • Urine C&S
    • BUN
    • Creatinine
    • KUB
    • IVP
    • VCG/VCUG
  • Normal Urinalysis
    • pH: 5.0-9.0
    • Sp Gr: 1.001-1.035
    • Protein: <20 mg/dL
    • Urobilinogen: up to 1 mg/dL
    • None of the following:
      • Glucose
      • Ketones
      • Hgb
      • WBCs
      • RBCs
      • Casts
      • Nitrites
  • Normal Characteristics of Urine
    • Color range
    • Clear
    • Newborn production—approx 1-2 mL/kg/hr
    • Child production—approx 1 mL/kg/hr
  • Urinary Tract Infection (UTI)
    • Is it REALLY that serious?
  • UTI (cont’d)
    • Concept of “asymptomatic bacteria” in urinary tract
  • UTI (cont’d)
    • Causes
    • E. coli most common pathogen
    • Streptococci
    • Staphylococcus saprophyticus
    • Occasionally fungal and parasitic pathogens
  • Classification of UTI
    • Upper tract: involves renal parenchyma, pelvis, and ureters
      • Typically causes fever, chills, flank pain
    • Lower tract: involves lower urinary tract
      • Usually no systemic manifestations
  • Classification of UTI (cont’d)
    • Lower tract
    • Cystitis
    • Urethritis
    • Upper tract
    • Pyelonephritis
    • VUR
    • Glomerulonephritis
  • Classification of UTI (cont’d)
    • Uncomplicated infection
    • Complicated infections
      • Stones
      • Obstruction
      • Catheters
      • Diabetes or neurologic disease
      • Recurrent infections
  • Types of UTIs
    • Recurrent—repeated episodes
    • Persistent—bacteriuria despite antibiotics
    • Febrile—typically indicates pyelonephritis
    • Urosepsis—bacterial illness; urinary pathogens in blood
  • Etiology and Pathophysiology of UTI
    • Physiologic and mechanical defense mechanisms maintain sterility
      • Emptying bladder
      • Normal antibacterial properties and urine and tract
      • Ureterovesical junction competence
      • Peristaltic activity
  • Etiology and Pathophysiology of UTI (cont’d)
    • Alteration of defense mechanisms increases risk of UTI
    • Organisms usually introduced via ascending route from urethra
    • Less common routes
      • Bloodstream
      • Lymphatic system
  • Etiology and Pathophysiology of UTI (cont’d)
    • Contributing factor: urologic instrumentation
      • Allows bacteria present in opening of urethra to enter urethra or bladder
    • Sexual intercourse promotes “milking” of bacteria from perineum and vagina
      • May cause minor urethral trauma
  • Etiology and Pathophysiology of UTI (cont’d)
    • UTIs rarely result from hematogenous route
    • For kidney infection to occur from hematogenous transmission, must have prior injury to urinary tract
      • Obstruction of ureter
      • Damage from stones
      • Renal scars
  • Etiology and Pathophysiology of UTI (cont’d)
    • UTI is a common nosocomial infection
      • Often E. coli
      • Seldom Pseudomonas
    • Urologic instrumentation common predisposing factor
  • Clinical Manifestations of UTI
    • Symptoms
      • Dysuria
      • Frequent urination (>q2h)
      • Urgency
      • Suprapubic discomfort or pressure
  • Clinical Manifestations of UTI (cont’d)
    • Urine may contain visible blood or sediment (cloudy appearance)
    • Flank pain, chills, and fever indicate infection of upper tract (pyelonephritis)
  • Pediatric Manifestations
    • Frequency
    • Fever in some cases
    • Odiferous urine
    • Blood or blood-tinged urine
    • Sometimes NO symptoms except generalized sepsis
  • Pediatric Manifestations (cont’d)
    • Pediatric patients with significant bacteriuria may have no symptoms or nonspecific symptoms like fatigue or anorexia
  • So how do you find out?
  • Diagnostic Studies of UTI
    • Dipstick
    • Microscopic urinalysis
    • Culture
  • Diagnostic Studies of UTI (cont’d)
    • Clean-catch is preferred
    • U-bag for collection from child
    • Specimen obtained by catheterization or suprapubic needle aspiration has more accurate results
      • May be necessary when clean-catch cannot be obtained
  • Diagnostic Studies of UTI (cont’d)
    • Sensitivity testing determines susceptibility to antibiotics
    • Imaging studies for suspected obstruction
      • IVP or Abd CT
  • Collaborative Care for UTI Drug Therapy: Antibiotics
    • Uncomplicated cystitis: short-term course of antibiotics
    • Complicated UTIs: long-term treatment
  • Collaborative Care for UTI Drug Therapy: Antibiotics (cont’d)
    • Trimethoprim-sulfamethoxazole (TMP-SMX) or nitrofurantoin
    • Amoxicillin
    • Cephalexin
    • Others
      • gentamycin, carbenicillin ++
    • Pyridium (OTC)
    • Combination agents (e.g., Urised) used to relieve pain
      • Preparations with methylene blue tint
  • Collaborative Care for UTI Drug Therapy
    • For Repeated UTIs
      • Prophylactic or suppressive antibiotics
      • TMP-SMX administered qd to prevent recurrence or single dose prior to events likely to cause UTI
  • Etiology and Pathophysiology of Acute Pyelonephritis
    • Inflammation caused by bacteria, fungi, protozoa, or viruses infecting kidneys
    • Urosepsis: systemic infection from urologic source
      • Can lead to septic shock and death in 15% of cases
  • Etiology and Pathophysiology of Acute Pyelonephritis (cont’d)
    • Usually infection is via ascending urethral route
    • Frequent causes
      • E. coli
      • Proteus
      • Klebsiella
      • Enterobacter
  • Etiology and Pathophysiology of Acute Pyelonephritis (cont’d)
    • Preexisting factor (usually)
      • Vesicoureteral reflux
      • Dysfunction of lower urinary tract function
        • Obstruction
        • Stricture
  • Etiology and Pathophysiology of Acute Pyelonephritis (cont’d)
    • Commonly starts in renal medulla and spreads to adjacent cortex
    • Recurring episodes lead to scarred, poorly functioning kidney and chronic pyelonephritis
  • Clinical Manifestations of Acute Pyelonephritis
    • Vary from mild to “classic” and very severe
    • Presenting symptoms
      • N/V, anorexia, chills, nocturia, frequency, urgency
      • Suprapubic or low back pain, dysuria
      • Fever, hematuria, foul smelling urine
    • Costovertebral tenderness
    • Symptoms often subside in a few days, even without therapy
      • Bacteriuria and pyuria still persist
  • Diagnostic Studies of Acute Pyelonephritis
    • Urinalysis
    • WBC casts
    • CBC
    • Imaging studies (IVP or CT)
    • Ultrasound
  • Collaborative Care of Acute Pyelonephritis
    • Hospitalization
    • Parenteral antibiotics
  • Collaborative Care of Acute Pyelonephritis (cont’d)
    • Relapses treated with 6-week course of antibiotics
    • Reinfections treated as individual episodes or managed with long-term therapy
      • Prophylaxis may be used for recurrent
  • Types of Glomerulonephritis
    • Most are postinfectious
      • Pneumococcal, streptococcal, or viral
    • May be distinct entity OR
    • May be a manifestation of systemic disorder
      • SLE
      • Sickle cell disease
      • Others
  • Glomerulonephritis Symptoms
    • Generalized edema due to decreased glomerular filtration
      • Begins with periorbital
      • Progresses to lower extremities and then to ascites
    • HTN due to increased ECF
    • Oliguria
  • Glomerulonephritis Symptoms (cont’d)
    • Hematuria
      • Bleeding in upper urinary tract->smoky urine
    • Proteinuria
      • Increased amt of protein = increased severity of renal disease
  • Acute Post-Streptococcal Glomerulonephritis
    • Is a non-infectious renal disease
      • (Auto immune)
    • Onset 5-12 days after OTHER type of infection
    • Often group A ß-hemolytic strep
    • Most common 6-7 y.o.
    • Uncommon in <2 y.o.
    • Can occur at any age
  • Diagnosing APSG
  • Prognosis
    • 95%-rapid improvement to complete recovery
    • 5%-15%-chronic glomerulonephritis
    • 1%-irreversible damage
  • Nursing Management of APSG
    • Manage edema
      • Daily weights
      • Accurate I&O
      • Daily abdominal girth
    • Nutrition
      • Low sodium, low-mod protein
    • Susceptibility to infections
    • Bed rest is not necessary
  • Nephrotic Syndrome
    • Most common presentation of glomerular injury in children
    • Characteristics
      • Proteinuria
      • Hypoalbuminemia
      • Hyperlipidemia
      • Edema
      • Massive urinary protein loss
  • Types of Nephrotic Syndrome
    • Minimal change nephrotic syndrome (MCNS)
      • AKA
        • Idiopathic nephrosis
        • Nil disease
        • Uncomplicated nephrosis
        • Childhood nephrosis
        • Minimal lesion nephrosis
    • Congenital nephrotic syndrome
    • Secondary nephrotic syndrome
  • Changes in Nephrotic Syndrome
    • Glomerular membrane
      • Normally impermeable to large proteins
      • Becomes permeable to proteins, especially albumin
      • Albumin lost in urine (hyperalbuminuria)
      • Serum albumin decreased (hypoalbuminemia)
      • Fluid shifts from plasma to interstitial spaces
        • Hypovolemia
        • Ascites
  • Nephrotic Syndrome
    • “Edema phase”
    • “Remission phase”
    • Prognosis
  • Nephrotic Syndrome Management
    • Supportive care
    • Diet
      • Low to moderate protein
      • Sodium restrictions when lg amt edema present
    • Steroids
      • 2 mg/kg divided into BID doses
      • Prednisone drug of choice ($$ and safest)
    • Immunosuppressant therapy (Cytoxan)
    • Diuretics
  • Family Issues
    • Chronic condition with relapses
    • Developmental milestones
    • Social isolation
      • Lack of energy
      • Immunosuppression/protection
      • Change in appearance due to edema self-image
  • Nursing Interventions
    • Aseptic technique during catheterizations
    • Avoid unnecessary catheterization and early removal of indwelling catheters
        • Prevents nosocomial infections
      • Wash hands before and after contact
      • Wear gloves for care of urinary system
  • Nursing Interventions (cont’d)
    • Routine and thorough perineal care for all hospitalized patients
    • Avoid incontinent episodes by answering call light and offering bedpan at frequent intervals
  • Nursing Interventions (cont’d)
    • Ensure adequate fluid intake (patient with urinary problems may think will be more uncomfortable)
      • Dilutes urine, making bladder less irritable
      • Flushes out bacteria before they can colonize
      • Avoid caffeine, alcohol, citrus juices, chocolate, and highly-spiced foods
        • Potential bladder irritants
  • Nursing Interventions (cont’d)
    • Discharge to home instructions
    • Follow-up urine culture
        • Recurrent symptoms typically occur in 1-2 weeks after therapy
      • Encourage adequate fluids even after infection
      • Low-dose, long-term antibiotics to prevent relapses or reinfections
      • Explain rationale to enhance compliance
  • Hemolytic-Uremic Syndrome
    • Pathophysiology
    • Diagnostic evaluation
    • Therapeutic management
    • Prognosis
    • Nursing consideration
  • Wilms' Tumor
    • AKA “nephroblastoma”
    • Malignant renal and intraabdominal tumor of childhood
    • Three times more common in African-American children
    • Peak age of diagnosis is 3 years
    • More frequent in males
  • Wilms' Tumor (cont’d)
    • Etiology
    • Diagnostic evaluation
    • Therapeutic management
      • Surgical removal
      • Chemotherapy and/or radiation
    • Nursing considerations
  • Renal Failure
    • Acute renal failure (ARF)
    • Chronic renal failure (CRF)
  • Acute Renal Failure (ARF)
    • Definition: kidneys suddenly unable to regulate volume and composition of urine
    • Not common in children
    • Principal feature is oliguria
      • Associated with azotemia, metabolic acidosis, and electrolyte disturbances
    • Most common pathologic cause: transient renal failure resulting from severe dehydration
  • ARF (cont’d)
    • Pathophysiology—usually reversible
    • Diagnostic evaluation
    • Therapeutic management
    • Nursing considerations
  • Complications of ARF
    • Hyperkalemia
    • Hypertension
    • Anemia
    • Seizures
    • Hypervolemia
    • Cardiac failure with pulmonary edema
  • Chronic Renal Failure (CRF)
    • Begins when diseased kidneys cannot maintain normal chemical structure of body fluids
    • Clinical syndrome called UREMIA
  • Potential Causes of CRF
    • Congenital renal and urinary tract malformations
    • VUR associated with recurrent UTIs
    • Chronic pyelonephritis
    • Chronic glomerulonephritis
  • CRF (cont’d)
    • Pathophysiology
    • Diagnostic evaluation
    • Therapeutic management
      • Manage diet, hypertension, recurrent infections, seizures
    • Nursing considerations
  • Dialysis
    • Peritoneal dialysis
    • Hemodialysis
    • Hemofiltration
  • Peritoneal Dialysis
    • The preferred method of dialysis for children
    • Abdominal cavity acts as semipermeable membrane for filtration
    • Can be managed at home in some cases
    • Warmed solution enters peritoneal cavity by gravity, remains for period of time before removal
  • Hemodialysis
    • Requires creation of a vascular access and special dialysis equipment
    • Best suited for children who can be brought to facility 3x/week for 4-6 hours
    • Achieves rapid correction of fluid and electrolyte abnormalities
  • Transplantation
    • From living related donor
    • From cadaver donor
    • Primary goal is LT survival of grafted tissue
    • Role of immunosuppressant therapy