pediatric renal disorders
TRANSCRIPT
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The Child with Genitourinary Dysfunction
Chapter 27
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Renal System Assessment
• Physical assessment
– Palpation, percussion
• Health history
– Previous UTIs, calculi, stasis, retention, pregnancy, STDs, bladder cancer
– Meds: antibiotics, anticholinergics, antispasmodics
– Urologic instrumentation
– Urinary hygiene
– Patterns of elimination
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Nursing Assessment of Urinary Tract Infection (UTI)
• Nausea, vomiting, anorexia, chills, nocturia, frequency, urgency
• Suprapubic or lower back pain, bladder spasms, dysuria, burning on urination
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Nursing Assessment of UTI (cont’d)
• Objective data
– Fever
– Hematuria, foul-smelling urine, tender, enlarged kidney
– Leukocytosis, positive findings for bacteria, WBCs, RBCs, pyuria, ultrasound, CT scan, IVP
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Diagnostic Studies
• Renal scan
• Cystogram
• Retrograde Pyelogram
• U/S
• CT
• MRI
• Renal arteriogram
• UA
• Urine C&S
• BUN
• Creatinine
• KUB
• IVP
• VCG/VCUG
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Normal Urinalysis
• pH: 5.0-9.0• Sp Gr: 1.001-1.035• Protein: <20 mg/dL• Urobilinogen: up to 1 mg/dL• None of the following:
– Glucose – Ketones – Hgb– WBCs
– RBCs– Casts– Nitrites
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Normal Characteristics of Urine
• Color range
• Clear
• Newborn production—approx 1-2 mL/kg/hr
• Child production—approx 1 mL/kg/hr
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Urinary Tract Infection (UTI)
• Is it REALLY that serious?
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UTI (cont’d)
• Concept of “asymptomatic bacteria” in urinary tract
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UTI (cont’d)
• Causes
• E. coli most common pathogen
• Streptococci
• Staphylococcus saprophyticus
• Occasionally fungal and parasitic pathogens
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Classification of UTI
• Upper tract: involves renal parenchyma, pelvis, and ureters
– Typically causes fever, chills, flank pain
• Lower tract: involves lower urinary tract
– Usually no systemic manifestations
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Classification of UTI (cont’d)
• Lower tract
• Cystitis
• Urethritis
• Upper tract
• Pyelonephritis
• VUR
• Glomerulonephritis
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Classification of UTI (cont’d)
• Uncomplicated infection
• Complicated infections
– Stones
– Obstruction
– Catheters
– Diabetes or neurologic disease
– Recurrent infections
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Types of UTIs
• Recurrent—repeated episodes
• Persistent—bacteriuria despite antibiotics
• Febrile—typically indicates pyelonephritis
• Urosepsis—bacterial illness; urinary pathogens in blood
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Etiology and Pathophysiology of UTI
• Physiologic and mechanical defense mechanisms maintain sterility
– Emptying bladder
– Normal antibacterial properties and urine and tract
– Ureterovesical junction competence
– Peristaltic activity
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Etiology and Pathophysiology of UTI (cont’d)
• Alteration of defense mechanisms increases risk of UTI
• Organisms usually introduced via ascending route from urethra
• Less common routes
– Bloodstream
– Lymphatic system
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Etiology and Pathophysiology of UTI (cont’d)
• Contributing factor: urologic instrumentation
– Allows bacteria present in opening of urethra to enter urethra or bladder
• Sexual intercourse promotes “milking” of bacteria from perineum and vagina
– May cause minor urethral trauma
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Etiology and Pathophysiology of UTI (cont’d)
• UTIs rarely result from hematogenous route
• For kidney infection to occur from hematogenous transmission, must have prior injury to urinary tract
– Obstruction of ureter
– Damage from stones
– Renal scars
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Etiology and Pathophysiology of UTI (cont’d)
• UTI is a common nosocomial infection
– Often E. coli
– Seldom Pseudomonas
• Urologic instrumentation common predisposing factor
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Clinical Manifestations of UTI
• Symptoms
– Dysuria
– Frequent urination (>q2h)
– Urgency
– Suprapubic discomfort or pressure
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Clinical Manifestations of UTI (cont’d)
• Urine may contain visible blood or sediment (cloudy appearance)
• Flank pain, chills, and fever indicate infection of upper tract (pyelonephritis)
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Pediatric Manifestations
• Frequency
• Fever in some cases
• Odiferous urine
• Blood or blood-tinged urine
• Sometimes NO symptoms except generalized sepsis
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Pediatric Manifestations (cont’d)
• Pediatric patients with significant bacteriuria may have no symptoms or nonspecific symptoms like fatigue or anorexia
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So how do you find out?
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Diagnostic Studies of UTI
• Dipstick
• Microscopic urinalysis
• Culture
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Diagnostic Studies of UTI (cont’d)
• Clean-catch is preferred
• U-bag for collection from child
• Specimen obtained by catheterization or suprapubic needle aspiration has more accurate results
– May be necessary when clean-catch cannot be obtained
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Diagnostic Studies of UTI (cont’d)
• Sensitivity testing determines susceptibility to antibiotics
• Imaging studies for suspected obstruction
– IVP or Abd CT
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Collaborative Care for UTI Drug Therapy: Antibiotics
• Uncomplicated cystitis: short-term course of antibiotics
• Complicated UTIs: long-term treatment
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Collaborative Care for UTI Drug Therapy: Antibiotics (cont’d)
• Trimethoprim-sulfamethoxazole (TMP-SMX) or nitrofurantoin
• Amoxicillin• Cephalexin• Others
– gentamycin, carbenicillin ++
• Pyridium (OTC)• Combination agents (e.g., Urised) used to
relieve pain– Preparations with methylene blue tint
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Collaborative Care for UTI Drug Therapy
• For Repeated UTIs
– Prophylactic or suppressive antibiotics
– TMP-SMX administered qd to prevent recurrence or single dose prior to events likely to cause UTI
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Etiology and Pathophysiology of Acute Pyelonephritis
• Inflammation caused by bacteria, fungi, protozoa, or viruses infecting kidneys
• Urosepsis: systemic infection from urologic source
– Can lead to septic shock and death in 15% of cases
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Etiology and Pathophysiology of Acute Pyelonephritis (cont’d)
• Usually infection is via ascending urethral route
• Frequent causes
– E. coli
– Proteus
– Klebsiella
– Enterobacter
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Etiology and Pathophysiology of Acute Pyelonephritis (cont’d)
• Preexisting factor (usually)
– Vesicoureteral reflux
– Dysfunction of lower urinary tract function
• Obstruction
• Stricture
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Etiology and Pathophysiology of Acute Pyelonephritis (cont’d)
• Commonly starts in renal medulla and spreads to adjacent cortex
• Recurring episodes lead to scarred, poorly functioning kidney and chronic pyelonephritis
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Clinical Manifestations of Acute Pyelonephritis
• Vary from mild to “classic” and very severe• Presenting symptoms
– N/V, anorexia, chills, nocturia, frequency, urgency
– Suprapubic or low back pain, dysuria– Fever, hematuria, foul smelling urine
• Costovertebral tenderness • Symptoms often subside in a few days, even
without therapy– Bacteriuria and pyuria still persist
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Diagnostic Studies of Acute Pyelonephritis
• Urinalysis
• WBC casts
• CBC
• Imaging studies (IVP or CT)
• Ultrasound
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Collaborative Care of Acute Pyelonephritis
• Hospitalization
• Parenteral antibiotics
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Collaborative Care of Acute Pyelonephritis (cont’d)
• Relapses treated with 6-week course of antibiotics
• Reinfections treated as individual episodes or managed with long-term therapy
– Prophylaxis may be used for recurrent
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Types of Glomerulonephritis
• Most are postinfectious
– Pneumococcal, streptococcal, or viral
• May be distinct entity OR
• May be a manifestation of systemic disorder
– SLE
– Sickle cell disease
– Others
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Glomerulonephritis Symptoms
• Generalized edema due to decreased glomerular filtration
– Begins with periorbital
– Progresses to lower extremities and then to ascites
• HTN due to increased ECF
• Oliguria
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Glomerulonephritis Symptoms (cont’d)
• Hematuria
– Bleeding in upper urinary tract→smoky urine
• Proteinuria
– Increased amt of protein = increased severity of renal disease
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Acute Post-Streptococcal Glomerulonephritis
• Is a non-infectious renal disease
– (Auto immune)
• Onset 5-12 days after OTHER type of infection
• Often group A ß-hemolytic strep
• Most common 6-7 y.o.
• Uncommon in <2 y.o.
• Can occur at any age
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Diagnosing APSG
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Prognosis
• 95%-rapid improvement to complete recovery
• 5%-15%-chronic glomerulonephritis
• 1%-irreversible damage
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Nursing Management of APSG
• Manage edema
– Daily weights
– Accurate I&O
– Daily abdominal girth
• Nutrition
– Low sodium, low-mod protein
• Susceptibility to infections
• Bed rest is not necessary
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Nephrotic Syndrome
• Most common presentation of glomerular injury in children
• Characteristics
– Proteinuria
– Hypoalbuminemia
– Hyperlipidemia
– Edema
– Massive urinary protein loss
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Types of Nephrotic Syndrome
• Minimal change nephrotic syndrome (MCNS)
– AKA
• Idiopathic nephrosis
• Nil disease
• Uncomplicated nephrosis
• Childhood nephrosis
• Minimal lesion nephrosis
• Congenital nephrotic syndrome
• Secondary nephrotic syndrome
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Changes in Nephrotic Syndrome
• Glomerular membrane
– Normally impermeable to large proteins
– Becomes permeable to proteins, especially albumin
– Albumin lost in urine (hyperalbuminuria)
– Serum albumin decreased (hypoalbuminemia)
– Fluid shifts from plasma to interstitial spaces
• Hypovolemia
• Ascites
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Nephrotic Syndrome
• “Edema phase”
• “Remission phase”
• Prognosis
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Nephrotic Syndrome Management
• Supportive care• Diet
– Low to moderate protein – Sodium restrictions when lg amt edema
present• Steroids
– 2 mg/kg divided into BID doses– Prednisone drug of choice ($$ and safest)
• Immunosuppressant therapy (Cytoxan)• Diuretics
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Family Issues
• Chronic condition with relapses
• Developmental milestones
• Social isolation
– Lack of energy
– Immunosuppression/protection
– Change in appearance due to edema self-image
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Nursing Interventions
• Aseptic technique during catheterizations
• Avoid unnecessary catheterization and early removal of indwelling catheters
• Prevents nosocomial infections
– Wash hands before and after contact
– Wear gloves for care of urinary system
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Nursing Interventions (cont’d)
• Routine and thorough perineal care for all hospitalized patients
• Avoid incontinent episodes by answering call light and offering bedpan at frequent intervals
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Nursing Interventions (cont’d)
• Ensure adequate fluid intake (patient with urinary problems may think will be more uncomfortable)
– Dilutes urine, making bladder less irritable
– Flushes out bacteria before they can colonize
– Avoid caffeine, alcohol, citrus juices, chocolate, and highly-spiced foods
• Potential bladder irritants
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Nursing Interventions (cont’d)
• Discharge to home instructions
• Follow-up urine culture
• Recurrent symptoms typically occur in 1-2 weeks after therapy
– Encourage adequate fluids even after infection
– Low-dose, long-term antibiotics to prevent relapses or reinfections
– Explain rationale to enhance compliance
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Hemolytic-Uremic Syndrome
• Pathophysiology
• Diagnostic evaluation
• Therapeutic management
• Prognosis
• Nursing consideration
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Wilms' Tumor
• AKA “nephroblastoma”
• Malignant renal and intraabdominal tumor of childhood
• Three times more common in African-American children
• Peak age of diagnosis is 3 years
• More frequent in males
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Wilms' Tumor (cont’d)
• Etiology
• Diagnostic evaluation
• Therapeutic management
– Surgical removal
– Chemotherapy and/or radiation
• Nursing considerations
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Renal Failure
• Acute renal failure (ARF)
• Chronic renal failure (CRF)
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Acute Renal Failure (ARF)
• Definition: kidneys suddenly unable to regulate volume and composition of urine
• Not common in children
• Principal feature is oliguria
– Associated with azotemia, metabolic acidosis, and electrolyte disturbances
• Most common pathologic cause: transient renal failure resulting from severe dehydration
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ARF (cont’d)
• Pathophysiology—usually reversible
• Diagnostic evaluation
• Therapeutic management
• Nursing considerations
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Complications of ARF
• Hyperkalemia
• Hypertension
• Anemia
• Seizures
• Hypervolemia
• Cardiac failure with pulmonary edema
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Chronic Renal Failure (CRF)
• Begins when diseased kidneys cannot maintain normal chemical structure of body fluids
• Clinical syndrome called UREMIA
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Potential Causes of CRF
• Congenital renal and urinary tract malformations
• VUR associated with recurrent UTIs
• Chronic pyelonephritis
• Chronic glomerulonephritis
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CRF (cont’d)
• Pathophysiology
• Diagnostic evaluation
• Therapeutic management
– Manage diet, hypertension, recurrent infections, seizures
• Nursing considerations
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Dialysis
• Peritoneal dialysis
• Hemodialysis
• Hemofiltration
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Peritoneal Dialysis
• The preferred method of dialysis for children
• Abdominal cavity acts as semipermeable membrane for filtration
• Can be managed at home in some cases
• Warmed solution enters peritoneal cavity by gravity, remains for period of time before removal
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Hemodialysis
• Requires creation of a vascular access and special dialysis equipment
• Best suited for children who can be brought to facility 3x/week for 4-6 hours
• Achieves rapid correction of fluid and electrolyte abnormalities
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Transplantation
• From living related donor
• From cadaver donor
• Primary goal is LT survival of grafted tissue
• Role of immunosuppressant therapy