Monday, March 9, 2009

Pediatric Nursing: Genito urinary disorders

Genitourinary Disorders


Alterations in Renal Function


Biological Variances

All nephrons are present at birth


Kidneys and tubular system mature throughout childhood
reaching full maturity during adolescence.


During first two years of life kidney function is less
efficient.



Bladder

Bladder capacity increases with age


20 to 50 ml at birth


700 ml in adulthood



Urinary Output


Urinary output per kilogram of body weight decreases as
child ages because the kidneys become more efficient.


Infants 1-2 mL/kg/hr


Children 0.5 – 1 mL/kg/hr


Adolescents 40 – 80 mL/hr

Growth and Development

Newborn = loss of the perfect child


Toddler = toilet training


Pre-school = curiosity


School age = embarrassment


Adolescent = body image / sexual function



Focused Health History

Single umbilical artery


Chromosomal abnormality


Congenital anomalies


Ear tags


Toilet training history


Family history


Growth patterns



Urine


Urinalysis

Protein


Leukocytes


Red blood cells


Casts


Specific Gravity


Urine Culture for bacteria



Diagnostic Tests





Urinalysis


Ultrasound


VCUG – Voiding cysto urethrogram


IVP – Intravenous pyelogram


Cystoscopy


CT Scan


Renal Biopsy



VCUG


IVP


Intra Venous Pyelogram


Renal Biopsy


Cystoscopy


CT Scan


Treatment Modalities





Urinary diversion


Stents


Drainage tubes


Intermittent catheterization


Watch for latex allergies


Pharmacological management


Antibiotics


Anticholinergic for bladder spasm



Urinary Tract Infection





Most common serious bacterial infection in infants and
children


Highest frequency in infancy


Uncircumcised males have a ten-fold incidence



Etiology





Anatomic abnormalities


Neurogenic bladder – incomplete emptying of bladder


In the older child: infrequent voiding and incomplete
emptying of bladder or constipation


Teenager: sexual intercourse due to friction trauma



UTI - Females





Most common in females


Short urethra


Improper wiping


Nylon under pants


Current guidelines – do ultrasound with first UTI followed
by VCUG if indicated



UTI – Males





Infant males


Needs to be investigated





VCUG – ureteral reflux


Ultrasound of kidneys – hydronephrosis or polycystic kidneys



Higher in un-circumcised males





Un-circumcised males





Instruct parents to gently retract foreskin for cleansing


Do not force the foreskin


Do not leave foreskin retracted or it may act as tourniquet
and obstruct the head of the penis resulting in emergency circumcision



Clinical Manifestations: UTI





Urinary frequency


Hesitancy


Dysuria


Cloudy, blood tinged


Must smell to urine


Temperature


Poor feeding / failure to grow


The neonate may only exhibit 6 & 7



Interventions





Antibiotic therapy for 7 to 10 days


E-coli most common organism 85%


Amoxicillin or Cefazol or Bactrim or Septra


Increase fluid intake


Cranberry juice


Sitz bath / tub bath


Acetaminophen for pain


Teach proper cleansing



Urethritis





Urethral irritation due to chemicals or manipulation


Most common in females


Bubble bath, scented wipes, nylon under wear


Self-manipulation


Child abuse



Voiding Disorders





Delay or difficulty in achieving control after a socially
acceptable age.


Enuresis


Nocturnal = at night


Diurnal = during the day


Secondary = relapse after some control



Toilet Training Readiness





12 months no control over bladder


18 to 24 months some children show signs of readiness


Some children may not be ready until around 30 months



Enuresis





Involuntary discharge of urine after the age by which
bladder control should have been established, usually considered to be age of
5 years.



Enuresis



Familial history


Males outnumber females 3:2


5 to 10% will remain enuretic throughout their lives


Rule out UTI, ADH insufficiency, or food allergies





Interventions





Pharmacological intervention:


Desmopressin synthetic vasopressin acts by reducing urine
production and increasing water retention and concentration


Tofranil: anticholinrgic effect – FDA approval for treatment
of enuresis





Side effect may be dry mouth and constipation


Some CNS: anxiety or confusion


Need to be weaned off




Treatment Enuresis





Diet control


Reduce fluids in evening


Control sugar intake


Bladder training


Praise and reward


Behavioral chart to keep track of dry nights


Alarm system





Ureteral Reflux





Males 6 to 1


Genetic predisposition


Present as UTI or FTT


Diagnostic tests


Antibiotics if indicated


Surgery to re-implant ureters




Hydronephrosis





Water on kidney


Due to obstruction


Congenital anomaly


Goals of care to maintain integrity of kidney until normal
urinary flow can be established.



Clinical Manifestations





History of UTI


Followed by flank pain, fever and chills


Decrease in urinary outflow


Neonate may present as UTI


An older child may be asymptomatic except for failure to
thrive



Diagnostics





Ultrasound


VCUG: voiding cyto urethrogram


IVP is the first two are positive



Goals of treatment





To preserve renal function


Temporary urinary diversion may be needed to relieve the
pressure.


Nephrectomy if renal damage is not reversible



Ambiguous Genitalia





Genital appearance that does not permit gender declaration.



Agenesis of Scrotum


Hypertrophy of Clitoris


Extrophy of Bladder





Interrupted abdominal development in early fetal life
produces an exposed bladder and urethra, pubic bone separation, and associated
anal and genital abnormalities.



Exstrophy of Bladder





Occurs is 1 of 30,000 births


Congenital malformation in which the lower portion of
abdominal wall and anterior bladder wall fail to fuse during fetal
development.



Clinical Manifestations





Visible defect that reveals bladder mucosa and ureteral
orifices through an open abdominal wall with constant drainage of urine.



Extrophy of Bladder


Treatment





Surgery within first hours of life to close the skin over
the bladder and reconstruct the male urethra and penis.


Urethral stents and suprapubic catheter to divert urine


Further reconstructive surgery can be done between 18 months
to 3 years of age



Goals of Treatment



Preserve renal function: prevent infection


Attain urinary control


Re-constructive repair


Sexual function



Long Term Complications





Urinary incontinence


Infection


Body image


Inadequate sexual function



Hypospadias





Most common anomaly of the male phallus


Incomplete formation of the anterior urethral segment


Urethral formation terminates at some point along the
ventral fusion line.


Cordee – downward curve of penis.



Newborn





Circumcision not recommended.


Foreskin may be needed for reconstructive surgery.



Tight Chordee


Goals of Treatment





Release of tight chordee


Placement of urethra opening at head of penis


Surgery recommended at around six to nine months of age


Long term outcomes:


Leaking at the site


Body image



Cryptorchidism (undescended testicles)





Hidden testicle


3 to 5% of males


High incidence in premature infants


Goals of treatment:


Preserve testicular function


Normal scrotal appearance





Treatment





Most testes spontaneously descend.


Surgical procedure, orchiopexy, if testicles do not descend
into the scrotal sac by 6 to 12 months of age


Hormone therapy – human chorionic gondadotropin


Slightly higher risk of testicular cancer if untreated


In the teen or adult the testicle would be removed



Long-term





Monthly testicular self-examination is recommended for all
males beginning in puberty, but is essential in males with history of
undescended testicle.



Testicular Torsion





Rotation of the testicle


Spermatic cord twists and obstructs circulation to the
testis


Left testicle affected more


Longer cord on left side



Clinical Manifestations



Sudden severe pain in the scrotal area


Highest incidence on left side due to longer cord on that
side



Goals of Treatment





Surgical intervention


To relieve obstruction


Preserve the testicular function


Secure testicle to avoid further twisting



Acute Renal Failure





Pre-renal, resulting from impaired blood flow to or
oxygenation of the kidneys.


Renal, resulting from injury to or malformation of kidney
tissues.


Post-renal, resulting from obstruction of urinary flow
between the kidney and urinary meatus.



Renal Failure





Newborn causes:


Congenital anomalies


Hypotension


Complication of open heart surgery





Renal Failure





Childhood causes:



Dehydration



Glomerular nephritis / Nephrotic Syndrome


Nephro-toxicity / drug toxicity



Clinical Manifestation: ARF





Sudden onset


Oliguria


Urine output less than 0.5 to 1 mL/kg/hour


Volume overload due to retained fluid


Hypertension, edema, shortness of breath


Acidosis



Diagnostic Tests





Decrease RBC due to erythropoietin



Urea and Creatinine
elevated



GFR (glomerular filtration rate)
most sensitive indicator of glomerular function.






Urea or BUN





Urea is normally freely filtered through the renal glomeruli,
with a small amount reabsorbed in the tubules and the remainder excreted in
the urine.


Decrease or increase in the value does not tell the cause:
pre-renal, post-renal or renal.


Elevated BUN just tells you the urea is not being excreted
by the kidney not why.



Creatinine





Creatinine is a very specific indicator of renal function.


If kidney function is decreased / creatinine level with be
increased


Conditions that will increase levels: glomerulonephritis,
pyelonephritis or urinary blockage



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.



Goals of Treatment: ARF





Reduce symptoms


Supportive care until renal function returns


Medications – corticosteroids


Dietary restrictions


Dialysis if indicated



Nursing Diagnosis





Fluid Volume excess


Potential for infection due to invasive procedures


Potential for activity intolerance


Altered nutrition: less than body requirements


Anxiety of patient and family



Peritoneal Dialysis





The child’s own peritoneal cavity acts as the semi-permeable
membrane across which water and solutes diffuse.


Often initiated in the ICU.


Dialysis set-ups are available commercially.



Peritoneal Dialysis





Soft catheter is used to fill the abdomen with a dialysis
solution.


The solution contains dextrose that pulls waste and extra
fluid into the abdominal cavity.


Dialysis fluid is then drained.



Dialysis fluid





High glucose concentrate: 2.5 to 4.25%


The osmotic pressure of the glucose in solution draws the
fluid from the vascular spaces into the peritoneum, making available for
exchange and elimination of excess fluid.



Complications of Peritoneal Dialysis





Peritonitis


Pain during infusion of fluids


Leakage around the catheter


Respiratory symptoms


Abdominal fullness from too much fluids


Leakage of fluid to chest from hole in diaphragm



Hemodialysis





Used in treatment of advanced and permanent kidney failure.


Blood flows through a special filter that removes waste and
extra fluids.


The clean blood is then returned to the body.


Done 3 times a week for 3 to 5 hours.



Dialysis


Nephrotic Syndrome / nephrosis





Etiology is not know, it is felt to be the result of an
alteration of the glomerular membrane, making it permeable to plasma proteins
(especially albumin).



Clinical Manifestations





Generalized edema


Edema is worse in scrotum and abdomen (results in ascites)


Dramatic weight gain


Pale, fatigue, anorexic


Urinary output decreased


Urine dark and frothy with elevated SG



Urine Specific Gravity





1.010 Normal value



Increased Urine SG





Dehydration – diarrhea – excessive sweating - vomiting



Decreased Urine SG





Excessive fluid intake – pyelonephritis - nephritis




Diagnostic evaluation





Proteinuria


* 4+ urine in urine


Hypoproteinemia


Low serum plasma protein


Hyperlipidemia


* Fat cells in blood


BUN and Creatinine normal unless renal damage





Goals of Treatment





To decrease urinary protein loss


Controlling edema





Corticosteroids up to 12 months



Balanced nutrition


Restore normal metabolic function


Prevent or treat any infection



Interventions





Diuretics (during acute phase lasix would be given after IV
albumin)


Fluid restriction if edema severe


Low sodium / high protein diet


Daily weights


Strict intake and output



Corticosteroid Therapy





High dose prednisone


Taper when protein loss in urine decreases


Current recommendations to keep on low dose every other day
for up to 6 months


If relapse or remission not obtained will try cytotoxic
medications



Physiologic Changes: cortisone





Catabolism of protein, leading to capillary weakness and
poor wound healing


Decreased absorption of calcium leading to demineralization
of bone / osteoporosis


Increased appetite


Salt-retaining activity of cortisol / hypertension



Side Effects





Hirsutism


Moon face with ruddy cheeks


Acne


Dorsocervical fat pads


Ecchymosis (easy bruising)


Truncal obesity


Mood swings – inability to sleep


Increase appetite



Moon Face


Before and After


Nursing Interventions for long tern use





Prednisone prescribed every other day


Instruct to take in the morning



Long Term Use - Prednisone every other day in the am



Take with food: can cause GI upset


Do not stop taking medication until instructed to do so


Medication needs to be tapered


Monitor for infection



Glomerulonephritis





Immune complexes become entrapped in the glomerular
membrane.


Symptoms appear 1 to 2 weeks after a Strep A skin or throat
infection.



Clinical Manifestations





Hematuria / red cells casts


Facial edema


Brown or frothy urine


Mild proteinuria


Hypertension



Management





Interventions:


Low sodium / high protein


Anti-hypertensive drugs


Diuretics


Antibiotics if + throat culture or blood culture


Monitor blood pressure


24 hour urine for Creatinine clearance



Teaching





Culture sore throats


Take antibiotics for full course prescribed


Do not share medications with others in family