Chapter 24: Child w/ renal dysfxn

Question 1

Renal development

Answer 1

-GFR low in infancy until age 1-2
-Newborn unable to concentrate urine well, reabsorb Na and H2, produces dilute urine

Question 2

UTI assessment

Answer 2

-N/V, anorexia, chills, nocturia, urinary frequency (> q2h), urgency
-Suprapublic or lower back pain, bladder spasms, dysuria, burning on urination
-Fever, hematuria (may be cloudy), foul-smelling urine, enlarged kidney
-Leukocytosis, positive for bacteria, WBCs (pyuria), RBCs

Question 3

Normal urinalysis

Answer 3

-pH: 5-9
-USG: 1.001-1.035
-Protein: > 20
-Urobilinogen: up to 1
-None of: glucose, ketones, Hgb, RBCs, WBCs, casts, nitrates
-Yes to: pale yellow, newborn production of 1-2 mL/kg/hr, child production of 1 mL/kg/hr

Question 4

UTIs: upper

Answer 4

-Renal parenchyma, pelvis, ureters
-No systemic s/s
-Pyelonephritis
-VUR (retrograde flow of urine)
-Glomerulonephritis (strep infection)

Question 5

UTIs: lower

Answer 5

-Fever, chills, flank pain
-Cystitis (contained in bladder)
-Urethritis (irritation, leading to ascending)

Question 6

Types of UTIs

Answer 6

-Recurrent: repeated episodes, don’t respond to tx (subacute)
-Persistent: bacteriuria despite abx ts or noncompliance w/ tx (subacute)
-Febrile: indicates pyelonephritis
-Urosepsis: bacterial, urinary pathogens in blood

Question 7

UTI Dx

Answer 7

-Dipstick
-Microscopic urinalysis
-Culture and sensitivity
-Clean catch specimen (preferred)
-U bag
-Specimen obtained by catheter or subrapubic needle aspiration is most accurate (when clean-catch can’t be obtained)

Question 8

UTI radiology

Answer 8

-Renal scan
-Cystogram
-Retrograde pyelogram
-Ultrasound
-CT
-MRI
-Renal arteriogram

Question 9

UTI Tx

Answer 9

-Uncomplicated cystitis: short-term abx (TMP-SMX, amoxicillin)
-Complicated UTi: prophylactic abx, TMP-SMX daily or before events likely to cause a UTI
-Comfort: antipyretics for pain, pyridium for s/s of urgency and frequency
-Education: encourage frequent voiding and increase fluid intake

Question 10

Vesicoureteral reflux (VUR)

Answer 10

-Retrograde flow of bladder urine into ureters
-Increases risk of infection (pyelonephritis)
-Primary vs secondary reflux
-Grades of reflux

Question 11

VUR Tx

Answer 11

-Low dose abx
-Urine culture q2-3m or when child has fever
-VCUG to assess status
-Most children outgrow VUR, but surgery for severe cases (prevent renal scarring which can cause HTN later on)

Question 12

Acute pyelonephritis

Answer 12

-Inflammation caused by bacteria, fungi, protozoa, viruses in kidneys
-Urosepsis-systemic infection
-Can lead to septic shock
-s/s: hematuria, proteinuria, oliguria, edema, HTN

Question 13

Glomerulonephritis types

Answer 13

-Post infection: pneumococcal, streptococcal, viral
-May be distinct or d/t systemic disorder (SLE, sickle cell)

Question 14

Glomerulonephritis s/s

Answer 14

-Generalized edema (periorbital –> lower extremities –> ascites)
-HTN d/t increased ECF
-Oliguria
-Hematuria (smoky urine)
-Proteinuria

Question 15

Acute poststreptococcal glomerulonephritis (APSG)

Answer 15

-Noninfectious renal disease (autoimmune)
-5-12 days after other infection
-Often d/t group A beta-hemolytic streptococci
-Most common 6-7 y
-Uncommon in children < 2 y

Question 16

APSG nursing mgmt

Answer 16

-Edema: daily weights, I&Os, daily abdominal girth
-Nutrition: low Na, moderate protein
-Bed rest not necessary but most children will restrict activity d/t malaise

Question 17

Nephrotic syndrome

Answer 17

-Common presentation of glomerular injury
-S/S: proteinuria, hypoalbuminemia, hyperlipidemia, edema, massive urinary protein loss

Question 18

Nephrotic syndrome types

Answer 18

-Minimal change (MCNS) (AKA idiopathic nephrosis, Nil disease, uncomplicated nephrosis, childhood nephrosis, minimal lesion nephrosis)
-Congenital nephrotic syndrome: presenting within 1st 3 m of life (genetic mutation)
-2ndary nephrotic syndrome
-Edema phase: beginning stages
-Remission phase: tx w/ corticosteroids

Question 19

Nephrotic syndrome mgmt

Answer 19

-Diet: low Na, moderate protein
-Steroids: 2 mg/kg BID doses, prednisone drug of choice
-Immunosuppressant (cytoxan)
-Diuretics
-Avoid caffeine, alc, citrus juices, chocolate, spicy foods
-Follow up urine culture: recurrent s/s 1-2 weeks after tx, low-dose and long-term abx to prevent relapses

Question 20

Nephrotic syndrome family issues

Answer 20

-Chronic condition w/ relapses
-Developmental milestones
-Social isolation: lack of energy, immunosuppression, change in appearance d/t edema

Question 21

Hemolytic-uremic syndrome

Answer 21

-Acute renal disease: hemolytic anemia, thrombocytopenia, renal injury, CNS s/s
-Hx: follows diarrheal illness (watery diarrhea –> hemorrhagic colitis –> hx of beef consumption, zoo/waterpark visit)
-S/S: N/V/D, oliguria/anuria, HTN, abdominal tenderness, edema, altered LOC, irritability, seizures, bruising, bleeding
-Mgmt: I&Os, diuretics, antihypertensives, seizure precautions, maybe dialysis
-Education: hand hygiene, food prep

Question 22

Defects of GU tract

Answer 22

-Phimosis (tight foreskin)
-Hydrocele (fluid-filled sac around testicle)
-Hypospadias: opening of urethra on underside of penis (circumcise after surgery)
-Epispadias: opening of urethra at top of penis (circumcise) after surgery)
-Exstrophy complex: bladder develops outside of body
-Obstructive uropathy: disorder of urinary tract that is d/t obstructed urinary flow

Question 23

Defects of GU tract

Answer 23

-Phimosis
-Balanitis
-Hydrocele
-Cryptorchidism
-Hypospadias
-Epispadias
-Exstrophy complex

Question 24

Acute renal failure (ARF)

Answer 24

-Kidneys unable to regulate urine
-Not common in children but reversible
-Main feature is oliguria (associated w/ azotemia, metabolic acidosis)
-D/t transient renal failure resulting from severe dehydration

Question 25

ARF complications

Answer 25

-Hyperkalemia
-HTN
-Anemia
-Seizures
-Hypervolemia
-Cardiac failure w/ pulmonary edema

Question 26

Chronic renal failure (CRF)

Answer 26

-Kidneys can’t maintain normal chemical structure of bodily fluids
-Clinical syndrome called uremia
-Mgmt: diet, HTN, infections, seizures

Question 27

CRF causes

Answer 27

-Congenital renal and urinary tract malformations
-VUR associated w/ recurrent UTIs
-Chronic pyelonephritis
-Chronic glomerulonephritis

Question 28

CRF renal replacement therapy: hemodialysis

Answer 28

-Creation of vascular access
-For children who can be brought to area 3x/week for 4-6hrs
-Rapid corrections of fluids

Question 29

CRF renal replacement therapy: peritoneal

Answer 29

-Abdominal cavity acts as semipermeable membrane
-Can be managed at home
-Wamed solution enter peritoneal cavity, later removed
-Preferred method
-CAPD: continuous ambulatory q3-4hrs
-CCPD: continuous cycle every night
-Tenckhoff catheter: narrow tube inserted into cavity

Question 30

CRF renal replacement therapy: hemodialysis

Answer 30

-Creation of vascular access
-AV fistula or graft (assess site for bruit and thrill)
-Suited for children who can be brought into area 3x/week for 4-6hrs
-Rapid correction of fluids
-Stricter diet

Question 31

CRF renal replacement therapy: continuous venovenous hemofiltration

Answer 31

-Ultrafiltration of blood at slow rate
-Works w/ fluid overload in postop period
-Alternative for critically ill children who might not survive rapid changes of hemodialysis or PD
-Catheter placed into main vein of body

Question 32

CRF transplantation

Answer 32

-Best tx
-From living, related, or cadaver donor
-Long-term survival of grafted tissue
-Immunosuppressants: no live vax, monitor for pain, diminished UO, HTN (sign of rejection)

Question 33

CRF nursing mgmt

Answer 33

-Adequate fluid intake
-Avoid caffeine, alc, citrus juice, chocolate, spicy food
-Follow up urine culture: recurrent s/s 1-2 weeks after tx, low-dose and long-term abx to prevent relapses