The Child with Genitourinary Alterations

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The Child with Genitourinary Alterations

• N422-Pediatrics
• Feb 2001
• Linda Heath

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Pediatric Differences

Kidney begins to reach adult functioning about 1
year of age Infants cannot concentrate urine as
efficiently as older children and adults
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Review Genitourinary System

• Maintain fluid electrolyte balance through
  glomerular filtration, tubular reabsorption, and
  secretion
• Hormonal functions
• Produces renin in glomerulusregulates BP
• Produces Erythropoietinstimulates RBC production
  in bone marrow
• Metabolized Vitamin Dto active form which is
  important in calcium metabolism

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Medications commonly used for GU Disorders
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Common Tests

• BUN (Increases in renal insufficiency)
• Creatinine
• Serum Osmolality
• Urinalysis
• Specific Gravity
• pH
• Protein
• Glucose
• Ketones
• WBCs, RBCs
• Bacteria

• CT scan
• Cystocopy
• IVP
• KUB
• Renal Arteriogram
• Renal Biopsy
• Renogram
• Renal Ultrasound
• VCUG

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Urinary Tract Infections

• Cystitis
• Pyelonephritis
• Incidence
• Assessment
• Evaluation
• Treatment
• Prevention

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Vesicoureteral Reflux (VUR)

• Backflow or reflux of urine from the bladder into
  the ureters and possibly to the kidney
• Urine returns to bladder after voiding
• UTI (urinary tract infection) is the most common
  clinical manifestation
• VCUG, renal scan
• Graded I V
• Low dose prophylactic antibiotic therapy

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Classification of Reflux
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Glomerulonephritis

• Injury in glomerulus
• Follows bacterial or viral infection (Strept)
• Hematuria
• Proteinuria
• Edema
• Renal insufficiency
• SS of fluid overload

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Pathophys of Glomerulonephritis
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Nsg Dx Glomerulonephritis

• Fluid volume excess r/t decreased U.O.
• Risk for activity intolerance r/t fatigue
• Risk for impaired skin integrity r/t edema and
  decreased activity
• Altered nutrition less than body requirements
  r/t fluid and diet restrictions
• Anxiety r/t hospitalization, knowledge deficit of
  disease

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Nephrotic Syndrome

• Primary
• Most common
• Disorder within glomerulus
• Proteinuria
• Hypoalbuminemia
• Edema
• Secondary
• Hepatitis
• SLE
• Heavy metal poisoning
• Cancer

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Pathophys of Nephrotic Syndrome
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Nephrotic Syndrome

• Edema
• Noted in periorbital spaces and dependent areas
  of the body
• Child may awaken with facial edema, as the day
  progresses, edema becomes less noticeable

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Nsg Dx Nephrotic Syndrome

• Risk for impaired skin integrity r/t edema and
  decreased circulation
• Risk for infections r/t urinary loss of
  gammaglobulins
• Risk for fluid volume deficit (intravascular) r/t
  proteinuria, edema, and effects of diuretics
• Fluid volume excess r/t decreased excretion of Na
  and water retention
• Anxiety (parental) r/t caring for child with
  chronic disease and hospitalization

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Comparison Nephrotic Syndrome Glomerulonephritis

• Nephrotic Syndrome
• 3-4 Proteinuria
• Microscopic Hematuria
• Low Serum Albumin
• Neg ASO streptozyme
• Normotensive
• Electrolytes normal

• Glomerulonephritis
• 0-2 Proteinuria
• Hematuria
• Normal Serum Albumin
• Positive ASO strepto
• Frequently hypertensive
• Na (low), K (elevated)

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Enuresis

• Unable to control bladder function although
  reached an age at which control of voiding is
  expected
• Nocturnal EnuresisBed wetting
• Most will eventually outgrow with therapeutic
  intervention

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Pathophys and etiology of Enuresis

• Control of urination is r/t maturation of CNS
• By 5 years, most are aware of bladder fullness
  and can control voiding
• Daytime first with nighttime dryness later
• Girls seems to master before boys
• Children with primary enuresis may have delayed
  maturations of this part of CNS. They are not
  able to sense bladder fullness and do not
  awaken to void

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Nsg Dx Enuresis

• Situational low self-esteem r/t bedwetting or
  urinary incontinence
• Impaired social interaction r/t bedwetting or
  urinary incontinence
• Ineffective family coping compromised r/t
  negative social stigma and increased laundry load

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Cryptorchidism

• Undescended or hidden testicle
• One or both testes fail to descend through
  inguinal canal into the scrotal sac
• Inguinal hernias are commonly associated with
  this
• Most infants with cryptorchidism will have
  spontaneous descent of their testes during the
  first year of life Surgical intervention after
  that

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Pathophys of Cryptorchidism

• Fetal development testes descend from the
  abdomen during 7th 9th month gestation
• Failure to descend unknown
• ?abnormality of testis itself
• ?insufficient hormonal stimulation for the normal
  descent process
• Sperm production is decreased in undescended
  testis and increased risk of developing a
  malignancy when child receives adulthood

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Nsg Dx Crytorchidism

• Knowledge deficit (parental) r/t cause and
  management of cryptorchidism
• Anxiety r/t possible decreased fertility and
  increased risk of testicular malignancy

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Hypospadius

• Congenital anomaly
• Actual opening of the urethral meatus is below
  the normal placement on the glans of the penis
• Goal of surgery to make urinary sexual
  function as normal as possible and improve
  appearance of penis

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Pathophys of Hypospadias

• Incomplete development of urethra in utero
• Exact cause unknown (? R/T genetic, environmental
  and hormonal influences)
• Displacement of urethral meatus does not usually
  interfere with urinary continence
• Stenosis of opening can occur causing problems
  with partial obstruction of outflowing urine.
  This might result in hydronephrosis or UTIs
• Ventral placement of urethral opening might
  interfere with fertility in the mature male, if
  left uncorrected

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Nsg Dx Hypospadius

• Knowledge deficit (parental) r/t diagnosis,
  surgical correction, post-op care
• Risk of infection r/t indwelling catheter
• Impaired physical mobility r/t surgical procedure
  of penis

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Bladder Extrophy

• Congenital anomaly
• Extrusion of bladder to the outside of the body
  through defect in lower abdominal wall
• May be associated with genital anomalies or
  defects of anus

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Pathophys of Bladder Exstrophy

• Result of inappropriate growth during embryonic
  development
• Degree of deformity depends on when the
  disruption occurs during fetal development. The
  earlier in development the more severe the
  deformity
• Most infants with bladder exstrophy have normal
  kidneys but may be at risk for kidney damage due
  to VUR and bladder dysfunction, which may occur
  after surgical reconstruction

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Nsg Dx Bladder Exstrophy

• Impaired tissue integrity r/t exposed bladder
  mucosa
• Knowledge deficit (parental) r/t diagnosis and
  anomaly
• Risk for Infection r/t anatomical defect,
  surgical procedures, and probable abnormal
  bladder function
• Body image disturbance r/t physical appearance of
  lower abdomen and genitalia

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Acute Renal Failure

• Sudden severe loss of kidney function
• Kidneys can no longer filter waste products,
  regulate fluid volume, nor maintain chemical
  balance
• Uncommon in the pediatric patient
• Most children with ARF regain renal function

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Pathophys of ARF

• Prerenal ARF
• Decreased perfusion of kidney
• Decreased blood flow and ischemia cause cell
  swelling, cell injury, and poss cell death
• Causes dehydration, perinatal asphyxia,
  hypotension, septic shock, hemorrhagic shock, and
  renal artery obstruction
• Intrarenal ARF
• Actual damage to kidney tissue
• Causes aminoglycosides, contrast dye,
  obstruction, HUS, glomerulonephritis,
  pyelonephritis
• Postrenal ARF
• Obstruction of urine outflow causing decreased
  renal function due to pressure within kidney
• Causes obstruction problems within kidney,
  neurogenic bladder, stones, tumor, edema

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Dialysis
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Chronic Renal Failure ESRD Kidney transplant
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Nsg Dx ARF

• Fluid volume excess r/t kidney dysfunction
• Risk for infection r/t invasive procedures and
  fluid overload
• Altered family process r/t child hospitalized
  with serious disorder
• Altered nutrition less than body requirements
  r/t anorexia and decreased intake due to
  restrictions
• Knowledge deficit r/t disease process, therapy,
  and prognosis

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Hemolytic Uremic Syndrome (HUS)

• Anemia
• Thrombocytopenia
• Acute renal failure
• E.coli 0157H7

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Pathophys of HUS

• Prodrome of GI symptoms
• E. coli 0157H7
• Bacteria grow and multiply in intestines
• Bacteria produce toxin that damages the
  endothelial cells of capillary walls leading to
  inflammation. Significant in renal glomeruli
• Occlusion of glomeruli decreases filtration and
  results in ARF
• Vascular process of HUS can affect any organ
• Anemia results damaged RBC as they pass through
  occluded vessels and are removed from circulation
  by spleen
• Thrombocytopenia occurs because the platelets get
  trapped within the small vessels