to show an in-depth understanding of the genito-urinary disorders in children and the process of...
TRANSCRIPT
To show an in-depth understanding of the genito-urinary disorders in children and the
process of care in the nursing management
Aim
By the end of this session, the student should be able to:Understand the anatomy and physiology of the renal
system and structure and functionIdentify the differences between adult and children GU
systemDescribe the most common diagnostic investigations and
procedures for GU disorders
Understand the general assessment of children with genitourinary disorders
Understand the common genitourinary disorders in children
Plan the nursing management for children with GU disorders
Begins during 1st week of gestationCompleted by end of 1st year after birthExcretion less than adultBy the age of 6 to 12 months, filtration and
absorption is nearly like adultsFor healthy infant, the kidneys operate at a
functional level appropriate for the size of the body.
Nephron
Glomeruli – filter water and solutes from blood Tubules – reabsorb needed substances (water,
protein, electrolytes, glucose, amino acids) from filtrate and allow unneeded substances to leave the body in urine
Urine formed in the nephron, passes into renal pelvis, through ureter into bladder and out of body through urethra
Urine formed in the nephron, passes into renal pelvis, through
ureter into bladder and out of body through urethra
Glomeruli : filter water and solutes from
blood
Tubules : reabsorb needed
substances (water, protein, electrolytes, glucose, amino acids) from filtrate and allow
unneeded substances to leave the body in urine
Maintaining body fluid volume and composition
Secretes hormones:-Renin – helps with the regulation of blood
pressureErythropoietin – stimulates red blood cell
production by the bone marrowMetabolised Vitamin D – responsible for
calcium metabolism
Urinalysis
CT Scan- an x-ray procedure that combines many x-ray images with the aid of a computer to generate cross-sectional views and, if needed, three-dimensional images of the internal organs and structures of the body.
gross indicator of renal function
(BUN) test measures the amount of nitrogen in blood that comes from the waste product urea.
Urea is made when protein is broken down in body.
Blood urea nitrogen (BUN) and creatinine tests can be used together to find the BUN-to-creatinine ratio (BUN:creatinine). body in the urine.
A blood urea nitrogen (BUN) test is done to determine :
kidneys are working normally.
kidney disease is getting worse.
See if treatment of kidney disease is working.
See if severe dehydration is present. Dehydration generally causes BUN levels to rise
more than creatinine levels. This causes a high BUN-to-creatinine ratio. Kidney disease or
blockage of the flow of urine from kidney causes both BUN and creatinine levels to go up.
KUB (Kidney, Ureter, Bladder) x-rayRenal Biopsy
Renal Ultrasound
An injection of x-ray contrast media via a needle or cannula into the vein, typically in the arm. The contrast is excreted or removed from the bloodstream via the kidneys, and the
contrast media becomes visible on x-rays almost immediately after injection
a urologic procedure where the physician injects contrast into the ureter in order to visualize the ureter and kidney.
Micturating Cystourethrography (MCUG) – serial x-ray of the bladder and urethra after IV infusion of iodine-bound contrast medium ( to detect blockage)
Urinary tract infection (UTI)Nephrotic syndromeAcute Post-Streptococcal Glomerulonephritis (APSGN)
Vesicoureteral refluxHypospadias
DefinitionUTI is the presence of bacteria in the urineInfection usually occur at the upper urinary
tract or at the lower urinary tract
IncidenceCommon age of onset for UTI is 2-6 yearsGirl>Boy - Female has shorter urethraUncircumcised male prone to develop UTI
Causative organisms – E. ColiRoute of entry -bacteria ascending from
the area outside of the urethra.Vesico-ureteral refluxInfections – URTI, GEPoor perineal hygiene - fecal organisms
are the most common infecting organisms due to the proximity of the rectum to the urethra.
Short female urethra
Urethritis – infection of the urethra
Cystitis – an infection in the bladder that has moved up from
the urethra
Pyelonephritis – a urinary infection of the kidney as a result of an infection in the urinary tract
Unexplained fever (febrile fits)
Abdominal pain
Poor growth Foul-smelling
urine
Weight loss(failure to weight gain)
Irritability
VomitingPoor feeding
Urinary frequency/urgency
DysuriaFoul-smelling urineCloudy urineIncontinence during
day and/or nightIncreased irritability
Nausea and vomitingLow abdominal or
flank painFever and chillsFatigueSmall amount of
urine while micturating despite feeling of urgency
Central pyrexia but peripherally coldPoor colourPale, grey mottled skinQuiet and lethargic childPoor toneTachycardic and hypertensive
Obtaining a urine specimen:-- Urine bag
- Clean catch urine- Mid-stream urine- Catheterisation
- Supra-pubic aspiration-draining the bladder by inserting a sterile needle through the skin above the pubic arch and into the bladder.
Ultrasound Plain x-ray Micturating Cystourethrogram (MCUG)
Obtain urine specimen before antibiotics started, sent for ME/CS
Blood tests Strict I/O chartMonitor vital signs esp. body temperatureAdminister antibiotics as prescribed (5
days course)Administer anti-pyretic drugs to reduce
fever and painAdvised to take plenty of fluids to prevent
dehydration and to flush the urinary tractIf the child is unable (vomiting) or refuse to
take fluids, administer IV fluids as prescribed
1. Fever due to increased body temperature related to urinary tract infection.
2. Alteration in urination (frequency, pain, burning, dribbling and enuresis) related to infection.
3. Pain related to inflammatory changes in the urinary tract.
4. Lack of knowledge about UTI and health prevention
Nursing interventions Rationales
• monitor body temperature every 4º • encourage plenty of fluid intake• administer anti-pyrexial medications as prescribed• maintain bed rest• wear thin loose clothing
• give tepid-sponging with luke-warm water
• baseline obs.• to maintain hydration• to maintain an optimum body temp.
• to reduce the body heat• to reduce body heat
Goal: to reduce fever and maintain normal body temperature
Nursing interventions Rationales
• assess the urinary frequency, pain or burning sensation during micturation • assess the colour & odour of urine• strict I/O chart
• administer antibiotics as prescribed
• observe for signs & symptoms of serious infection
• as baseline obs.
• as baseline obs.• to observe urinary frequency• to prevent spread of infection• to prevent complications
Problem 2: Alteration in urination (frequency, pain, burning, dribbling and enuresis) related to infection
Goal: to ensure that the child is comfortable during urination
Ensure the child to pass urine regularly (every 2-3 hours) and take the time to completely empty the bladder
Avoid holding urine for prolonged period of time
Perineal hygiene - wipe from front to backAvoid tight fitting clothing or diapers; wear
cotton pantiesAvoid constipationEncourage fluid intakeAvoid bubble baths
You are required to do the nursing care plan for problem no. 3 & 4, including nursing
interventions and rationales
Alteration of glomerular membrane permeability with massive proteinuria, hypoalbuminaemia, hyperlipidaemia and oedema
It occurs when the filters in the kidney leak an excessive amount of protein. The level of protein in the blood ↓ and this allows fluid to leak across the blood vessels into the tissues – causing oedema
Nephrotic syndrome are caused by changes in the immune system
For unknown reason, the glomerular membrane, usually impermeable to large proteins becomes permeable.
Protein, especially albumin, leaks through the membrane and is lost in the urine.
Plasma proteins decrease as proteinuria increase.
The colloidal osmotic pressure which holds water in the vascular compartments is reduced owing to decrease amount of serum albumin. This allows fluid to flow from the capillaries into the extracellular space, producing oedema.
Accumulation of fluid in the interstitial spaces and peritoneal cavity is also increased by an overproduction of aldosterone, which causes retention of sodium.
There is increased susceptibility to infection due to decreased gamma-globulin.
Causing generalised oedema
1 : 50 000 childrenMales > femalesCommon age of onset is between 2 to 6 years,
but can occur at any age
Oedema- initially noted in the periorbital area- ascites- intense scrotal oedema- striae may appear due to skin overstretching- pitting oedema
↑ weight
↓ urine outputProteinuria (foamy urine
indicates proteinuria)FatigueIrritable and depressionSevere recurrent
infectionsAnorexiaWasting of skeletal
muscles
Urinalysis- protein 3+ - 4+ on dipstick- haematuria may be absent or microscopic
Blood test- total serum protein – low- serum albumin – low- cholesterol and lipoproteins – high
Renal function test – often normalBlood pressure – often normal but 25%
hypertensionRenal biopsy
1. Generalised oedema due to fluid volume excess related to glomerular dysfunction
2. Impaired skin integrity related to oedema3. Altered urinary pattern related to
glomerular dysfunction4. Increased susceptibility to infection related
to disease process and steroid therapy
5. Altered body image (round face) due to side-effects of medication
6. Inadequate nutritional intake related to large loss of protein from the urine
7. Knowledge deficit of the disease process and treatment
8. Anxiety and depression due to the up and down of the course of disease
Goal : to relieve oedemaNursing interventionsAdminister steroids – prednisolone 2-4mg/kg
to control oedemaObserve for side-effects of steroids –
Cushing’s syndrome (moon face, abdominal distension, striae, ↑ appetite, ↑ weight, aggravation of adolescent acne)
Administer diuretic – frusemide. Diuretics can cause loss of electrolytes esp. potassium, encourage ↑ potassium food e.g. citrus fruits, date, apricot, banana
Keep the child CRIB during periods of severe oedema
Strict I/O chart – restrict intake of fluid – offer small amount of measured fluid during severe oedema, for infant measure the diaper’s wt.
Measure daily weight and abdominal girth – to check any weight gain due to water retention
Goal : to protect the child from skin breakdown Nursing interventionPosition the child comfortably in bed so that
oedematous skin is well-support with a pillowElevate the child’s head to reduce peri-
orbital oedemaProvide good skin care – give bath and
maintain hygiene esp. genitals and moist area
Change bedding daily and free from creases and sharp objects – to avoid cut
For problems 3 – 9, you are required to look for the nursing interventions yourself.
Admission to wardExplain to parents nature of illnessBlood for FBC/DC, U +E, Creat., Serum lipid,
C&S, LFT, serum albuminFor CXR and EchoDaily urine dipstick for protein, ME and C&S –
every morningDaily BP, weight and abdominal girthStart on IV infusion
Administration of IV albuminStart on steroid therapy – prednisolone given
at a dose of 2mg/kg/day divided into 2-3 doses. This regimen is continued until remission is achieved
Remission is achieved when the urine is 0 or trace for protein for 5 to 7 consecutive days
Administer prophylactic antibiotics to reduce infections
Start on diuretic therapy – frusemide (lasix)Dietary restriction – provide ↑ protein, high
carbohydrate, ↑ potassium diet & no salt dietStrict I/O chartProvide careful skin careGood hygieneCRIB
Question and Answer
DEFINITION
The backflow or reflux of urine from the bladder into the ureters and possibly the kidneys. The urine returns to the bladder after passing urine.
Fever >39ºCIrritabilityPoor feedingVomitingDysuria as evidenced by crying when passing
urineChange in urine colour or odor
Abdominal or suprapubic painFrequency in passing urineUrgency in passing urineDysuriaNew or increased incidence of enuresis
In normal functioning urinary tract, there is a valve-like mechanism at the junction of the ureter and bladder that prevents urine from refluxing in the ureters
As urine fills the bladder or the bladder contracts during micturating, pressure in the bladder occludes the opening to the ureter
When a defect occur at the vesioco-ureteral junction, VUR occur
MCUG – to visualise the urethra, evaluate degree of reflux and define any abnormalities
Renal scan – to assess renal scarring and function
Urodynamic studies – this is done when there is micturating dysfunction (frequency, urgency, or incontinence) is present
CystogramsUrine cultureBlood test – serum creatinine
GRADE I: reflux into ureter only – no dilatation
GRADE II: reflux into ureter, pelvis and calyces with no dilaltation and normal calyceal fornices
GRADE III: mild dilatation of ureter and renal pelvis
GRADE IV: moderate dilatation of ureter, pelvis and calyces
GRADE V: gross dilatation of ureter, pelvis and calyces
GRADE IVGRADE IV: : moderate dilatation moderate dilatation of ureter, of ureter, pelvis and calycespelvis and calyces
GRADE VGRADE V: : gross dilatation gross dilatation of ureter, of ureter, pelvis and calycespelvis and calyces
Reflux can be divided into 2 categories :-
1. PRIMARY REFLUX - caused by abnormal position of the ureteral bud on the wolffian duct during development of the urinary tract, resulting in smaller, tunneled segment of the ureter
2. SECONDARY REFLUX- occurs as a result of acquired bladder dysfunction
Daily low dose of prophylactic antibiotic to prevent UTI
Urinalysis and urine ME/CS – every 3 to 4 months to evaluate for UTI
Monitor ↑BP
Surgery – reimplantation of the ureter into the bladder
Indicated due to recurrent UTI despite antibiotics, Grade 5 reflux or progressive renal injury
Definition
Hypospadias is a congenital anomaly in which the actual opening of the urethral meatus is “below” the normal placement on the glans of penis
Occurs from incomplete development of the urethra in utero
Exact causes unknown – may be genetic, environmental or hormonal factor
Stenosis of the opening could occur – may lead to UTI or hydronephrosis
May interfere with fertility if left uncorrectedThe location of the meatus may make it
difficult for the child to urinate standing up
The choice of surgical correction is affected primarily by the severity of the defect
Surgery is done when the child’s age is less than 18 months
Reconstruction of the meatal opening is done – Meatal advancement granuloplasty (MAGPI)
The goal for surgical correction:-To enhance the child’s ability to pass urine in
the standing position with a straight streamTo improve the physical appearance of the
genitalia for psychological reasonsTo preserve a sexually adequate organ
1. Ashwill, J.W. and Droske, S. C. 1997. Nursing Care of Children. Principles and Practice. USA: W.B. Saunders.
2. Brunner, L.S. and Suddarth, D.S. 1986. The Lippincott Manual of Peadiatric Nursing. (3rd ed.) UK: Chapman & Hall.
The End