genitourinary children

1. 11
JoyA.Shepard,PhD,RN-BC,CNE
JoyceBuck,PhD(c),MSN,RN-BC,CNE
1

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 tubules
ofthenephronandbloodvessels
 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
 Malereproductive system
 Testes,scrotum,penis,prostate,vasdeferens(drainsintourethra)
Testesproducetestosterone(primarymalesexhormone);spermafter
puberty
 Femalereproductive system
 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

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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
 Urinaryoutputperkilogramofbodyweightdecreasesas
childagesbecausethekidneysbecomemoreefficient
 Infants 2-3mL/kg/hr
 Toddler/Preschooler 2mL/kg/hr
 SchoolAge 1-2mL/kg/hr
 Adolescent 0.5-1mL/kg/hr
(40-80mL/hr)
1515
1 gram diaper weight = 1 mL of urine

16. 16
Bladder
 Bladdercapacityincreaseswithage
 20to50mLatbirth
 700mLinadolescence
 Estimate bladdercapacity(inounces)–add2tochild’sage
1616

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Pediatric Differences – Reproductive System
17

18. 18
Pediatric Differences: Reproductive System
 Infemaleinfants,theexternalgenitaliamaybeprominentdueto
maternalestrogen
 Labiaminoramayprotrudebeyondlabiamajora
 Testiclesmayappearlargeatbirthinproportiontosizeofinfant
 Mayfailtomoveintothescrotum,causingundescendedtestes
 Theforeskinmaybetightatbirth,causing phimosis
 Thesexorgansdonotmatureuntilonsetofpuberty
 Secondarysexcharacteristicsoccurwithonsetofpuberty
18

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History & Physical
19

20. 20
Terms Commonly Used to Describe Urinary Dysfunction
 Dysuria:Difficultyinurination
 Frequency:Abnormalnumberofvoidings inashortperiod
 Urgency:Urgetovoidbutinability todoso
 Nocturia:Awakening duringthenighttovoid
 Enuresis:Uncontrolled voidingafterbladdercontrolhasbeen
established (bedwetting)
 Polyuria:Increasedurineoutput
 Oliguria:Decreased urineoutput
20

21. 21
Focused Health History
 Mother’s pregnancy/ child’s birth history
 Family history: GU-specific disorders
 Review of fluid intake (including type of fluid)
 Urinary tract infections, fevers of unknown origin, dysuria
 Toilettraininghistory,voidingandbowelhistory,voidinghabits(e.g.,positioningduringvoiding)
 Any problems or changes with voiding (e.g., nocturia or enuresis)
 Rectum/ genitalia: any rashes, sores, or discharges
 Male children: circumcision status, prepuce issues, inguinal bulge/ scrotal swelling,
failure of testes to descend
 Females (if appropriate):
 Menstrual History – menarche, LMP, interval, regularity, duration, amount of flow, dysmenorrhea
 Obstetrical History - Gravida, Term, Para, Abortion, Live, Stillbirth (GTPALS)
 ****For adolescents, ask about sexual activity with parents out of room****
21

22. 22
Urinary Symptoms
 Enuresis(bedwetting)
 Newonsetincontinence
 Frequency,urgency,quantity
 Dysuriaanditstimingduringvoiding(atbeginningorend,throughout)
 Changeincolorandodorofurine
 Hematuria
 Presenceofstonesorsedimentintheurine
 Toilettrainingproblems
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23. 23
Toilet Training Readiness
 Children<2yrsgenerallycannotmaintainbladdercontrol
 12months:nocontroloverbladder
 18to24months:somechildrenshowsignsofreadiness
 Somechildrenmaynotbereadyuntilaround30months
 Thepotty-trainingyearsareespeciallyriskyfordevelopingUTI
 Remindchildtovoidoftenevenifhe/sheisnothavingaccidents
 Remindfemalechildrentowipefromfronttoback
 Achildwhoisuncircumcisedshouldbetaughtatpottytraininghowto
graduallyandgentlyretracttheprepuceforvoidingandhygiene
2323

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Review Question
 Amotherisinquiringaboutherchild'sabilitytopottytrain.
Whichofthefollowingfactorsisthemostimportantaspect
oftoilettraining?
A. Theageofthechild
B. Thechild’sabilitytounderstand instructions.
C. Theoverallmentalandphysicalabilities ofthechild.
D. Frequentattemptswithpositivereinforcement.
25

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Anomalies & Diseases: Genitourinary
 Congenital/chromosomalanomalies(e.g.,singleumbilical
artery,low-setears,eartags);ambiguousgenitalia
 Cystitis,pyelonephritis,renaldisease
 GUsurgeryorprocedures
 Male:
Phimosis,cryptorchidism, hydrocele,testiculartorsion
26

27. 27
Single Umbilical Artery
Associated with
increased incidence of
urogenital
abnormalities
27
Single Umbilical Artery
Normal – 2 Arteries, 1 Vein

28. 28
Low-Set Ears & Urinary Tract Anomalies
28
Suspect urinary
tract/ kidney
anomalies

29. 29
Skin Tags/ Preauricular Sinus
29

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Assessment of the Genitourinary System
 Review:AssessingtheAbdomenforShape,Bowel
Sounds,andUnderlyingOrgans(pp.127-128[new],143-145[old])
 Review:AssessingtheGenitalandPerinealAreasfor
ExternalStructuralAbnormalities(pp.128-130[new],145-149[old])
30
See video “Pediatric Assessment” 24:07 – 25:47
See video “Physical Exam & Health Assessment: Child”
17:08 – 18:49

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Nursing Diagnoses
 UrinaryIncontinence
 ImpairedUrinaryElimination
 UrinaryRetention
 ExcessFluidVolume
 RiskforDeficientFluidVolume
 RiskforImbalanced FluidVolume
 RiskforElectrolyteImbalance
 Toileting Self-CareDeficit
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GU Process Focus
 Dailymonitoringofintake/outputandweightarevitalinassessingalterationsinfluid-
electrolytebalanceinthepediatricpatient
 Assessvitalsigns,notingthatbloodpressureisoftenelevatedwithglomerulonephritis
andnephroticsyndrome
 Monitorserumelectrolytes,creatinine,andBUNlevels(arisingcreatinineandBUN
suggestspoorrenalfunctioning)
 Measureheight,weight,andbodymassindex(failuretothrivecanbeassociated
withurinarytractinfectionsininfancyandincreasedweightcanbeassociatedwith
nephroticsyndrome)
 Noteearpositionandformation(low-setorabnormalearsmaybeanindicationof
congenitalrenalconditions)
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Diagnostic Tests
3434

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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
 Reliable assessmentofpatient’s hydrationstatus
 1.001–1.035 Normalvalue
IncreasedUrineSG
Dehydration–diarrhea–excessivesweating-vomiting
DecreasedUrineSG
Excessivefluidintake–pyelonephritis-glomerulonephritis
3737

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Urine Collection
38
Application of urine collection bag
38
See Videos: Urine Samples Collection Pediatric
Urine Specimen Collection of Infant

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Review Question
 Whichofthefollowinginterventionswillhelpobtainaccurate
urinalysisdata?
A. Forcefluidsto1000mLpriortospecimencollection.
B. Cleansethespecimencontainerwithpovidone-iodine(Betadine)prior
tocollectingthespecimen.
C. Allowtheurinetocooltoroomtemperaturebeforetakingittothelab.
D. Provideclient/parenteducationforspecimencollectionbeforethe
specimenisobtained.
3939

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Diagnostic Tests (p. 704 [new], 766 [old])
 ComputedTomography(CT)
 Cystoscopy
 FunctionalRadionucleotideRenalScan
 IVP–IntravenousPyelogram
 RenalBiopsy
 RenalorBladderUltrasound
 VCUG–VoidingCystourethrogram
4040

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Computerized Tomography (CT Scan)
4141
Abdomen CT Scan

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Cystoscopy
42
Invasive surgical
procedure
Visualizes bladder,
urethra, and ureter
placement
42

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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)
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Intravenous Pyelogram (IVP)
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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

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Review Question
Achildreturning totheunit after anintravenous
pyelogram (IVP) hasanorder todrinkextrafluids.When
themother asksthepurpose of thesefluids,thenurse
responds thatincreased fluidintakewill:
A. Overhydratethechild.
B. Increaseserumcreatininelevels.
C. Make-upforfluidlossesfromNPOstatusbeforetests.
D. Flushanyremainingdyefromtheurinarytract.
4646

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Renal Biopsy
4747

48. 48
Renal Bladder Ultrasound (RBUS)
4848

49. 49
Voiding Cystourethrogram (VCUG)
4949

50. 50
Treatment Modalities
 Urinarydiversion
Stents
Drainagetubes
 Intermittent catheterization
Watchforlatexallergies
 Pharmacologicalmanagement
Antibiotics
Anticholinergicforbladderspasm(oxybutynin[DitropanXL])
5050

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Urinary Tract Infection
5151

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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

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Review Question
Which of the following organisms is the most
common cause of UTI in children?
A. Staphylococcus
B. Klebsiella
C. Pseudomonas
D. Escherichiacoli
54

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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

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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
 Donotleaveforeskinretractedoritmayactastourniquet and
obstructtheheadofthepenisresultinginemergency
circumcision
5757

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UTI: Diagnostic Tests
 Urine for culture and sensitivity
 Clean catch
 Catheterization
 Suprapubic aspiration
 A Positive Test
 Bacteria colony ≥ 50,000 per mL
 Positive leukocyte esterace; positive nitrite tests; white blood cell
(WBC) casts
 Ultrasound: structural abnormalities, scarring
 Voiding cystourethrogram (VCUG): vesicoureteral reflux
58

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UTI: Clinical Manifestations
 Signs & symptoms not always clear (atypical presentation)
 Typical S & S of older children and adults – dysuria, frequency,
urgency, burning, hematuria – may not be present
 Newborn/ infant: unexplained fever; failure to thrive; poor feeding;
vomiting; diarrhea; foul-smelling urine; irritability; lethargy
 Fever of unknown origin (child ≤ 2 yrs): test for UTI
 Toilet-trained child: new onset incontinence, wetting accidents
 Upper UTI S & S: high fever, chills, abdominal pain, flank pain,
costovertebral-angle tenderness, vomiting, malaise (i.e., vague
feeling of general discomfort)
5959
See “Clinical Manifestations Urinary Tract Infection” – p. 705 (new), 768 (old)

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Review Question
UTI: What are the differences between older
child/ adult S & S and infant-child S & S
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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–usuallyafter72hrsoftxtomakesuretxiseffective
6161
See “Prevention of Urinary Tract Infections” – p. 706 (new), 769 (old)

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UTI: Nursing Education
 Antibiotics–takefullcourse
 Changediaperfrequently
 Teachgirlstowipefronttoback
 Encouragechildrentodrinkperiodicallyduringtheday
 Nobubblebaths
 Encouragefrequentvoiding
 Discourage“holding”urine
 Usecottonunderwear
 Menstruatinggirl– changepadevery4hours
 Whengirlsbecomesexuallyactive– urinateimmediatelyafterintercourse
6262

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64. 64
Review Question
 Themostimportant nursingactivity inmanagingayoung
child diagnosed withurinarytract infection (UTI)isto:
A. Provideadequate nutrition toprevent dehydration.
B. Prevent enuresis.
C. Administer ordered antibiotics onschedule.
D. Restrictfluidsto provide kidneyrest.
6464

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Review Question
 Theparentsofachilddiagnosedwithupperurinarytract
infection(UTI)askthenursewhythechildneedsadaily
weight.Informulatingaresponse,thenurseincludesthatit
isimportantbecauseadailyweightwill:
A. Determineifthechild’scaloricintakeisadequate.
B. Indicatetheneedfordietaryrestrictionsofsodiumandpotassium.
C. Keeptrackofpossiblelossorgainoffluidretainedinbodytissues.
D. Tracktheamountoffluidingestedorallyeachday.
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Bladder Exstrophy
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
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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;provide
meticulouswound/skincare
 Monitorrenalfunction;strictI&O;observeforsignsofobstruction;promotecomfort;
administerantibiotics
 Supportparents;promotebonding;guidance&dischargeteaching
72
ModifiedBryant’straction

73. 73
Review Question
Whichofthefollowing positions would best facilitate
healing fortheinfant after bladder exstrophy repair?
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

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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,examination atbirth
 Circumcisionnotrecommended(foreskinmaybeneededfor
reconstructive surgery)
 Notreatment necessaryinmilddisorder
 Hypospadiasrepair:4-18mos(earlyintervention preferred)
 Epispadiasrepair:12-18mos(allowsbladdertimetoenlarge)
 Post-op:Forcefluids,keepurinarystentpatent,leavebandagein
place,notubbathing untilstentisremoved
7777
See “Caring for the Child After Hypospadias and Epispadias Repair” – p. 708 (new), 772 (old)

78. 78
Review Question
 Shortlyafterbirth,thenewbornwasfoundtohaveepispadias.Priorto
delivery,themotherhadsignedpermissionforacircumcision.The
obstetricianisplanningtoperformthecircumcisionimmediatelyafter
delivery.Thenurseexplainstothemotherthatthecircumcisionwillnot
bedoneatthistimebecause:
A. Themothershouldnothavesignedconsentbeforedelivery.
B. Thefatheralsoneedstosignpermissionforsurgery.
C. Theprepucewillbeusedforthesurgicalcorrection.
D. Theriskofinfectionisgreaterwithachildwithepispadias.
7878

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Hypospadias & Epispadias: Nursing Care
 Keeptheareacleantopreventinfection
 Assessforpostsurgicalcomplications
 Monitorforsignsofinfection
 WatchforevidenceofUTI
 Assesspain(oxybutyninrelievesbladderspasms)
 Encouragetheparentstoexpresstheirfeelings/concernsandprovide
emotionalsupport
 Dischargeinstructions: Bandagedressingcare,careofstent,activity
restrictions,nutrition,paincontrol,andsigns/symptomsofcomplications
79
See “Caring for the Child After Hypospadias and Epispadias Repair” – p. 708 (new), 772 (old)

80. 80
Review Question
 Aninfanthasbeenadmittedfortreatmentofhypospadias.
Nursingmanagement ofthechildandfamilyincludes:
A. Parenteducation regarding steroidtherapy.
B. Addressingparentalanxietyrelatedtofunctioning and
appearanceofthepenis.
C. Homehealthteaching ofproperstraightcatheterization
techniques.
D. Monitoring forsignsandsymptomsofnephroticsyndrome.
8080

81. 81
Double-Diapering Technique After Surgery for
Hypospadias/Epispadias Repair
81

82. 82
Review Question
 Themotherofaninfantwhounderwentsurgerytorepair
hypospadiasasksthenursewhytheinfantisdouble-
diapered.Thenursewouldrespondthatthismethodof
diapering:
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
Review Question
 Aparentasksthenursewhatwilleventuallyhappeniftheinfant
doesnothavehiscongenital hydronephrosistreated.Themost
accurateanswerbythenursewillbewhichofthefollowing?
A. “Ifthehydronephrosisisnottreated,thechildcandevelopbladdercancer.”
B. “Theinfantcanbecomedangerouslyhypotensivebecauseoftheobstructionto
urineflow.”
C. “Smallcalciumstonescanoccurasaresultofuntreatedhydronephrosis,
causingfurtherobstruction.”
D. “Untreatedhydronephrosiscanleadtoirreversiblekidneydamageand
eventualkidneyfailure.”
85

86. 86
Hydronephrosis: Clinical Manifestations
 Distended bladder/abdomen
 HistoryofUTI:flankpain,feverandchills
 S&Srenalinsufficiency: decreaseinurinaryoutflow,swelling,
hypertension, anemia,poorappetite; decreasedabilityofkidney
toconservesodiumandconcentratetheurine
 NeonatemaypresentasUTI
 Outerearabnormalities, singleumbilical artery
 Anolderchildmaybeasymptomatic exceptforFTT
8686

87. 87
Review Question
 Anurseisreviewingapatient’schartandnoticesthatthechild
suffersfromhydronephrosis. Whichofthefollowing wouldthe
nurseexpecttoseewiththispatient?
 A.Swollenkidneyduetourinenotdraining fromkidney
 B.Dehydrationfromspittingupandseveralloosestools
 C.Profuseurinationandurinaryfrequency
 D.Spinalcorddefectcausinginability toemptybladder
87

88. 88
Hydronephrosis: Diagnostics
 Ultrasound of
kidneys/bladder
 VCUG: voiding
cystourethrogram
 Diuretic renography with
radioisotope
 Requires use of a
radiopharmaceutical tracer
& intravenous furosemide
through IV
8888

89. 89
Hydronephrosis: Collaborative Care
 Goalsofcorrection:Preserverenalfunction,lowerpressurewithin
collectionsystem
 Temporaryurinarydiversionmaybeneededtorelievethepressure
 Surgicaltreatment:insertionofureteralstents,nephrostomy tube;
pyeloplasty; valverepair/reconstruction
 Nephrectomy ifrenaldamageisnotreversible
 Nursingcare:support/educateparents;monitorVS,I&O;
observeforsignsofurinaryretention; administermedications
8989

90. 90
Vesicoureteral Reflux (VUR)
 Regurgitation of urine from the bladder into the ureters due to
faulty valve mechanism at the ureterovesicular junction
 Predisposes child to: UTIs; pyelonephritis; hydronephrosis
 White children, girls, children ≤ age 2; tends to run in families
 Assessment findings: same as for UTIs/ FTT
 Diagnostic tests: kidney/ bladder US, VCUG, nuclear scan
 Goals: prevent pyelonephritis, renal scarring, chronic renal failure
 Tx: Long-term daily low-dose antibiotic prophylaxis; valve repair or
reconstruction; endoscopic surgery; surgery to re-implant ureters
9090

91. 91
Ureteral Reflux
9191

92. 92
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

93. 93
Nephrotic Syndrome
Acute Poststreptococcal
Glomerulonephritis
RenalFailure
Renal Disorders: Acute, Chronic, &
Structural Causes
9393

94. Nephrotic Syndrome/ Nephrosis
(Minimal Change Nephrotic Syndrome)
94
 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)

95. 95

96. Review Question
96
Nephrotic
syndrome is
caused by damage
to which part of the
nephron?????
MinimalChangeNephroticSyndrome/ Effacement of foot processes

97. 97
Contrast Between Normal Glomerular Anatomy &
Changes of Nephrotic Syndrome (p. 713 [new], 818 [old])
97
Massiveamountsofproteinare
excretedinurine
Edemaresultsfromdecreased
oncoticplasmapressure,renin-
angiotensin-aldosteroneactivation,&
antidiuretichormonesecretion
Loweralbuminbloodlevel
stimulatesthelivertogeneratelipids
&excessiveclottingfactors
Loss of podocyte foot processes = MASSIVE PROTEINURIA

98. 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
98
Periorbital, scrotal edema

99. Nephrotic Syndrome: Anasarca
99
Describe the fluid shifts in
Anasarca….
What sorts of health
complications do you anticipate?

100. 100
MCNS: Diagnostic Evaluation
 Proteinuria (First morning urine sample)
 Urine protein/ creatinine ratio > 2
 Hypoproteinemia
 Serum albumin < 2.5 g/dL
 Hyperlipidemia/ Lipiduria
 ↑ Cholesterol, triglycerides; lipids in the urine
 Hypercoagulability (PT/PTT/INR/ antithrombin III)
 Basic metabolic panel (BMP)
 BUN/ Creatinine normal unless renal damage
 Hyponatremia (low serum sodium)
 Kidney biopsy
100100
Monitor serum albumin and electrolytes, particularly potassium and sodium.

101. 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
101

102. 102
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
102

103. 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
103

104. MCNS: Nursing Care
104
 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

105. 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
105

106. Corticosteroids: Side Effects
106
 Immunodeficiency
 Hirsutism
 Moonfacewithruddycheeks
 Acne
 Dorsocervicalfatpads
 Ecchymosis(easybruising)
 Truncalobesity
 Moodswings–inability tosleep
106106

107. 107
Moon Face
107
High-dose
corticosteroid
therapy produces
a characteristic
“moon face”
appearance
107

108. Symptoms of Cushing’s Syndrome
108
High blood pressure, abdominal obesity with
thin arms and legs, reddish stretch marks,
round red face, fat lump between the
shoulders, weak muscles, acne, fragile skin Prolonged exposure to corticosteroids

109. 109
Before and After
109109
Cushingoid Appearance

110. 110
Review Question
While a child is receiving prednisone (Orapred) for
treatment of nephrotic syndrome, it is important for
the nurse to assess the child for:
A. Infection.
B. Urinaryretention.
C. Easybruising.
D. Hypoglycemia.
110110

111. 111
Review Question
 Achildhasrecurrentnephroticsyndrome.Themotherreportstothe
nursethatsheisoverwhelmedwiththecareofherchild.Afterthenurse
discussesoptionswiththemother,whichstatementbythemother
indicatescontinuedcopingdifficulties?
A. “Ijoinedasupportgrouplikeyousuggested.Ihopeitdoessomegood.”
B. “I’mgoingtoaskmymother-in-lawtocomeonaregularbasistoallowme
anafternoonout.”
C. “Myhusbandhasagreedtohelpmemanagemyson’smedication.”
D. “We’regoingtoskiphisdietaryrestrictionsonedayaweektoallowusboth
somerelaxation.”
111111

112. Acute Poststreptococcal Glomerulonephritis
112
 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

113. Group A Streptococcal Infection Manifestations
113

114. 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
114

115. 115
Infection from group A beta-hemolytic Streptococcus leads to an immune
response that causes inflammation and damage to glomeruli
115
Protein&redblood
cellsareallowedtopass
throughglomeruli
Bloodflowtoglomeruli
isreduceddueto
obstructionwithdamaged
cells
Renalinsufficiency
results,leadingto
retentionofsodium,
water,&waste
IMMUNE ACTIVITY targeted at GLOMERULUS
Vessels
clogged
with
cells

116. Glomerular Capillaries Clogged With Cells
116
 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

117. 117
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
117117
Tea- or cola-colored urine
The most common clinical sign of glomerulonephritis is blood in the urine

118. 118118
118

119. 119
 Dx: streptozyme test; ↓ H & H; ↑ BUN, creatinine; hematuria, proteinuria,
RBC casts; ↑ erythrocyte sedimentation rate
 Tx goals: relief of symptoms, supportive therapy
 Monitor urinary output, daily weights, blood pressure, & serum electrolytes
 Limited activity, bed rest
 Diuretics such as furosemide (Lasix) to reduce fluid overload
 Antihypertensive drugs to treat increased blood pressure
 Antibiotics (penicillin) if a streptococcal infection is documented or detected
 Restriction of fluids to replace insensible losses
 Low-sodium, low protein diet (during acute phase)
119119
Acute Poststreptococcal Glomerulonephritis:
Collaborative Care

120.  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
120
Acute PoststreptococcalGlomerulonephritis:
Nursing Care

121. 121
Review Question
When reviewingaurinalysisreport ofaclientwithacute
glomerulonephritis, the nurse wouldexpecttonote:
A. Decreased creatinine clearance.
B. Decreased specificgravity.
C. Hematuria.
D. Decreased erythrocyte sedimentation rate(ESR).
121121

122. 122
Acute Renal Failure/ Acute Kidney Injury
 Life-threateningdisorder
 Kidneysunableto
 Clearwastes
 Regulatefluidvolume,sodiumbalance, &acid-basehomeostasis
 Pre-renal,resultingfromimpairedbloodflow
tooroxygenationofthekidneys
 Renal,resultingfrominjurytoormalformation
ofkidneytissues
 Post-renal,resultingfromobstructionof urinaryflowbetweenkidney &meatus
 Seevideo3MinuteAcuteRenalFailureforNursingStudents
122122
Suddenlossofrenalfunction

123. 123

124. 124
Review Question
Thenurseadmits children withthe following diseases to
theunit.Which disease places the childatriskforthe
development ofacuterenal failure (ARF)?
A. Leukemia.
B. Cryptorchidism.
C. Nephroticsyndrome.
D. Phenylketonuria.
124124

125. 125
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
125
Injurytothekidneycan
occurbecauseofglomerular
injury,vasoconstrictionof
capillaries,ortubularinjury
Allconsequencesof
injuryleadtodecreased
glomerularfiltration&
oliguria
Acute Renal Failure/ Acute Kidney Injury

126. 126
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.
126126

127. Newborn Causes Childhood Causes
 Congenital anomalies
 Hypotension
 Complication ofopenheart
surgery
 Dehydration
 Glomerulornephritis /
NephroticSyndrome
 Nephro-toxicity /drugtoxicity
Acute Renal Failure
127

128. 128
Review Question
 Achildisadmitted tothenursingunitwithacuterenalfailure
(ARF).Whenreviewingthenursinghistory,thenursenotesa
historyofallofthefollowing medicalconditions. Whichismost
likelytohaveprecipitated theonsetofARF?
A. Chickenpox.
B. Influenza.
C. Dehydration.
D. Hypervolemia.
128128

129. 129
Acute Renal Failure: Clinical Manifestations
 Suddenonset
 Oliguria
 Urineoutputlessthan0.5to1mL/kg/hour
 Darkurine
 Volumeoverloadduetoretainedfluid
 Hypertension,edema,shortnessofbreath
 ElectrolyteImbalances–seechart,p.719(new),783(old)
 Acidosis
 Nonspecificsymptoms:nausea,vomiting,lethargy
129
See “Clinical Manifestations” – p. 718 (new), 783 (old)

130. 130
Diagnostic Tests
 Basic Metabolic Panel (BMP)
 BUN and Creatinine elevated
 Serum Potassium elevated
 Decreased CO2
 CBC
 Decreased RBCs, H & H due to deficient erythropoietin
 ABG
 Decreased pH
 Decreased Bicarbonate (HCO3−)
 GFR (glomerular filtration rate) decreased – most sensitive
indicator of glomerular function
130130

131. 131131
131

132. The Most Deadly Electrolyte Imbalance…
132

133. 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
133

134. 134

135. 135
Review Question
The priority concern for the nurse in assessing a
child with acute renal failure (ARF) should be to
look for which electrolyte imbalance?
A. Potassium.
B. Sodium.
C. Calcium.
D. Phosphorous.
135135

136. 136
Urea or BUN
Urea is normally freely filtered throughthe renal
glomeruli, with a small amount reabsorbedin the
tubules andthe remainder excreted in the urine
Decrease or increaseinthe valuedoes nottell the
cause: pre-renal, post-renal or renal
Elevated BUN just tells youthe urea isnot being
excreted by the kidney, not why
136136

137. 137
Creatinine
Creatinine is a very specific indicator of renal
function
If kidney function is decreased / creatinine level will
be increased
Conditions that increase levels: glomerulonephritis,
pyelonephritis or urinary blockage
137137

138. 138
Creatinine Levels
Adult female: 0.5-1.1 mg/dL
Adult male: 0.6-1.2 mg/dL
Adolescent: 0.5-1.0 mg/dL
Child: 0.3-0.7 mg/dL
Infant: 0.2-0.4 mg/dL
Newborn: 0.3-1.2 mg/dL.
138138

139. 139
Acute Renal Failure: Collaborative care
 Treatmentdependsontheunderlyingcause
 Preventpermanentrenaldamage
 Reducesymptoms
 Supportivecareuntilrenalfunctionreturns
 Medications– seechart,p.723(new),787(old)
 Avoidnephrotoxicmedications(NSAIDs.,radiocontrastagents,
aminoglycosideabx)
 Dietaryrestrictions–seeTable26-9,p.724(new),788(old)
 Dialysisifindicated
 Seevideo4NursingInterventionsforAcuteRenalFailurePart1andPart2
139139

140. 140
Acute Renal Failure: Nursing Care
 Provideemotional supportforchildandfamily
 MonitorVS,I&O,dailyweights,serumelectrolytes
 Administermedications asordered
 Monitornutritional intake–sodium,potassium,andphosphorus
mayneedtoberestricted(Table26-9)
 Meetfluid,electrolyte,andnutritional needs
 Preventinfections andcomplications
 Dischargeplanning &homecareteaching
140

141. 141141

142. 142
Review Question
Afour-year-old childhasbeen diagnosed withrenal
failure.Thenurse would ensure thatthedietforthischild
wouldcontain:
A. Foodshighinpotassiumandsodium.
B. Adequatecaloriestooptimizegrowth.
C. Foodshighinphosphoruscontenttopromotebonegrowth.
D. Increasedfluidintaketoflushtheurinarysystem.
142142

143. 143
Review Question
Ateenager inacuterenal failure has anorderforfluid
restriction. What assessment criteriawouldindicate that
insufficient fluids arebeing administered tothischild?
A. Increasedweightwithdecreasedserumpotassiumlevels.
B. Proteinuria.
C. Hypernatremiawithweightloss.
D. Decreasedpulse.
143143

144. 144
Chronic Renal Failure
 Progressive,irreversibledeteriorationofrenalfunction, usually
overaperiodofmonthsoryears
 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,centralnervoussystem abnormalities, delayedsexualmaturation
 Seevideo4StagesofChronicRenalFailure&ESRD
144

145. 145
Effects of Chronic Renal Failure
 Growthdelays
Duetoanemia,metabolismdisturbances,decreasedcaloricintake,
metabolicacidosis
 Cognitivedelays
Duetodecreasedalertness,fatigue,poorschoolattendance
 Socialdevelopmentimpairment
Duetoalterationofbodyimage,delayedonsetofpuberty,sideeffects
ofmedications
145145

146. Chronic Real Failure: Collaborative Care
 Dx:BUN/serumcreatinine(mostimportanttests);serumelectrolytes,
bicarbonate;CBC;urinalysis(proteinuria,hematuria,pyuria,sp.gravity,hyaline
casts);estimationofGFR;US/radionuclidestudies;renalbiopsy
 Treatmentdependsoncourseofthedisease
 Medications -seechart,p.723(new),787(old)
 Diettherapy–limit potassium,phosphorus,sodium(seeTable26-9,p.724[new],788{old})
 Proteinrestrictedonlytotherecommendeddailyallowanceforchildren
 Preventionandtreatmentofcomplicationsofdecreasedkidneyfunction(e.g.,anemia,bonedisease,
cardiovascularmanifestations,hypertension,growthfailure)
 Avoidnephrotoxicmedications(NSAIDs.,radiocontrastagents,aminoglycosideabx)
 Renalreplacementtherapy,ifsigns/symptomsofuremiaarepresent
 Regularlifelongfollow-up
146

147. 147147
147

148. 148
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.
148148

149. 149

150. 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
150

151. 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
151

152. 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;developmeal
plansthatfitarestricteddiet
 Dischargeplanningandhomecareteaching
152

153. 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
153

154. 154
PeritonealDialysis
Hemodialysis
KidneyTransplantation
Renal Replacement Therapy
154154

155. 155
Renal Replacement Therapy:
Peritoneal Dialysis
 Peritonealdialysis-child’sownperitonealcavityactsasthesemi-permeable
membraneacrosswhichwaterandsolutesdiffuse
155
•SeevideoPeritonealDialysis(NursingConsiderations,Risks,PatientTeaching)

156. Peritoneal Dialysis –Peritonealmembraneusedtofilter
 Softcatheterisusedtofillthe
abdomenwithadialysissolution
 Solutioncontainsdextrose(1.5,2.5,
or4.25%)thatpullswasteandextra
fluidintotheabdominalcavity
 Osmoticpressureofglucosein
solutiondrawsfluidfromvascular
spacesintotheperitoneum,making
availableforexchange/elimination
ofexcessfluid&wastes
 Dialysisfluidisthendrained
156156156

157. 157157
157

158. Peritoneal Dialysis: Nursing Care
 Assistparentsinlearningperitonealdialysis
 Makesurestrictsteriletechniqueisusedatalltimesduringcatheter
placementandperitonealdialysis(handhygiene,gloves,masks)
 Monitorthechild’sresponsetothetherapy
 Assessforcomplications:bleedingfromthecathetersite,signsof
infectionatthecathetersite,peritonitis,abdominalhernia
 Maintainpatencyoftheperitonealdialysiscatheter:keepitinplace,
withoutkinksorpulling,andwiththefluidbagsatthecorrectlevel
 Noteifreturningdialysatesolutionhasunusualcolororiscloudy
158
See “Nursing Care Plan: Child Receiving Home Peritoneal Dialysis” – p. 728 (new), 792 (old)

159. 159
Review Question
Anappropriate nursingdiagnosis forachildreceiving
peritoneal dialysisis:
A. Fluidvolumedeficitrelatedtosodiumandwaterretention.
B. Imbalanced nutrition,greaterthanbodyrequirements relatedto
increasedhunger.
C. Riskforinfectionrelatedtoinvasiveproceduresanddiminished
immunefunctioning.
D. Alteredrenaltissueperfusion relatedtohypervolemia.
159159

160. 160
Hemodialysis –Man-mademembraneusedtofilter
 Inhemodialysis,amachinefilterswastes,saltsandextrafluidfromtheblood;
thecleanbloodisthenreturnedtothebody
 Requiresstricttreatmentschedule;adherencetomedications/dietrestrictions
 Done3timesaweekfor3to4hoursatadialysiscenter
 Attheonset,achildmayexperienceseveralsideeffects(disequilibrium
syndrome)—hypotension,dizziness,weakness,nausea,ormusclecramps
 SeevideosHemodialysis(Labs,H&H,Cautions)
 WhatDoesaKidneyDialysisAccessLookLike?
 HemodialysisandHowItWorks
160

161. 161
Hemodialysis: Types of Access
161161

162. Hemodialysis uses a special filter called a dialyzer to
remove wastes and extra fluid from the blood
162

163. 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
163

164. 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
164

165. 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
165
• Rejection – major cause of
transplanted kidney loss
o S/S rejection: Fever; ↑ BUN &
creatinine; pain & tenderness;
irritability; weight gain

166. 166166
166

167. 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
167

168. 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
168

169. 169
Cryptorchidism
Structural Defects of the
Reproductive System
169169

170. 170
Cryptorchidism
 Failure of one or both testes to descend
through inguinal canal; hidden testis
 3-6% term; 20-30% preterm infants
 Testosterone deficiency, an defective
testis, structural problem, early gestational
age
 Complications: infertility, testicular CA
 Usually detected newborn exam
 Goals of treatment:
 Preserve testicular function
 Normal scrotal appearance
170
Bilateral Cryptorchidism

171. 171
Review Question
Why isitimportant that thetestes areinthescrotalsac?
171

172. Cryptorchidism: Collaborative Care
 Mosttestesspontaneouslydescend
 Hormonetherapy–humanchorionic
gondadotropin (hCG)
 Surgicalprocedure(orchiopexy)iftestes
donotdescendintoscrotalsacby6-12
months
 Riskoftesticularcancerifuntreated
 Monthlytesticularself-examinationis
recommendedforallmalesbeginningin
puberty,butisessentialinmaleswith
historyofundescendedtestis
172
Orchiopexy

173. 173
Review Question
 Thenewbornhasbeendiagnosed withcryptorchidism.The
physicianhasorderedhumanchorionic gonadotropin (hCG)to
beadministered tothebaby.Themotherasksthenursewhythe
babyisreceiving thisdrug.Thenurse’sbestexplanation wouldbe
thedrugwill:
A. Maintainanadequatetemperaturearoundthetestes.
B. Preventinfectionsintheundescendedtestes.
C. Preventthedevelopmentofcancer.
D. Promotedescentofthetestes.
173173

174. 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)
174

175. 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)
175

176. 176
Review Question
 Ababyisborn6weeksprematurely.Onadmissiontothe
nursery,thenurseisunabletolocateanytesticlesinthe
scrotum.Thenurseshould:
A. Immediatelynotifythephysicianasthechildisatriskforrenalfailure.
B. Notethefindingsinthechild’srecordandtakenofurtheractionatthis
time.
C. Discusswiththefathertheneedforsurgicalcorrectionofcryptorchidism.
D. Catheterizethechildtodetermineifurineispresentinthebladder.
176176

177. 177
Review Question
 Whentalkingwiththeparentsofachildoradolescentwhohas
ahistoryofcryptorchidism, thenursewillmoststressthe
importanceofthechilddoingwhichofthefollowingthings?
A. Gettingamumpsvaccineboosterevery5years
B. Complying100%withhormonetherapybeginningatage15
C. Wearingatesticularsupport(jockstrap)whileparticipating in
sports
D. Doingmonthlyself-testicular examinations beginning atage13
177

178. 178