gu dysfunction
TRANSCRIPT
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Genitourinary Dysfunction
in Children
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Pediatric Differences in theGU System:
• By age 1 year: kidneys function at adult level• Premature infants: glucose, sodium, bicarbonate,
phosphate reabsorption is decreased• Infant: only 20% of nephrons have Loops of Henlelong enough to reach medulla, thus cannotconcentrate urine as efficiently
• Bladder moves to pelvic cavity by early childhood• Children have shorter urethras predisposing them toUTI
• Achieve complete bladder control by 4-5 years of age
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Urinary Tract Infection
• Prevalence: 5% in females, 1% in males
• Prevalence: Before age 6 months morecommon in uncircumcised males
• Can cause impaired renal function
• Unexplained fever: obtain urinalysis andurine culture
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Etiology
• Bacteria ascending from the urethra into thebladder and to the upper urinary tract
• Escherichia coli : predominate organism• Candida rarely causes infection• Obstruction• Voiding dysfunction
• Constipation• Vesicoureteral Reflux (VUR)• Intercourse
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Manifestations
• Often vague and nonspecific
• Fever: 100.4 or higher without evidence of
infection in children age 2-24 months• Irritability
• New or increased enuresis
• Dysuria
• Poor weight gain
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Diagnostic Evaluation
• Urinalysis: hematuria, WBC’s, nitrites
• Urine culture: single-strain of bacteria in a clean
catch urine• Use a urine bag to collect sample
• Consider catheterization for sample
• May see a suprapubic aspiration for culture• Refrigerate urine if it is not processed within 10-15 minutes of collection
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Nursing Management
• Obtain history including elimination patterns• VS: particular attention to blood pressure• Assess for CVA tenderness
• Assess for phimosis• Antibiotic instructions – 3-5 day course – Take single dose course at night – Prophylaxis in recurrent cases (VUR)
• Accurate I and O
• Encourage fluid intake (PO or IV)• Education regarding effects of untreated UTI in children• Review symptoms with caregiver• Follow-up diagnostic evaluation to confirm treatment efficacy• Additional education and evaluation for those who are sexually active
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Cryptorchidism
• Undescended or hidden testes
• Begin descent at 26-28 weeks gestation• Premature infants have higher incidence
• Occurs in 5% of healthy full term males
• Etiology unknown
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Associated Risks
• Most testes spontaneously descend withinthe first year of life
• If remains undescended: – Increased risk of malignancy
– Sperm production decreased
– Inguinal hernia more common
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Nursing Interventions
• Assessment/Identification!!
– Assess in a warm environment
– Examine the older child sitting and in a frogleg position
– Milk the testis downward from the groin
– Assess for a hernia – Assess the abdomen
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Nursing Interventions
• Parental education/reassurance
• Review the risks of an undescended testes
• If surgically corrected, postoperative care
– Assess site
– Incentive spirometry
– Skin integrity
– Increase activity
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Hypospadias and Epispadias
• Urethral meatus below or above normalplacement.
• Epispadias is rare• Hypospadias:
– 2/500 males
– Increased risk if father or sibling affected – Testes undescended in 10% of those affected
– Assess for stenosis
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Manifestations
• Altered placement of urethral opening
• Altered urinary stream• Chordee (downward curvature of penis)
• Assess for obstruction of urine outflow
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Therapeutic Management
• No circumcision
• Correction requires surgical intervention
• Done between 6-12 months of age (ideallybefore toilet training)
• Goal of surgery:
– Normalize urinary function – Normalize sexual function
– Cosmetic
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Nursing Interventions
• Identification through assessment
• Obtain history:
– Urinary tract infection
– Quality of urine stream
– Incontinence
– Family History
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Nursing Interventions
• Post-operative care:
– Pressure dressing for 4 days
– Stent or catheter for urine drainage – Hydration (IV the PO)
– Assess urine color, odor, clarity
– Monitor temperature
– Prophylactic antibiotics – Quiet, diversional play
– Pain management
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Nursing Interventions
• Extensive family education
• Restrict activity for 1-2 weeks
• Continued monitoring for UTI
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Glomerulonephritis
• Inflammatory injury in the glomerulus
• Infection, Lupus, Schonlein-Henoch
purpura, vasculitis• Sudden onset, self-limiting, resolve
• Poststreptococcal is the most common
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Pathophysiology
• Antigen-antibody complex formed
• Become trapped in the glomerulus
• Activation of inflammatory response
• Damage to capillary walls
• Decrease in GFR; renal insufficiency
• Large molecules are allowed to pass tourine
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Incidence
• Group A beta-hemolytic streptococcalinfection (throat or skin)
• Young school age children• Higher incidence in winter and summer
• Symptoms appear 8-21 days after
infection
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Manifestations
• Hematuria (smoky, tea colored urine)
• Edema (orbital, worse in a.m.)
• Decreased urinary output
• Hypertension
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Relevant Laboratory Tests
• Proteinuria (mild)
• BUN and creatinine elevated in severe
renal insufficiency• Dilutional anemia
• C3 (serum complement) low
• Antistreptolysin (ASO) titer elevated (onlyuseful for recent infection where the childhas not received antibiotics)
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Nursing Management
• Strict, accurate I and O (hourly)
• Report oliguria
• Accurate daily weights
• Monitor for hypertension• Antihypertensive medication if necessary
• Astute respiratory assessment
• Fluid restriction (monitor for signs of dehydration)
• Low-sodium diet• Cluster care to provide rest
• Reassurance the illness is self-limiting
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Nephrotic Syndrome
• Primary (MCNS): most common
• Secondary: acquired from systemic
disease (lupus, hepatitis, cancer)• Arises from one of 4 types of renal lesions
which all affect the basement membrane
of the glomerulus
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Incidence:
• Children ages 2-6 years
• Slightly higher in boys
• Prognosis for MCNS is good
• Symptoms decrease with age
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Pathophysiology
• Insult to glomerular basement membrane
• Increased permeability resulting in loss of
plasma proteins• Fluid shift to interstitial space
• Hypovolemia and decreased renal blood flow
•Renin production stimulated
• Reabsorption of sodium and water
• Edema
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Pathophysiology (cont’d)
• IgG levels decreased
• Cholesterol and triglycerides elevated
• Hypercoagulable
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Manifestations
• Proteinuria* (frothy urine)
• Hypoalbuminemia*
• Edema* (orbital, worse during day)
• Normotensive
• Increased weight
• Respiratory infection
• Abdominal pain (fluid in peritoneal space)
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Diagnostic Evaluation
• 3+ - 4+ urine protein
• Dark, frothy urine
• Decreased serum albumin• Increased Hgb and Hct
• Increased serum cholesterol
• Increased serum triglycerides• Negative ASO
• Evaluate for underlying etiology
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Management
• Prednisone
• Diuretics
• Albumin
• Antibiotics
• No-added-salt diet
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Nursing Interventions
• Assess VS (hypovolemia)
• Strict I and O
• Assess for dehydration
• Daily weights• Assess exposure to communicable disease
• Prophylactic Penicillin
• Follow labs closely (risk of venous thrombus)
• Measure abdominal girth• Astute assessment of pulmonary status
• No salt added diet
• Consider fluid restriction if becomes hypervolemic
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Acute Renal Failure
• Sudden, severe loss of kidney function
• Prerenal causes: dehydration,
hypotension, shock, renal arteryobstruction, aminoglycosides, contrast dye
• Postrenal causes: structural abnormalities(tumor, ureterovesical obstruction,
neurogenic bladder)• Rare in children
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Manifestations
• Electrolyte and fluid imbalance
• Increased BUN and creatinine
• Acid-base imbalance (acidosis)
• Oliguria (urine output <1cc/kg/hr)
• Poor feeding
• Lethargy
• Seizures
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Hemolytic Uremic Syndrome asa cause of ARF
• Most common cause of acute renal failure
• Shiga’s E-coli
• Causes an inflammatory process• Anemia
• Thrombocytopenia
• Acute renal failure• Source: improperly cooked meat and
contaminated dairy
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Laboratory Data in ARF
• Azotemia (elevated BUN, creatinine, anduric acid)
• Metabolic acidosis (low serumbicarbonate)
• Increased potassium
• Increased or decreased sodium
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Nursing Goals
• Monitoring and maintaining fluid andelectrolyte balance
• Prevention of Infection• Adequate nutrition
• Parental education (decreasing parent an
child anxiety)
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Chronic Renal Failure
•Irreversible loss of kidney function
• Progresses to end stage renal disease
• Common cause: congenital anomaly
• Rare in children (18/1 million)
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Manifestations
• All associated with acute renal failure
• Renal bone disease
• Poor growth (FTT)
• Chronic hypertension
• Neurologic symptoms
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Nursing Goals
• Adequate nutrition
– Na and fluid restriction
– Protein restriction – Potassium restriction
– Phosphorus restriction
– Vitamin D – High calorie foods
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Nursing Goals
• Prevention of infection
• Skin integrity
• Family education
• Developmental activites based on child’sage
• Multidisciplinary approach
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The End