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Child Child Health Health Nursing Nursing Partnering with Partnering with Children & Families Children & Families Chapter 31 Chapter 31 Alterations in Alterations in Genitourinary Function Genitourinary Function Jane W. Ball Jane W. Ball Ruth C. Bindler Ruth C. Bindler Child Health Nursing: Partnering with Children & Families By Jane W. Ball and Ruth C. Bindler © 2006 Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, NJ 07458

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Page 1: Genitourinary Power Point

Child HealthChild HealthNursingNursing

Partnering withPartnering withChildren & FamiliesChildren & Families

Chapter 31Chapter 31

Alterations inAlterations inGenitourinary FunctionGenitourinary Function

Jane W. BallJane W. BallRuth C. BindlerRuth C. Bindler

Child Health Nursing: Partnering with Children & FamiliesBy Jane W. Ball and Ruth C. Bindler

© 2006 Pearson Education, Inc.Pearson Prentice HallUpper Saddle River, NJ 07458

Page 2: Genitourinary Power Point

Urinary SystemUrinary System• Maintains balance• Removal of waste products• Functionally immature until puberty

Page 3: Genitourinary Power Point

Urinary SystemUrinary System• Functions:

– Excrete wastes– Maintain acid-base and fluid and

electrolyte balance– Regulation of Blood pressure– Stimulation of production of

erythropoietin– Regulation of calcium metabolism

• By activation of vitamin D

Page 4: Genitourinary Power Point

Review of Urinary A&PReview of Urinary A&P

• The key structures of the urinary sx are the Kidneys and the Urinary Tract

• To produce urine, the various parts of the kidney perform 3 basic functions– Glomerular filtration (the process of filtering

blood as it flows through the kidneys)– Tubular resorption (necessary fluids,

electrolytes, proteins + blood cells are retained)

– Tubular secretion (waste products+ fluids filtered out)

Page 5: Genitourinary Power Point

FIGURE 31–1FIGURE 31–1 The urinary system is comprised of the kidneys, The urinary system is comprised of the kidneys, ureters, bladder, and urethra. The kidneys are located between the ureters, bladder, and urethra. The kidneys are located between the twelfth thoracic (T12) and third lumbar (L3) vertebrae.twelfth thoracic (T12) and third lumbar (L3) vertebrae.

Jane W. Ball and Ruth C. BindlerJane W. Ball and Ruth C. BindlerChild Health Nursing: Partnering with Children & FamiliesChild Health Nursing: Partnering with Children & Families

© 2006 by Pearson Education, Inc.© 2006 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458Upper Saddle River, New Jersey 07458

All rights reserved.All rights reserved.

Page 6: Genitourinary Power Point
Page 7: Genitourinary Power Point

Urinary SystemUrinary System• Ureters

– Carry waste fluid from kidneys to bladder

• Bladder– Stores urine– Bladder capacity in ounces estimated by

adding 2 to child’s age– Bladder can hold 1-1 ½ ounces for every year

of age– Muscular organ

Page 8: Genitourinary Power Point

Urinary SystemUrinary System• Kidneys:

– Nephrons• Perform filtration, reabsorption and

secretion

– Filtration occurs at the glomerulus, Bowman’s capsule and the basement membrane

– Most renal growth occurs during the first 5 years of life. This increase in size is d/t the enlargement of the nephrons.

Page 9: Genitourinary Power Point

FIGURE 31–2FIGURE 31–2 The nephrons are the structural and functional unit of the kidneys. The nephrons are the structural and functional unit of the kidneys. They filter water and wastes across the glomerular capillaries to maintain the body They filter water and wastes across the glomerular capillaries to maintain the body fluid level, electrolyte composition, and pH. A nephron holds six glomeruli, fluid level, electrolyte composition, and pH. A nephron holds six glomeruli, Bowman’s capsule, proximal tubule, loop of Henle, distal tubule, and the collecting Bowman’s capsule, proximal tubule, loop of Henle, distal tubule, and the collecting duct.duct.

Jane W. Ball and Ruth C. BindlerJane W. Ball and Ruth C. BindlerChild Health Nursing: Partnering with Children & FamiliesChild Health Nursing: Partnering with Children & Families

© 2006 by Pearson Education, Inc.© 2006 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458Upper Saddle River, New Jersey 07458

All rights reserved.All rights reserved.

Page 10: Genitourinary Power Point

Kidneys Kidneys • Kidneys are immature at birth. As

child grows, concentration of urine becomes more efficient– Refer to Box 31-3– First 2 years of life: less efficient at

regulating f/e and acid/base balance– Urine output per kg body weight is

greater in infancy than childhood/ adolescents.• Kidney less able to concentrate urine

Page 11: Genitourinary Power Point

Urinary SystemUrinary System• For the kidneys to function

effectively, the following conditions need to be present– Unimpaired renal blood flow– Adequate glomerular ultrafiltration– Normal tubular function– Unobstructed urine flow

Page 12: Genitourinary Power Point

Urinary SystemUrinary System• Diagnostic tests for Urinary System

Conditions:– Refer to Table 31-2 p1178 in text

• Normal Urinalysis Results:– Refer to Table 31-3 p 1179 in text

Page 13: Genitourinary Power Point

Structural Defects of the Urinary Structural Defects of the Urinary SystemSystem

• Bladder Exstrophy• Hypospadias and Epispadias• Obstructive Uropathy• Congenital Hydronephrosis• Vesicoureteral Reflux

Page 14: Genitourinary Power Point

Bladder ExstrophyBladder Exstrophy• Rare congenital defect (1 in 40,000

newborns)• Etiology: failure of abdominal wall to

close during fetal development – Leads to eversion of the bladder

• Treatment:– Surgical reconstruction in several stages

• Nursing care:– Cover w/ wet sterile gauze post-delivery,

prepare for surgery

Page 15: Genitourinary Power Point

FIGURE 31–3FIGURE 31–3 This child has exstrophy of the bladder. Note the extrusion of the This child has exstrophy of the bladder. Note the extrusion of the posterior bladder wall through the lower abdominal wall and deformity of the penis.posterior bladder wall through the lower abdominal wall and deformity of the penis.

Jane W. Ball and Ruth C. BindlerJane W. Ball and Ruth C. BindlerChild Health Nursing: Partnering with Children & FamiliesChild Health Nursing: Partnering with Children & Families

© 2006 by Pearson Education, Inc.© 2006 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458Upper Saddle River, New Jersey 07458

All rights reserved.All rights reserved.

Page 16: Genitourinary Power Point

Hypospadias and EpispadiasHypospadias and Epispadias• Congenital anomalies involving and

abnormal location of the urethral meatus• Result from failure of the urethra folds to

fuse completely over the urethral groove• Familial tendency but exact mechanism

unknown• Hypospadias often occurs in conjunction

with congenital inguinal hernias, undescended testes, chordee

• Epispadias often occurs with bladder exstrophy

Page 17: Genitourinary Power Point

FIGURE 31–4FIGURE 31–4 Hypospadias and epispadias. Hypospadias and epispadias. AA, In hypospadias, the , In hypospadias, the urethral canal is open on the ventral surface of the penis. urethral canal is open on the ventral surface of the penis. BB, In epispadias , In epispadias the urethral canal is open on the dorsal surface.the urethral canal is open on the dorsal surface.

Jane W. Ball and Ruth C. BindlerJane W. Ball and Ruth C. BindlerChild Health Nursing: Partnering with Children & FamiliesChild Health Nursing: Partnering with Children & Families

© 2006 by Pearson Education, Inc.© 2006 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458Upper Saddle River, New Jersey 07458

All rights reserved.All rights reserved.

Page 18: Genitourinary Power Point

Hypospadias vs epispadiasHypospadias vs epispadias• The urethral

meatus may be located anywhere along the course of the ventral surface of the penile shaft

• The meatal opening islocated on the dorsal surface of the penile shaft, and may be at the level of the bladder neck.

Page 19: Genitourinary Power Point

Hyposapdias/ Epispadias Hyposapdias/ Epispadias TreatmentTreatment

• For mild cases of hypospadias, no intervention is necessary

• Surgical correction is the tx of choice– Corrected during the first year of life

• DO NOT CIRCUMCISE as foreskin tissue may be used in reconstruction

• Goals of Surgery:– Placement of the urethral meatus at the end of

the glans penis allowing for good urine stream– Release of chordee to straighten penis– Cosmetic appearance

Page 20: Genitourinary Power Point

Hypospadias/ Epispadias Hypospadias/ Epispadias Nursing ResponsibilitiesNursing Responsibilities

• Assist in the identification of defects in complete newborn exam

• Prevent potential complications• Promote parental understanding and

attachment• Promote normal voiding pattern

Page 21: Genitourinary Power Point

Obstructive UropathyObstructive Uropathy• Structural or functional abnormalities

of the urinary system that interferes with urine flow and results in urine backflow into the kidneys.

• The condition can occur anywhere along the urinary tract.

• Pressure caused by urine backup often leads to hydronephrosis

Page 22: Genitourinary Power Point

FIGURE 31–6FIGURE 31–6 Obstruction may occur in either the upper or lower urinary tract. Common sites Obstruction may occur in either the upper or lower urinary tract. Common sites of obstruction occur at the ureteropelvic valve, the ureterovesicular junction, or the posterior of obstruction occur at the ureteropelvic valve, the ureterovesicular junction, or the posterior urethral valve. Why would damage from posterior urethral valves potentially be worse than urethral valve. Why would damage from posterior urethral valves potentially be worse than other obstructions? Renal failure is most likely to occur when both kidneys are affected by other obstructions? Renal failure is most likely to occur when both kidneys are affected by hydronephrosis.hydronephrosis.

Jane W. Ball and Ruth C. BindlerJane W. Ball and Ruth C. BindlerChild Health Nursing: Partnering with Children & FamiliesChild Health Nursing: Partnering with Children & Families

© 2006 by Pearson Education, Inc.© 2006 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458Upper Saddle River, New Jersey 07458

All rights reserved.All rights reserved.

Page 23: Genitourinary Power Point

HydronephrosisHydronephrosis• An accumulation of urine in the renal pelvis as a

result of obstructed outflow, and compromises kidney function.

• Most children with hydronephrosis are born with the condition although it can develop during childhood. It is the most common urinary tract anomaly (abnormality) and ranges in severity. In mild hydronephrosis, the pelvic (the part of the kidney that collects the urine) dilation is barely noticeable, whereas in severe hydronephrosis the swelling occupies much of the abdomen.

Page 24: Genitourinary Power Point

HydronephrosisHydronephrosis

Page 25: Genitourinary Power Point

Pathophysiology of Pathophysiology of HydronephrosisHydronephrosis

• When pressure in the kidney pelvis= the filtration pressure in the glomerular capillary, glomerular filtration stops. In response, Blood pressure increases as the body attempts to increase the glomerular filtration pressure, however increasing pressure usually leads to cell death.

• Metabolic acidosis results when the distal nephrons are impaired in their ability to secrete H+ ions.

• Impaired ability to concentrate urine results in polydypsia and polyuria.

• Obstruction results in urinary stasis, promoting bacterial growth

• Chronic renal failure eventually results when hydronephrosis damages the renal parenchyma causing obstructive nephropathy

Page 26: Genitourinary Power Point

HydronephrosisHydronephrosis• Facts about hydronephrosis • It is four to five times more common

in males than females. • It can occur in one or both kidneys. • Most mild cases and even some

moderate cases may resolve on their own.

• More severe cases may require surgery.

Page 27: Genitourinary Power Point

HydronephrosisHydronephrosis• What are the symptoms of

hydronephrosis? – In mild cases and even some moderate cases

of hydronephrosis, children will have no symptoms and the condition may disappear on its own within the first year of life.

– In more severe cases, when kidney function is affected, the infant or child can experience pain, bleeding and infections. These symptoms may not develop until months or years after hydronephrosis is first detected.

– Tx= surgery to correct blockage

Page 28: Genitourinary Power Point

Vesicoureteral RefluxVesicoureteral Reflux• VUR results in backflow of urine from

the bladder into the kidneys• Prevents complete emptying of the

bladder and creates a reservoir for bacterial growth

• The defect results from incomplete development of the ureterovesical junction, or from a structural anomaly.

Page 29: Genitourinary Power Point

VUR Grades (I-VI)VUR Grades (I-VI)

Page 30: Genitourinary Power Point

VURVUR• 70% of children with symptomatic UTI’s

have VUR• Diagnosis:

– Renal US– VCUG

• a voiding cystourethrogram (VCUG) is an x-ray examination of a child's bladder and lower urinary tract that uses fluoroscopy and a contrast material.

• Complications– Reflux of infected urine can cause pylonephritis

Page 31: Genitourinary Power Point

Disorders Affecting Urinary Disorders Affecting Urinary EliminationElimination

• Urinary Tract Infections (UTI’s)• Enuresis

Page 32: Genitourinary Power Point

UTIUTI• A microbial invasion of the kidneys,

ureters, bladder, or urethra• In the neonatal period, UTI’s occur

most commonly in males, possibly b/c of the higher incidence of congenital abnormalities

• By age 4 months, UTIs are more common in females b/c of the placement and size of the urethra

Page 33: Genitourinary Power Point

UTIUTI• Causes:

– Incomplete bladder emptying– Irritation by bubble baths– Poor hygiene – VUR– Urinary tract obstruction

• Pathophysiology:– Bacteria enter the urethra and ascend the

urinary tract– E.coli (Gram -) causes approximately 75-90%

of all UTIs in females

Page 34: Genitourinary Power Point

UTIUTI• What is the difference b/t these 3

conditions?– Cystitis (bladder)– Urethritis (urethra)– Pyelonephritis (ureters, renal pelvis and

renal parenchyma)

– Most common disorder of GU tract in children

Page 35: Genitourinary Power Point

UTIUTI• Complications:

– Risk of renal failure:• UTI under age 1• Delay in diagnosis• Anatomic or neurologic obstruction• Recurrent episodes of upper UTI

Page 36: Genitourinary Power Point

UTIUTI• Complications:

– VUR– Glomerulonephritis– Bacteremia– Sepsis– Septic Shock

• Tests:– Clean catch Urine Analysis and urine Cx-

results yield large amounts of bacteria– Increased urine pH

Page 37: Genitourinary Power Point

UTIUTI• Clinical Findings:

– Abdominal pain– Enuresis– Frequency and Urgency– Pain/ burning w/ urination (dysuria)– Hematuria– Lethargy or irritability– Poor feeding patterns– Cloudy, foul-smelling urine

Page 38: Genitourinary Power Point

UTIUTI• What is the most common clinical

presentation of UTI in the child under 2?– Fever with associated s/sx including:

• V/D• Irritability • Poor PO intake• Malodorous urine• Oliguria• Constipation

– Please Refer to Table on page 1187 for other clinical manifestations of UTIs

Page 39: Genitourinary Power Point

Normal Urinalysis ResultsNormal Urinalysis Results• Normal values used in many laboratories are given below:• Glucose: negative (quantitative less than 130 mg/day or 30

mg/dL). • Bilirubin: negative (quantitative less than 0.02 mg/dL). • Ketones: negative (quantitative 0.5–3.0 mg/dL). • pH: 5.0–8.0. • Protein: negative (quantitative 15–150 mg/day, less than 10

mg/dL). • Blood: negative. • Nitrite: negative. • Specific gravity: 1.015–1.025. • Urobilinogen: 0–2 Ehrlich units (quantitative 0.3–1.0 Ehrlich units). • Leukocyte esterase: negative. • Red blood cells: 0–2 per high power field. • White blood cells: 0–5 per high power field (0–10 per high power

field for some standardized systems).• Also note color and odor of urine

Page 40: Genitourinary Power Point

Urine CultureUrine Culture• A urine culture is a diagnostic

laboratory test performed to detect the presence of bacteria in the urine (bacteriuria).

• Usually takes 24-48 hours for results• If symptomatic, treat empirically

Page 41: Genitourinary Power Point

Nursing care of UTI’sNursing care of UTI’s• Administer abx as Rx’d; instruct parents to

complete entire course of abx• Encourage fluids to help to flush infection

from the urinary tract• Teach proper toileting hygeine• Encourage child to use toilet every 2 hours• Discourage bubble baths• Teach parents about s/sx of UTIs

Page 42: Genitourinary Power Point

EnuresisEnuresis• Repeated involuntary voiding by a

child who has reached an age which bladder control is expected (5-6 y.o)– Enuresis at night= nocturnal enuresis

• 50% of cases• More common in boys

– Enuresis during day= diurnal enuresis• More common in girls

– Further categorized as primary, intermittent and secondary

Page 43: Genitourinary Power Point

EnuresisEnuresis• Primary:

– Child has never had a dry night; attributed to maturational delay and small functional bladder

• Intermittent:– Child has occasional nights or periods of

dryness

• Secondary:– Child begins bedwetting who has been reliably

dry for 6-12 months; associated with stress, infections and sleep disorders

Page 44: Genitourinary Power Point

EnuresisEnuresis• Clinical manifestations for diurnal

enuresis:– Frequency– Urgency– Constant dribbling– Involuntary loss of control after voiding

• Clinical manifestations for nocturnal enuresis:– bedwetting

Page 45: Genitourinary Power Point

EnuresisEnuresis• A thorough hx is obtained. See Box 31-3• Clinical therapy:

– Spontaneous cure rate in 15% of cases/year– Multitreatment approach most efficient

• 1/3 of nocturnal enuresis tx’d w/ meds• See page 1191 for meds used to tx enuresis• Behavioral interventions

– Fluid intake programs, bladder alarms, and bladder training

Page 46: Genitourinary Power Point

EnuresisEnuresis• Nursing management:

– Thorough hx– Evaluate if parents and child are equally

motivated to resolve problem– Teaching

Page 47: Genitourinary Power Point

Kidney DisordersKidney Disorders• Nephrotic Syndrome• Renal Failure• Glomerulonephritis• Hemolytic Uremic Syndrome• Polycystic Kidney Disease

Page 48: Genitourinary Power Point

Nephrotic SyndromeNephrotic Syndrome• Condition in which the kidneys lose a

significant amount of protein in the urine, resulting in low blood levels of protein.

• Nephrotic syndrome refers not to a specific disease but to a clinical state characterized by:– Proteinuria– Hypoalbuminemai– Hyperlipidemia– edema

Page 49: Genitourinary Power Point

Nephrotic SyndromeNephrotic Syndrome• If nephron’s allow increased protein

to escape from the blood what does this lead to?

Page 50: Genitourinary Power Point

Nephrotic SyndromeNephrotic Syndrome

Page 51: Genitourinary Power Point

FIGURE 31–7FIGURE 31–7 Note the contrast between the normal glomerular anatomy and the Note the contrast between the normal glomerular anatomy and the changes that exist in nephrotic syndrome permitting protein to be excreted in the changes that exist in nephrotic syndrome permitting protein to be excreted in the urine. The lower albumin blood level stimulates the liver to generate lipids and urine. The lower albumin blood level stimulates the liver to generate lipids and excessive clotting factors. Edema results from decreased oncotic plasma pressure, excessive clotting factors. Edema results from decreased oncotic plasma pressure, renin-angiotensin-aldosterone activation, and antidiuretic hormone secretion.renin-angiotensin-aldosterone activation, and antidiuretic hormone secretion.

Jane W. Ball and Ruth C. BindlerJane W. Ball and Ruth C. BindlerChild Health Nursing: Partnering with Children & FamiliesChild Health Nursing: Partnering with Children & Families

© 2006 by Pearson Education, Inc.© 2006 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458Upper Saddle River, New Jersey 07458

All rights reserved.All rights reserved.

Page 52: Genitourinary Power Point

FIGURE 31–9FIGURE 31–9 The initial kidney injury is usually associated with an acute condition such as The initial kidney injury is usually associated with an acute condition such as sepsis, trauma, and hypotension, or the result of treatment for an acute condition with a sepsis, trauma, and hypotension, or the result of treatment for an acute condition with a nephrotoxic medication. Injury to the kidney can occur because of glomerular injury, nephrotoxic medication. Injury to the kidney can occur because of glomerular injury, vasoconstriction of capillaries, or tubular injury. All consequences of injury lead to decreased vasoconstriction of capillaries, or tubular injury. All consequences of injury lead to decreased glomerular filtration and oliguria.glomerular filtration and oliguria.

Jane W. Ball and Ruth C. BindlerJane W. Ball and Ruth C. BindlerChild Health Nursing: Partnering with Children & FamiliesChild Health Nursing: Partnering with Children & Families

© 2006 by Pearson Education, Inc.© 2006 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458Upper Saddle River, New Jersey 07458

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Page 53: Genitourinary Power Point

Nephrotic SyndromeNephrotic Syndrome• Primary nephrotic syndrome occurs

predominantly in preschool children• Incidence peaks b/t ages 2-3 years• Syndrome rare after age 8• More common in boys• Some forms may progress to ESRD

Page 54: Genitourinary Power Point

Nephrotic SyndromeNephrotic Syndrome• How does this happen?

– Injury to glomerular filtraiton membrane allows the loss of plasma proteins (especially albumin and immunoglobulin)

– This results in decreased levels of serum albumin (hypoalbuminemia)

– Hypoalbuminemia results in decreased colloidal osmotic pressure and fluid accumulation in the interstitial spaces.

– Edema results from Na and H2O retention

Page 55: Genitourinary Power Point

Nephrotic Syndrome Nephrotic Syndrome • Clinical Manifestations by body

system:– Renal

• Oliguria, and dark, frothy urine– CV

• HTN (later stages), tachycardia– Vascular

• Thrombosis– Gastrointestinal

• Anorexia, abd pains, n/v/d– Skin

• Pallor, shiny w/ prominent veins, brittle hair, edema, skin breakdown

– Pulmonary• Respiratory distress and pulmonary congestion

Page 56: Genitourinary Power Point

FIGURE 31–8FIGURE 31–8 This boy has generalized edema, a characteristic finding in nephrotic This boy has generalized edema, a characteristic finding in nephrotic syndrome.syndrome.

Jane W. Ball and Ruth C. BindlerJane W. Ball and Ruth C. BindlerChild Health Nursing: Partnering with Children & FamiliesChild Health Nursing: Partnering with Children & Families

© 2006 by Pearson Education, Inc.© 2006 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458Upper Saddle River, New Jersey 07458

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Page 57: Genitourinary Power Point

Nephrotic SyndromeNephrotic Syndrome• Diagnostic Tests:

– Ua= severe proteinuria (primary indicator), hematuria and casts; also an elevated spec grav b/c of the proteinuria

– Renal biopsy= identifies the type of nephrotic syndrome the child has, and can be used to monitor response to medical management

– Blood studies show: serum creatinine, BUN, choles

Page 58: Genitourinary Power Point

Minimal Change Nephrotic Minimal Change Nephrotic SyndromeSyndrome

• Glomeruli appear normal or show only minimal changes on microscopic eval.

• Most common form of Nephrotic Syndrome– MCNS affects 85% children w/ nephrotic

syndrome – Usually affects children b/t 2-7 years– Poorer prognosis, progresses more rapidly to

renal failure

Page 59: Genitourinary Power Point

MCNSMCNS• Etiology and Pathophysiology:

– Cause unknown; immune-mediated • (often preceded by URI)

– The glomeruli appear normal or only have a minimal change in appearance, but their permeability is greatly affected

– Characteristic symptoms include• Edema…weight gain• Excessive clotting factors• Hyperlipidemia• Low serum sodium

Page 60: Genitourinary Power Point

Nursing Care of the Child Nursing Care of the Child with Nephrotic Syndromewith Nephrotic Syndrome

• Physiologic/ Psychosocial assessment• Administer medications• Prevent infections• Prevent skin breakdown• Nutrition/ fluid needs• Promote rest• Provide emotional support• Teaching/ DC planning

Page 61: Genitourinary Power Point

Nephrotic SyndromeNephrotic Syndrome• Medications: refer to pgs 1196-1197• Corticosteroid therapy• Alylating/ Cytotoxic Agents • Cylosporine Therapy

(immunosuppressants)• Diuretics• ACE Inhibitors• Antithrombolitic therapy• NSAIDS

Page 62: Genitourinary Power Point

Nephrotic SyndromeNephrotic Syndrome• Medications:

– Prednisone or prednisolone• Stimulates remission by reducing the

excretion of protein in the urine• Children who respond to this therapy will

continue to take Rx X 6 weeks, and then taper

Page 63: Genitourinary Power Point

Nephrotic SyndromeNephrotic Syndrome• Discharge Planning:

– Parents need to monitor protein in urine daily using dipsticks

– Understand that relapses do occur– No added salt diet– Monitor weight

Page 64: Genitourinary Power Point

Acute and Chronic Renal Acute and Chronic Renal FailureFailure

• Occurs when the kidney is unable to excrete wastes and concentrate urine

• Acute- occurs suddenly and may be reversible

• Chronic-occurs gradually and permanently• Azotemia: accumulation of nitrogenous

wastes in blood• Oliguria: urine output 0.5-1ml/kg/hour• Anuria: absent urine output

Page 65: Genitourinary Power Point

FIGURE 31–11 (continued)FIGURE 31–11 (continued) This child is undergoing hemodialysis. This child is undergoing hemodialysis. AA, Note the , Note the surgically implanted vascular graft. One needle is placed in the arterial end of the surgically implanted vascular graft. One needle is placed in the arterial end of the graft (red tubing), and one needle is placed in the venous end (blue tubing) for graft (red tubing), and one needle is placed in the venous end (blue tubing) for blood return. blood return. BB, The child is able to draw or perform other quiet activities during , The child is able to draw or perform other quiet activities during dialysis treatment. Note that the child’s blood pressure is carefully monitored dialysis treatment. Note that the child’s blood pressure is carefully monitored throughout the treatment.throughout the treatment.

Jane W. Ball and Ruth C. BindlerJane W. Ball and Ruth C. BindlerChild Health Nursing: Partnering with Children & FamiliesChild Health Nursing: Partnering with Children & Families

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B

Page 66: Genitourinary Power Point

Renal FailureRenal Failure• Acute Renal Failure:

– Refer to Table on pg 1200 for Clinical Manifestations

• Nursing Management:– Monitor side effects of medications– Prevent infection– Meet nutritional needs (Table 31-8 p 1207)– Maintain fluid restrictions– Provide emotional support– D/C planning: anticipatory teaching

Page 67: Genitourinary Power Point

Acute Postinfectious Acute Postinfectious GlomerulonephritisGlomerulonephritis

• Glomerulonephritis: an inflammation of the glomeruli of the kidneys– Acute or chronic– In children, most often a response to

GABHS infection of skin or pharynx (aka Post-Strep Glomerulonephritis)

– Other organisms: Staph, Pneumococcus and coxsackievirus

– Abx are not a tx for APIGN. Abx are Rx’d to tx the original infection

Page 68: Genitourinary Power Point

APIGNAPIGN• Highest in children ages 2-12• More common during winter and spring

months• The child typically has a h/o a recent

respiratory infection (w/in 1-2 weeks) or impetigo.

• The child recovers from infection, then develops APIGN after 8-14 days

• Glomerular damage occurs as a result of an immune complex reaction that localizes on the glomerular capillary wall

Page 69: Genitourinary Power Point

APIGNAPIGN• Clinical Manifestations:

– % of children are asymptomatic– Abrupt onset of abdominal pain– Irritability – Microscopic hematuria (most all cases)– Acute HTN

• Nonspecific symptoms– These can include general malaise,

weakness, and anorexia and are present in 50% of patients.

– Approximately 15% of patients complain of nausea and vomiting.

Page 70: Genitourinary Power Point

APIGNAPIGN• Clinical Manifestations:• Dark urine (brown-, tea-, or cola-colored)

– This is often the first clinical symptom.– Dark urine is caused by hemolysis of red blood

cells that have penetrated the glomerular basement membrane and have passed into the tubular system.

• Periorbital edema and dependent edema– The onset of puffiness of the face or eyelids is

sudden. It is usually prominent upon awakening and, if the patient is active, tends to subside at the end of the day.

– In some cases, generalized edema and other features of circulatory congestion, such as dyspnea, may be present.

– Edema is a result of a defect in renal excretion of salt and water, and can result in HTN

Page 71: Genitourinary Power Point

FIGURE 31–13FIGURE 31–13 Infection from group A beta-hemolytic Streptococcus causes an immune response that Infection from group A beta-hemolytic Streptococcus causes an immune response that causes inflammation and damage to the glomeruli. Protein and red blood cells are allowed to pass through the causes inflammation and damage to the glomeruli. Protein and red blood cells are allowed to pass through the glomeruli. Blood flow to the glomeruli is reduced due to obstruction with damaged cells and renal insufficiency glomeruli. Blood flow to the glomeruli is reduced due to obstruction with damaged cells and renal insufficiency results, leading to the retention of sodium, water, and waste. results, leading to the retention of sodium, water, and waste.

Jane W. Ball and Ruth C. BindlerJane W. Ball and Ruth C. BindlerChild Health Nursing: Partnering with Children & FamiliesChild Health Nursing: Partnering with Children & Families

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Page 72: Genitourinary Power Point

APIGNAPIGN• Lab Findings:

– Hematuria– Proteinuria– Leukocytes – Decreased serum protein– Anemia – ESR increased– Serum IgG antibodies against Strep +– Circulatory overload causing EKG changes

Page 73: Genitourinary Power Point

APIGN Nursing CareAPIGN Nursing Care• Assessment:

– VS, especially BP– F&E’s with strict I’s & O’s, specific gravity– Daily weights– Urine dipstick for + hematuria, +proteinuria– Assess edema (periorbital, dependent)– Measure abdominal girth– Auscultate heart and lung sounds, not

respiratory effort– Monitor neurologic signs secondary to HTN

(LOC, HA, sz activity, vomitting)

Page 74: Genitourinary Power Point

Hemolytic Uremic SyndromeHemolytic Uremic Syndrome

• Hemolytic uremic syndrome (HUS) is a disease primarily of infancy and early childhood.

• It is characterized by the triad of hemolytic anemia, thrombocytopenia, and acute renal failure.

• Diarrhea and upper respiratory infection are the most common precipitating factors.

• HUS is the most common cause of acute renal failure in children.

• It occurs mostly in infants and children from 6 months to 4 years.

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HUSHUS• Verotoxin causes damage to the lining of the glomerular

arterioles resulting in swelling of the endothelial cells.• The lining of the glomerular arterioles becomes inflamed,

swollen, and occluded w/ particles of platelets and fibrin.• RBC and PLTs are damaged as they flow through the

partially occluded vessels.• As the damaged cells reach the spleen, they are destroyed

and removed from circulation. This leads to hemolytic anemia.

• 90% of children w/ this syndrome, have recently experienced E.coli GI infection.– Over ½ cases by contaminated beef

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HUSHUS• The bacterial infection causes endothelial cell

injury in the lining of the small glomerular arterioles.

• This cell damage triggers clotting mechanisms that occlude the arterioles and capillaries.

• This plt aggregation results in thrombocytopenia (b/c plts are damaged by irregular blood cells), and the kidneys become swollen

• Although damage occurs mainly in the endothesial lining of the glomerular arterioles, other organs can be involved (heart, pancreas)

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HUS Clinical ManifestationsHUS Clinical Manifestations

• Prodromal stage: – URI

• 1-7 days: – fever, Irritability, weakness, lethargy,

lymphadenopathy, skin rash, abdominal pain w/ N/V/D

• Acute Stage:– Hemolytic anemia, HTN, Pallor and

purpura, neurologic involvement, and renal failure

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Management of HUSManagement of HUS• Supportive tx to maintain kidney

function• Daily plasma exchange until remission is

achieved• Maintenance of fluid and electrolyte

balance and correction of acidosis to prevent szs

• Corticosteroids• Early dialysis if ARF develops• Management of HTN

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HUSHUS• Nursing Management:

– Same as with acute kidney failure– Dialysis– Diet of small, high-calorie, high-carbohydrate– Diet of low Na++, potassium and phosphorus

• Education and Prevention:– Reduce risk of consumption of cantaminated

beef– Cook ground beef to 155 degrees– Wash hands when handling raw meat– Use meat thermometer

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Toilet TrainingToilet Training• Physical Readiness• Social and cultural aspects of toilet

training in children (p 446 in text)