Ch. 24 Flashcards
cryptorchidism
- 1 or 2 testicles without descent by age 6 months
- Testes that are not palpable or not easily guided into the scrotum
- Managed by observation as testes may descend within the first year
- surgical repair if testes do not descend (recommended around 1 yr old by AAP)
enuresis
uncontrolled bed wetting
- higher incidence in B>G
- usually ceases btwn 6-8 years
- primary vs secondary
epispadias
- Less frequent than hypospadias; EXTREMELY RARE!!
- Dorsal (top) surface urethral opening (if seen in females opening is between clitoris and labia or on abdomen)
- Congenital
- Surgical repair is required….no circumcision
hypospadias
- Urethral opening is located below the glans penis or anywhere along the underside of the penile shaft (ventral opening)
- congenital
- hereditary
- 1/300 births
- Requires surgical correction around 6-12 months old (normal adult sexual functioning)…no circumcision
- Nursing assessment of every male newborn
hydrocele
- Presence of peritoneal fluid in the scrotal area
- May be indicative of an inguinal hernia
- Common in newborns but may not resolve until the end of infancy
- May prevent teste from descending
- Resolves spontaneously
- Surgical repair if continues into toddlerhood
neurogenic bladder
lack of bladder control due to nerve, spinal, brain injury
- MS
- spinal cord injury
- CP
catheter to empty bladder
oliguria v anuria
decreased urine output
v
no urine output
phimosis
the inability to retract the foreskin from the glans on the penis
- okay in newborn phase
- should retract by 3 years old
- may require circumcision to correct
paraphimosis
when foreskin is trapped behind the corona of the glans penis
pyelonephritis
inflammation of upper urinary tract and may involve kidneys
pyeloplasty
surgery performed when the tube that drains urine from the kidneys to the bladder is blocked
- if not corrected causes loss of kidney function, infections, and pain
renal insufficiency
poor function of the kidneys
- may be due to reduction in blood flow to the kidneys (renal artery disease)
vesicoureteral reflux (VUR)
- backwards ureteral flow of urine
- can be uni or bilateral
- normally affects the ureterovesical junction
GU physical exam: inspection
- general appearance
- physical growth (wt, ht, or length, Tanner staging)
- skin assessment
- LOC
- external genitalia
- abdomen: distention/mass
what are you “inspecting” when looking at the external genitalia?
- diaper rash
- placement of urethral opening
- discharge
- urine dribbling
- swelling
- bruising
GU physical exam: percussion and palpation
- distention/masses
- CVA tenderness (push on flank- assess for pain, if yes could be kidney infection)
GU physical exam: auscultation
- heart sounds
- HR- tachycardia?
- BP (machine <3, manual >3)
- lung sounds if child seems “puffy” (think pulmonary edema)
- bowel sounds
a + murmur is seen in children with what disorders?
- anemia
- renal disease
HTN is a sign of what GU disease?
renal disease
hypoactive or absent bowel sounds could mean what?
peritonitis
urine output: infants
9-10x/day
urine output: preschoolers
4-8x/day
*need reminders
expected urine output is calculated with what formula?
UO = 1ml/kg/hr
*newborns will produce 1-2ml/kg/hr; after 1 month, 1ml/kg/hr
1 gram of wet diaper = ___ mL of urine
1mL of urine
when is bladder capacity close to that of an adults?
12 years
normal urine characteristics: urine specific gravity
USG: 1.005-1.020
in-hospital hydration status; normal intake status
normal urine characteristics: appearance
clear, pale, yellow/gold
should be transparent straw color with minimal odor
normal urine characteristics: pH
avg. 6 (5-8)
- want the urine to be closer to 5 (more acidic to prevent infection)
acid base balance
abnormal urine lab characteristics
presence of:
- protein
- glucose (diabetes)
- ketones
- leukocyte esterase
- nitrites
- WBCs (< 1-2 is normal- irritation)
- RBCs (< 1-2 is normal- irritation)
- Bacteria
- Casts
pediatric issues related to GU
- can be difficult to examine (restraint)
- urine collection is complicated by age and determination of child
- conflict is created btwn parental teaching r/t exposed “private parts” and the need to perform exams, lab specimen collection, and nursing interventions
DDAVP (desmo-pressin)
action: antidiuretic hormone effect; causes renal tubule to increase H2O absorption leading to decreased volume of urine
indication: nighttime enuresis
nursing implications with DDAVP (desmo-pressin)
- nasal spray may cause irritation, nausea, flushing, or headache
- administer at bedtime alternating nostrils
- PO is preferred at bedtime
Lasix
action: inhibits reabsorption of sodium/chloride; leads to increased excretion of H2O and lytes
indication: nephrotic syndrome
nursing implications with Lasix
- give with food/milk
- monitor BP, renal function, lytes (esp. K+)
Albumin (IV)
action: results in fluid shift from interstitial to intravascular space
indication: nephrotic syndrome
nursing implications with Albumin (IV)
- use filter on IV tubing
- rapid infusion can cause vascular overload
- monitor VS
- observe for cardiac failure and pulmonary edema
antibiotics for a UTI are
not always appropriate for use in children
- some are, some aren’t
corticosteroids
indication: nephrotic syndrome
action: induces remission and promotes diuresis
ie. prednisone
what % of children respond to prednisone within 2 weeks?
90%
after remission of proteinuria, how long is prednisone continued for?
another 6 weeks at lower doses
IVIG
medication used for nephrotic syndrome
renal diagnostic studies
- UA
- Urine C&S
- BUN
- uric acid
- creatinine
- KUB
- IVP
- VCG/VCUG
- renal scan
- cystogram
- retrograde pyelogram
- ultrasound
- CT scan
- MRI
- renal arteriogram
- renal biopsy
renal biopsy
removal of a small piece of the kidney to examine the tissue
ultrasound
can be used on abdominal area or back to get a picture/scan of kidneys, bladder, ureters
VCG/VCUG
- a voiding cystourethrogram uses a small amount of radiation to make images of a person’s urinary system
- these images help doctors see problems in parts of the urinary system: bladder, urethra, ureters
creatinine
elevated in renal disease
infant: 2-5.5
child: 0.3-0.7
adolescent: 0.5-1
uric acid
elevated in renal disease
2-5.5
BUN
elevated in renal disease
newborn: 4-18
infant, child: 2-5.5
urine C&S
urine culture
- tests for bacteria
- next test after a UA
- 48hr results
UA
urinalysis
- the urine that is sent off to the lab for analysis (USG, pH, protein, ketones, nitrites, etc.)
how is urine collected for an infant?
- collection bag
- wool cotton pads
- perez reflex stimulation
- catheterization
- suprapubic needle aspiration
how is urine collected for a child?
- on toilet into hat
- catheterization
- suprapubic needle aspiration
how is urine collected for a teenager/adolescent?
typically clean-catch
UTI: lower tract
- cystitis: contained in bladder
- urethritis: irritation; infection; potential for ascending
UTI: upper tract
- pyelonephritis: inflammation of the upper tract; may involve kidneys
- VUR: retrograde flow of urine from bladder into upper tract
- glomerulonephritis: immunologic disease un kidney proper; did not begin in the bladder and ascend
UTI: complicated infections
UTI is complicated by another condition
- stones
- obstruction
- catheters
- diabetes or nephrotic disease
- recurrent infections
types of UTIs
recurrent: repeated episodes in a person whose prior infection was successfully eradicated
persistent: bacteria despite antibiotics; occurs because original infection was not adequately eradicated
febrile: typically indicates pyelonephritis
urosepsis: bacterial illness; urinary pathogens in blood
unresolved bacteriuria: bacteria resistant or drug discontinued before bacteria is completely eradicated
UTI: subjective s/sx
- N/V
- anorexia
- chills
- nocturia
- urinary frequency
- urgency
- incontinence
- dysuria
- suprapubic or low back pain
- bladder spasms
- dysuria
- burning on urination
UTI: objective s/sx
- fever
- hematuria: foul odor; tender, enlarged kidney
- UA: leukocytosis: increase in WBCs; Nitrates, Blood
- positive findings of bacteria, WBCs, RBCs, pyuria, ultrasound, CT scan, IVP
- inconsolable
- grimacing, visible signs of pain
vesicoureteral reflux (VUR): anatomy
- bladder tunnel is too short “leaky valve”
- urine flows in both directions
VUR management: grade I & II
- Prophylaxis antibiotics (bactrim, nitrofurantoin)
- Voiding schedule
- Hygiene
- Routine VCUG
- can self resolve
VUR management: grade III, IV, V
- Same as I and II plus
- Surgical intervention (ureteral re-implantation) for severe cases (does not self resolve)
- VCUG procedure is upsetting for toilet trained children
VUR management: post-op
IVF at 1 ½ times FMR
I & O
Foley, suprapubic, and/or ureteral tubes for urine drainage (bloody urine- inform parents this is normal)
Pain mgmt.
OOB (out of bed- promotes motility, gravity & healing, prevent blood clots & PNA)
Abd. assessments
Advance diet as tolerated
Prophylaxis antibiotics for 1-2 months, small dose/day
Follow-up VCUG
Psychosocial support
how does a VCG/VCUG work?
- the patient’s bladder is filled with liquid contrast material
- X-ray machine sends radiation beams through abdomen and pelvis
- images are recorded in special film/computer
urethral reimplantation
a surgery to treat VUR
- reimplantation of the ureter(s)
- corrects the anatomy at the insertion of the refluxing ureter into the bladder
acute glomerulonephritis (AGN)
- inflammatory response in the glomerular system
- inflammation of kidney tubules
- most common form: (APSGN) acute post-streptococcal glomerulonephritis
- most commonly caused from strep throat infection
- usually in ages 3-12 years; uncommon in children <3 years
onset of AGN
- 1-2 weeks after other type of pneumococcal, streptococcal, and viral infections
- 3-6 weeks after skin infections, ie. impetigo
diagnosis of AGN is made through testing:
- throat culture: +/-
- urine: + bld, + protein, ^ USG, + RBCs, + HGB, + leukocytes, + red casts
- serology: electrolytes WNL, ^ BUN, ^ CR, + ASO (anti-streptolysin O) titer, decreased C3&C4
- EKG: heart fx eval if HTN develops
- CXR: cardiac enlargement, pulmonary congestion, plural effusion
- renal biopsy (only in atypical cases)
AGN clinical presentation: latent phase
- Previously healthy kids are often asymptomatic.
- Mild URI (respiratory) s/sx.
- Recent history of strep infection.
AGN clinical presentation: acute phase
s/sx:
Periorbital Edema (Worse In Am Then Becomes Dependent)
Anorexia, Pallor, Irritability, Lethargy
Older Children: Headaches, Abdominal Pain, And Dysuria
Cola (Smoky Or Tea) Colored Urine
Hematuria, Proteinuria (Mild/Moderate),
Azotemia (Elevated Nitrogen)
Oliguria (decreased UO)
Hypertension (Mild To Severe)
Weight Fluctuations
Hypervolemia
Rare: Seizures From Hypertensive Encephalopathy, CHF, Or Hematuria Without HTN Or Edema
AGN clinical presentation: recovery phase
s/sx:
Increase in UO
Decrease in weight (resolution of edema)
Increased appetite
Normalized BP
Normalized Renal function and hypocomplementemia
timeline of AGN latent phase
begins 7-21 days between onset of strep and development of clinical s/sx
timeline of AGN acute phase
begins 1-2 weeks post-strep or 3-6 weeks post skin infection
- usually persists 1-3 weeks
- encourage rest during this phase
timeline of AGN recovery phase
begins with s/sx of improvement
- most s/sx resolve within 8 weeks of onset of latent phase
prognosis of AGN
- 95% rapid improvement to complete recovery
- 5-15% chronic glomerulonephritis
- 1% irreversible damage
management of AGN
Serial VS, weight, and I/O
Na (NAS) and H20 restriction
Limit potassium with oliguria
Protein restriction with azotemia
Diuretics with mild renal failure
Dialysis (rare)
BP q 4 hrs.
Antihypertensives
Possible anticonvulsants with BP meds
ABTs if strep +
May test other family members
Bedrest-acute phase
Restrict strenuous activity until urine is negative
nephrotic syndrome (NS)
- can be primary or secondary
- different types
- occurs in all ages but most frequently in preschoolers
- swollen eyes*, swollen feet, swollen abdomen
- result of increased glomerular basement membrane permeability –> proteinuria (usually albumin)
most common type of glomerular injury in children
nephrotic syndrome
more common in boys than girls
80% of nephrotic syndrome types are classified as
80% are classified as minimal change nephrotic syndrome
what is the relationship between viral URI and NS
viral URI typically preceded diagnosis but is not the cause of MCNS
diagnosis of NS is made through testing:
- urine: +++ proteinuria, + casts, RBCs, ^ USG
- serology: decrease protein, decrease albumin, ^ lipids, ^ cholesterol, ^ PLT (hemoconcentration), H&H (slightly ^), decrease Na, decrease Ca
- renal biopsy: will differentiate type and probable course of disease (not always performed)
MCNS clinical presentation
Child is previously well and begins to develop:
**Periorbital edema (worse in am)
***Progresses to swelling generalized edema (anasarca) from abdomen to feet bilaterally
**Weight gain greater than expected for age
**Urine characteristics: dark white (opal), frothy/bubbles
**Skin breakdown
** Gradual or rapid onset.
Pallor
Fatigue
Irritable, easily fatigued, lethargic
Hypoalbuminemia → white lines on fingernails
Normal BP (or slightly decreased)
Edema of the intestinal mucosa results in diarrhea, anorexia, and ↓ intestinal absorption.
UO
Dull hair
Ear cartilage may feel less firm
Food intolerances or allergies
MCNS management
VS with close B/P monitoring
Daily wt.
Monitor for s/sx edema. Assess degree of edema.
I & O (strict)
Routine vaccinations. No live vaccines until steroids are discontinued
Urine dipsticks (inpatient and at home)
Heart, lung, and abdomen assessments
Skin assessments/skin care
MCNS nutrition management
Low Na++ - if edema and steroid therapy
Fluid restriction- if renal failure or if hospitalized
Low protein foods-if azotemia or renal failure
MCNS pharmacology management
Corticosteroids (starts at around 60mg/day and slowly taper down)
- IV in hospital, po post discharge
- Immunosuppressant therapy (some cases)
- IV albumin (protein) f/b diuretic (i.e. furosemide)
- Antibiotics PRN- for secondary infections
MCNS activity management
bedrest (edema phase)
cluster care
what are the concerns with long-term steroid use?
- itching
- may harm immunity: immunocompromised
- moon face
- increased appetite
- emotional, very energetic
family concerns with NS
- chronic condition with relapses
- developmental milestones
- social isolation: lack of energy, immunosuppression/protection, change in appearance due to edema- self-image
hemolytic-uremic syndrome (HUS)
- acute pediatric renal disease
- caused by e. coli (diarrhea +)
- preceded 1-2 weeks by severe gastroenteritis, UTI, or URI
most common cause of ARF in infants and children under 3?
hemolytic-uremic syndrome (HUS)
HUS: classic triad of s/sx
- AKI: acute kidney impairment/injury
- hemolytic anemia: RBCs are destroyed faster than they are made
- thrombocytopenia: low platelets
hemolytic-uremic syndrome (HUS): prodromal phase symptoms
V/D (Most common)
** Diarrhea (often bloody)
Abdominal pain, cramping or bloating
Vomiting
Fever
If URI, UTI, or viral cause will present differently
hemolytic-uremic syndrome (HUS): prodromal phase management
Symptomatic care
Enteral nutrition
Parenteral PRN (colitis)
hemolytic-uremic syndrome (HUS): hemolytic phase symtoms
Days to 2 weeks
Anorexia
Personality changes (irritable, lethargic)
*Rapid onset of pallor
*Hemorrhagic features (ecchymosis, purpura, rectal bleeding, orifice bleeding)
If mild=anemia, thrombocytopenia, azotemia
If severe=oliguria or anuria and HTN
If CNS involvement=seizures, LOC→ stupor, stroke
If cardiac involvement=HF (ex. SOB)
If GI involvement: mild jaundice, ascites
If renal involvement: ↑ BUN ↑ CR ↓ Hgb ↓ Hct. ↑ retic. count
(effects all symptoms)
hemolytic-uremic syndrome (HUS): hemolytic phase management
Focus on controlling complications and managing ARF
Calorie intake (foods)
Monitor fluid balance
Restrict fluids
Routine labs
Assess for physical s/sx
Assess for fluid overload
Limit fluid volume with IV meds
Keep child calm and afebrile
Education on prevention
Peritoneal dialysis (PRN)
defects in the GU tract
- enuresis
- phimosis
- hydrocele
- cryptorchidism
- hypospadias
- epispadias
primary enuresis
bed-wetting in children who have never been dry for extended periods of time
secondary enuresis
the onset of bed-wetting after a period of established urinary continence
enuresis: diagnostic criteria
- developmental age > 5 years
- careful history of baseline information
- physical exam
management of enuresis
Conditioning therapy
Bladder retention training
Fluid restriction in evenings
Interruption of sleep to void
Conditioned reflex response devices
Drugs: DDVAP, oxybutynin, imipramine (tofranil)
phimosis is treated with
- steroid cream BID
- vitamin E cream
phimosis: patient teaching
- Not forcing foreskin retraction in newborns
- Frequent diaper changes
- Washing penis daily with soap and water
- Cleansing skin around glans when able to retract skin routinely (infant and older)
- Always remembering to replace retracted foreskin (after age 3)
post-op hydrocele
- no straddle toys or strenuous activities x1 month post-op
- dressing in place until bathing is allowed
- bathing pos-op day 3
cryptorchidism surgery
- Surgery involves incision to release spermatic cord, pull down of testes, and “tacking in place”
- Typically between 9-15 months of age
- orchidopexy
- Must be corrected before school-age years otherwise
what are some considerations with cryptorchidism surgery?
- sterility
- high risk for testicular cancer
predisposing factors to cryptorchidism
Predisposing factors:
Premies
First born males
Section babies
LBW
Hypospadias
retractile testes
testes can be manually descended but migrate out of the scrotum
- not problematic *UNLESS no descent is possible OR continues past age 14 yr
assessing for crytorchidism
Examine the infant in a warm environment. Be sure the infant is calm before the examination.
*Warm your hands before touching the infant.
*Milk the testis downward from the groin and document its distal point.
*Examine the older child in both a sitting and a frog-leg position.
the testes normally descend by what age?
6 months (may take longer for adjusted age infants)
what may cause a false dx of cryptorchidism?
- testes retract if the infant is upset or cold
- the cremasteric reflex: testicular retraction in response to tactile stimulation to the front inner thigh
why is a male infant with hypospadias/epispadias not circumcised?
no circumcision- skin is used for reconstructive surgery
long term effects of epispadias
- incontinence
- infertility
- UTIs
hypospadias post-op care
Surgery typically between age 6-12 months
Urine drainage tube care and maintenance
Teaching re: catheter care…..d/c’d home with tube
Penis should remain in upright position to reduce incision strain
Compression Dressing maintenance; DO NOT CHANGE (removed typically on day 4)
ABT’s
Pain management (i.e., analgesics, antispasmodics) for bladder spasms
Double diapering (inner smaller diaper for stool, outer larger for urine; cut slit in small to pull catheter through (see next slide)
Encourage PO intake
Assess for s/s UTI/infection
Quiet play
double diapering
used for hypospadias post-op infants
- hole in first diaper where catheter goes through
- put second diaper over first to keep sanitary (d/t hole in first diaper)
elevated HR, elevated BP related to renal disease because
the heart is working harder to pump blood to the kidneys
KUB
flat plate the scans the kidneys, ureters and bladder
uncomplicated UTI
treated, 3 weeks later repeat culture is clear
1 pathogen causing UTI
E. coli
VUCG is required for what circumstances? (r/t UTI)
children < 2 years old, 2 UTIs with a fever or 1 UTI with renal issues
treatment for UTI
- bactrim
- nitrofutantoin
