Alterations in genitourinary function in children

11
JoyA.Shepard,PhD,RN-BC,CNE
JoyceBuck,PhD(c),MSN,RN-BC,CNE
1
Alterations in Genitourinary Function
(Urinary Tract, Renal, and Reproductive
Conditions)

2
Learning Outcomes
1. Describeanatomy&physiologyof thegenitourinarysystemandpediatric
differences
2. Discussnursingmanagementofchildwithgenitourinarystructuraldefect
3. Developnursingcareplanforchildwithurinarytractinfection
4. Outlineaplantomeetfluidanddietaryrestrictionsofchildwithrenaldisorder
5. Summarizepsychosocialissuesforchildrequiringgenitourinarysurgery
6. Plannursingcareforchildwithacute&chronicrenalfailure
7. Identifygrowth&developmentissuesforchildwithchronicrenalfailure
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3
Comprised of:
Kidneys
Ureters
Bladder
Urethra
Review: Anatomy Urinary System

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
Review: Anatomy of the Kidney
 Outercortex
 Composedoftheglomeruliandconvoluted tubules
ofthenephronandbloodvessels
 Innermedulla
 Composedoftherenalpyramid
5

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
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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
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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

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Children are not just small adults….
1010

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Development of the Genitourinary System

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Pediatric Differences – Urinary System
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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
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Pediatric Differences: Urinary System
 Allnephronspresentatbirth
 Renalgrowth
 Mostduringfirst5yrs
 Fullsizebyadolescence
 Renalefficiencyincreasesaschildmatures
 Kidneyfunctionisimmatureuntilafter2yearsofage
 Glomerularfiltration&absorptionimmature
 Infantsmorepronetofluidvolumeexcess&dehydration
 Lessefficientregulatingelectrolyte&acid-basebalance
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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
1515
1 gram diaper weight = 1 mL of urine

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Bladder
 Bladdercapacityincreaseswithage
 15to50mLatbirth
 700mLinadolescence
 Estimate bladdercapacity(inounces)–add2tochild’sage
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Pediatric Differences – Reproductive System
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Pediatric Differences: Reproductive System
 Infemaleinfants,theexternalgenitaliamaybeprominentdueto
maternalestrogen
 Labiaminoramayprotrudebeyondlabiamajora
 Testiclesmayappearlargeatbirthinproportiontosizeofinfant
 Mayfailtomoveintothescrotum,causingundescendedtestes
 Theforeskinmaybetightatbirth,causing phimosis
 Thesexorgansdonotmatureuntilonsetofpuberty
 Secondarysexcharacteristicsoccurwithonsetofpuberty
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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
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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****
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Urinary Symptoms
 Enuresis(bedwetting)
 Newonsetincontinence
 Frequency,urgency,quantity
 Dysuriaanditstimingduringvoiding(atbeginningorend,throughout)
 Changeincolorandodorofurine
 Hematuria
 Presenceofstonesorsedimentintheurine
 Toilettrainingproblems
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Toilet Training Readiness
 Children<2yrsgenerallycannotmaintainbladdercontrol
 12months:nocontroloverbladder
 18to24months:somechildrenshowsignsofreadiness
 Somechildrenmaynotbereadyuntilaround30months
 Thepotty-trainingyearsareespeciallyriskyfordevelopingUTI
 Remindchildtovoidoftenevenifhe/sheisnothavingaccidents
 Remindfemalechildrentowipefromfronttoback
 Achildwhoisuncircumcisedshouldbetaughtatpottytraininghowto
graduallyandgentlyretracttheprepuceforvoidingandhygiene
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Review Question
 Amotherisinquiringaboutherchild'sabilitytopottytrain.
Whichofthefollowingfactorsisthemostimportantaspect
oftoilettraining?
A. Theageofthechild
B. Thechild’sabilitytounderstand instructions.
C. Theoverallmentalandphysicalabilities ofthechild.
D. Frequentattemptswithpositivereinforcement.
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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
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Single Umbilical Artery
Associated with
increased incidence of
urogenital
abnormalities
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Low-Set Ears & Urinary Tract Anomalies
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Suspect urinary
tract/ kidney
anomalies

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Skin Tags/ Preauricular Sinus
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Assessment of the Genitourinary System
 Review:AssessingtheAbdomenforShape,Bowel
Sounds,andUnderlyingOrgans(pp.143-145)
 Review:AssessingtheGenitalandPerinealAreasfor
ExternalStructuralAbnormalities(pp.145-149)
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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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Laboratory Tests
 Urinalysis
 Urineculture
 Bloodureanitrogen(BUN)
 Serumcreatinine
 Creatinineclearancetest/glomerularfiltrationrate(GFR)
 Urinealbumin(proteinuria)
 Urineproteintocreatinineratio
 Basicmetabolicpanel/CBC
 Serumalbumin
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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?

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Urine Specific Gravity
 Reliable assessmentofpatient’s hydrationstatus
 1.001–1.035 Normalvalue
IncreasedUrineSG
Dehydration–diarrhea–excessivesweating-vomiting
DecreasedUrineSG
Excessivefluidintake–pyelonephritis-glomerulonephritis
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Urine Collection
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Application of urine collection bag
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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.
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Diagnostic Tests (p. 766)
 ComputedTomography(CT)
 Cystoscopy
 FunctionalRadionucleotideRenalScan
 IVP–IntravenousPyelogram
 RenalBiopsy
 RenalorBladderUltrasound
 VCUG–VoidingCystourethrogram
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Computerized Tomography (CT Scan)
4141
Abdomen CT Scan

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Cystoscopy
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Invasive surgical
procedure
Visualizes bladder,
urethra, and ureter
placement
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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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Intravenous Pyelogram (IVP)
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Kidney function analyzed
Watch for allergic reaction
to dye
Dye can be toxic to kidneys
Push fluids
Monitor I & O
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Review Question
 Achildreturningtotheunitafteranintravenouspyelogram(IVP)
hasanordertodrinkextrafluids.Whenthemotherasksthe
purposeofthesefluids,thenurserespondsthatincreasedfluid
intakewill:
A. Overhydratethechild.
B. Increaseserumcreatinine levels.
C. Make-upforfluidlossesfromNPOstatusbeforetests.
D. Flushanyremaining dyefromtheurinarytract.
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Renal Bladder Ultrasound (RBUS)
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Voiding Cystourethrogram (VCUG)
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Treatment Modalities
 Urinarydiversion
Stents
Drainagetubes
 Intermittent catheterization
Watchforlatexallergies
 Pharmacologicalmanagement
Antibiotics
Anticholinergicforbladderspasm(oxybutynin[DitropanXL])
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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

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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
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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
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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
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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

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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
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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. 768

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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. 769

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

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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
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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
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Details: http://www.pediatricurologybook.com/bladder_exstrophy.html

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Goals of Treatment
 Closebladder/abdominalwall
 Preserverenalfunction
 Attainurinarycontrol
 Acceptableappearance/
functionofgenitals
 Sexualfunction
 Typical&normalchildhood
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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
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ModifiedBryant’straction

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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
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Long Term Complications
 Urinaryincontinence
 Infection
 Bodyimage
 Inadequatesexualfunction
7474

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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)

7676
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Hypospadias
 Ventral surface
 Below glans penis
Epispadias
 Dorsal surface
 Above glans penis

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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. 772

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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. 772

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Review Question
 Aninfanthasbeenadmittedfortreatmentofhypospadias.
Nursingmanagement ofthechildandfamilyincludes:
A. Parenteducation regarding steroidtherapy.
B. Addressingparentalanxietyrelatedtofunctioning and
appearanceofthepenis.
C. Homehealthteaching ofproperstraightcatheterization
techniques.
D. Monitoring forsignsandsymptomsofnephroticsyndrome.
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Double-Diapering Technique After Surgery for
Hypospadias/Epispadias Repair
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Review Question
 Themotherofaninfantwhounderwentsurgerytorepair
hypospadiasasksthenursewhytheinfantisdouble-
diapered.Thenursewouldrespondthatthismethodof
diapering:
A. Protectstheurinarystentthathasbeenputinplace.
B. Adequatelymeasurestheurinaryoutput.
C. Providesformaximumabsorptionofurine.
D. Providesoptimalprotectionofperinealskinfrominfectedurine.
8282

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
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
Review Question
 Aparentasksthenursewhatwilleventuallyhappeniftheinfant
doesnothavehiscongenital hydronephrosistreated.Themost
accurateanswerbythenursewillbewhichofthefollowing?
A. “Ifthehydronephrosisisnottreated,thechildcandevelopbladdercancer.”
B. “Theinfantcanbecomedangerouslyhypotensivebecauseoftheobstructionto
urineflow.”
C. “Smallcalciumstonescanoccurasaresultofuntreatedhydronephrosis,
causingfurtherobstruction.”
D. “Untreatedhydronephrosiscanleadtoirreversiblekidneydamageand
eventualkidneyfailure.”
85

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

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
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
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

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
Nephrotic Syndrome
Acute Poststreptococcal
Glomerulonephritis
RenalFailure
RenalReplacement Therapy
Renal Disorders: Acute, Chronic, &
Structural Causes
9393

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)

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

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

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

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

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.

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
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

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

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

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

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

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

109
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.
109109

110
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.”
110110

Acute Poststreptococcal Glomerulonephritis
111
 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

Group A Streptococcal Infection Manifestations
112

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
113

114
Infection from group A beta-hemolytic Streptococcus leads to an immune
response that causes inflammation and damage to glomeruli
114
Protein&redblood
cellsareallowedtopass
throughglomeruli
Bloodflowtoglomeruli
isreduceddueto
obstructionwithdamaged
cells
Renalinsufficiency
results,leadingto
retentionofsodium,
water,&waste
IMMUNE ACTIVITY targeted at GLOMERULUS
Vessels
clogged
with
cells

Glomerular Capillaries Clogged With Cells
115
 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

116
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
116116
Tea- or cola-colored urine
The most common clinical sign of glomerulonephritis is blood in the urine

118
 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)
118118
Acute Poststreptococcal Glomerulonephritis:
Collaborative Care

 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
119
Acute PoststreptococcalGlomerulonephritis:
Nursing Care

120
Review Question
When reviewingaurinalysisreport ofaclientwithacute
glomerulonephritis, the nurse wouldexpecttonote:
A. Decreased creatinine clearance.
B. Decreased specificgravity.
C. Hematuria.
D. Decreased erythrocyte sedimentation rate(ESR).
120120

121
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
121121
Suddenlossofrenalfunction

123
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.
123123

124
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
124
Injurytothekidneycan
occurbecauseofglomerular
injury,vasoconstrictionof
capillaries,ortubularinjury
Allconsequencesof
injuryleadtodecreased
glomerularfiltration&
oliguria
Acute Renal Failure/ Acute Kidney Injury

125
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.
125125

Newborn Causes Childhood Causes
 Congenital anomalies
 Hypotension
 Complication ofopenheart
surgery
 Dehydration
 Glomerulornephritis /
NephroticSyndrome
 Nephro-toxicity /drugtoxicity
Acute Renal Failure
126

127
Review Question
 Achildisadmitted tothenursingunitwithacuterenalfailure
(ARF).Whenreviewingthenursinghistory,thenursenotesa
historyofallofthefollowing medicalconditions. Whichismost
likelytohaveprecipitated theonsetofARF?
A. Chickenpox.
B. Influenza.
C. Dehydration.
D. Hypervolemia.
127127

128
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
128
See “Clinical Manifestations” – p. 783

129
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
129129

The Most Deadly Electrolyte Imbalance…
131

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
132

134
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.
134134

135
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
135135

136
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
136136

137
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.
137137

138
Acute Renal Failure: Collaborative care
 Treatmentdependsontheunderlyingcause
 Preventpermanentrenaldamage
 Reducesymptoms
 Supportivecareuntilrenalfunctionreturns
 Medications– seechart,p.827
 Avoidnephrotoxicmedications(NSAIDs.,radiocontrastagents,
aminoglycosideabx)
 Dietaryrestrictions–seeTable26-5,p.831
 Dialysisifindicated
 Seevideo4NursingInterventionsforAcuteRenalFailurePart1andPart2
138138

139
Acute Renal Failure: Nursing Care
 Provideemotional supportforchildandfamily
 MonitorVS,I&O,dailyweights,serumelectrolytes
 Administermedications asordered
 Monitornutritional intake–sodium,potassium,andphosphorus
mayneedtoberestricted
 Meetfluid,electrolyte,andnutritional needs
 Preventinfections andcomplications
 Dischargeplanning &homecareteaching
139

141
Review Question
Afour-year-old childhasbeen diagnosed withrenal
failure.Thenurse would ensure thatthedietforthischild
wouldcontain:
A. Foodshighinpotassiumandsodium.
B. Adequatecaloriestooptimizegrowth.
C. Foodshighincalciumcontenttopromotebonegrowth.
D. Increasedfluidintaketoflushtheurinarysystem.
141141

142
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.
142142

143
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
143

144
Effects of Chronic Renal Failure
 Growthdelays
Duetoanemia,metabolismdisturbances,decreasedcaloricintake,
metabolicacidosis
 Cognitivedelays
Duetodecreasedalertness,fatigue,poorschoolattendance
 Socialdevelopmentimpairment
Duetoalterationofbodyimage,delayedonsetofpuberty,sideeffects
ofmedications
144144

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.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
145

147
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.
147147

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
149

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
150

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
151

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
152

153
Renal Replacement Therapy:
Peritoneal Dialysis
 Peritonealdialysis-child’sownperitonealcavityactsasthesemi-permeable
membraneacrosswhichwaterandsolutesdiffuse
153
•SeevideoPeritonealDialysis(NursingConsiderations,Risks,PatientTeaching)

Peritoneal Dialysis
 Softcatheterisusedtofillthe
abdomenwithadialysissolution
 Solutioncontainsdextrose(1.5,2.5,
or4.25%)thatpullswasteandextra
fluidintotheabdominalcavity
 Osmoticpressureofglucosein
solutiondrawsfluidfromvascular
spacesintotheperitoneum,making
availableforexchange/elimination
ofexcessfluid&wastes
 Dialysisfluidisthendrained
154154154

Peritoneal Dialysis: Nursing Care
 Assistparentsinlearningperitonealdialysis
 Makesurestrictsteriletechniqueisusedatalltimesduringcatheter
placementandperitonealdialysis(handhygiene,gloves,masks)
 Monitorthechild’sresponsetothetherapy
 Assessforcomplications:bleedingfromthecathetersite,signsof
infectionatthecathetersite,peritonitis,abdominalhernia
 Maintainpatencyoftheperitonealdialysiscatheter:keepitinplace,
withoutkinksorpulling,andwiththefluidbagsatthecorrectlevel
 Noteifreturningdialysatesolutionhasunusualcolororiscloudy
156
See “Nursing Care Plan: Child Receiving Home Peritoneal Dialysis” – p. 792

157
Review Question
Anappropriate nursingdiagnosis forachildreceiving
peritoneal dialysisis:
A. Fluidvolumedeficitrelatedtosodiumandwaterretention.
B. Imbalanced nutrition,greaterthanbodyrequirements relatedto
increasedhunger.
C. Riskforinfectionrelatedtoinvasiveproceduresanddiminished
immunefunctioning.
D. Alteredrenaltissueperfusion relatedtohypervolemia.
157157

158
Hemodialysis
 Inhemodialysis,amachinefilterswastes,saltsandextrafluidfromtheblood;
thecleanbloodisthenreturnedtothebody
 Requiresstricttreatmentschedule;adherencetomedications/dietrestrictions
 Done3timesaweekfor3to4hoursatadialysiscenter
 Attheonset,achildmayexperienceseveralsideeffects(disequilibrium
syndrome)—hypotension,dizziness,weakness,nausea,ormusclecramps
 SeevideosHemodialysis(Labs,H&H,Cautions)
 WhatDoesaKidneyDialysisAccessLookLike?
 HemodialysisandHowItWorks
158

159
Hemodialysis: Types of Access
159159

Hemodialysis uses a special filter called a dialyzer to
remove wastes and extra fluid from the blood
160

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
161

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
162

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
163
• Rejection – major cause of
transplanted kidney loss
o S/S rejection: Fever; ↑ BUN &
creatinine; pain & tenderness;
irritability; weight gain

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
165

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
166

167
Cryptorchidism
Structural Defects of the
Reproductive System
167167

168
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
168
Bilateral Cryptorchidism

169
Review Question
Why isitimportant that thetestes areinthescrotalsac?
169

Cryptorchidism: Collaborative Care
 Mosttestesspontaneouslydescend
 Hormonetherapy–humanchorionic
gondadotropin (hCG)
 Surgicalprocedure(orchiopexy)iftestes
donotdescendintoscrotalsacby6-12
months
 Riskoftesticularcancerifuntreated
 Monthlytesticularself-examinationis
recommendedforallmalesbeginningin
puberty,butisessentialinmaleswith
historyofundescendedtestis
170
Orchiopexy

171
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.
171171

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)
172

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)
173

174
Review Question
 Ababyisborn6weeksprematurely.Onadmissiontothe
nursery,thenurseisunabletolocateanytesticlesinthe
scrotum.Thenurseshould:
A. Immediatelynotifythephysicianasthechildisatriskforrenalfailure.
B. Notethefindingsinthechild’srecordandtakenofurtheractionatthis
time.
C. Discusswiththefathertheneedforsurgicalcorrectionofcryptorchidism.
D. Catheterizethechildtodetermineifurineispresentinthebladder.
174174

175
Review Question
 Whentalkingwiththeparentsofachildoradolescentwhohas
ahistoryofcryptorchidism, thenursewillmoststressthe
importanceofthechilddoingwhichofthefollowingthings?
A. Gettingamumpsvaccineboosterevery5years
B. Complying100%withhormonetherapybeginningatage15
C. Wearingatesticularsupport(jockstrap)whileparticipating in
sports
D. Doingmonthlyself-testicular examinations beginning atage13
175

Alterations in genitourinary function in children

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