Genitourinary Flashcards
Dev diff in GI sys
- nephrons less mature and effecient
- glomerular filtration and abs rates low bc kidneys of newborns are immature
- dec ability to conc urine and reabs AAs
- loop of Henle shorter which dec ability to reabs Na and water making very dilute urine for first 3M of life
- H+ excretion red; acid secretion dec, bicarb levels are lower–more vulnerable to acidosis
- bladder in abdomen until 3-4M
- vulnerable to electrolyte overload
S/s GU disease in newborns
- poor feeding
- resp distress
- poor urinary sys
- jaundice
- sz
- dehydration
- vomiting
s/s GU disease in infants
- poor feeding
- pallor
- fever
- failure to gain wt
- persistent diaper rash
- sz
- dehydration
- vomit
s/s GU disease in children
- enuresis
- freq or painful urination
- smelly urine
- enlarged bladder or kidneys
- pallor
- poor appetite
- hematuria
- ab or back pain
- tetany (common in chronic condx)
- HTN
- edema
- growth failure
NC for GU disease
- accurate measure of BP, wt, I&O
- prep kids and parents for tests (can be painful like inserting dye into bladder)
- collection of specimens (maybe wee bag or in/out cath)
Best way to measure urine output in non-potty trained kids besides a catheter
Weigh diapers
Desired urinalysis results
- clear and yellow
- Sp gr 1.01-1.03 (how dilute it is)
- pH 4.5-8
- Glucose—negative (pos–GN or DM)
- Protein—negative
- Ketone—negative
- RBCs <1
- WBCs <1 (higher means infection)
- casts–moderate clear protein
- nitrite–negative (positive is nitrates–bacteria in urine (infection))
- volume 1-2 mL/kg/hr
Normal serum lab values
- uric acid (2-5.5)–kidneys ability to clear products of metabolism
- BUN (5-18)
- creatinine (0.3-07)
BUN and creatinine indicate how well kidneys are working
***should draw BUN and creatinine about the same time daily
Diagnostics eval of GU disease
- urine culture and sensitivity
- IV pyelography
- voiding cystourethrography (inject dye into bladder to watch urine path)
- renal ultrasound
- kidney, ureters, bladder (KUB)–flat image of abdomen
- cystoscopy
- renal biopsy–high risk of bleed, NPO, stay flat after
GU physical assessment
- hx (UTIs, etc)
- fam hx
- respirations
- HTN
- fever
- growth retardation
- signs of circ congestion
- ab distention
- early signs of uremic encephalopathy (lethargy and confusion)
- hypospadias or epispadias
- ear abnormalities since ears and kidneys dev around same time in kids
Hypospadias
Urethral opening does not extend to tip of penis
- urethra on underside of penis
- vary in severity
- unknown cause
- may be sign of ambiguous genitalia
Epispadias
Urethra goes up instead of to tip of penis
- more common
Hypospadias complications
- inc risk of UTI
- may interfere with procreation if not fixed
- body image disturbance
Hypospadias tx goal and management
- surgical repair in stages
- goals of correction–enable child to void in standing position, fix physical appearance, preserve fxn of sex organ
- ideal time is 6-18M bc kids don’t realize diff in their body yet
Hypospadias NC
- examine every newborn carefully
- delay circumcision bc may use foreskin in surg cosmetically
- psych prep of parent and child
- postop: pressure dressing (check tip freq, don’t change dressing but check for bleeding), catheter/stent care, double diaper, teach home care
- avoid tub baths until stent is removed
- don’t carry baby on hip or ride straddle toy bc don’t want to put pressure on site
Cryptorchidism
one or both testicles fail to descend into scrotum
Cryptorchidism types
- undescended - testes somewhere along normal pathway of descent
- ectopic - testes located outside normal pathway
- retractile - testes manipulated into scrotum
- absent - testes is absent
Cryptorchidism therapeutic management
- ultrasonography or surgical exploration to locate testes
- AAP reccs tx before age 1
- admin HCG (low success)
- Orchiopexy b/t 6-24M (avoid pressure on site, watch for bleeding)
- health teaching–inc risk of testicular cancer in 3rd and 4th decade of life
Obstructive uropathy
obstruction at any level of the upper or lower urinary tract
- blockage of urine flow makes dilation of the affected kidney (hydronephrosis)
Obstructive uropathy CM
- recurrent UTI
- incontinence
- fever
- flank or ab pain
- smelly urine
- hematuria
- dysuria
- polyuria, polydipsia, urgency
- anemia
- FTT
- nocturnal enuresis
Obstructive uropathy management
- surgical correct if needed
- monitor BP
- may need defect fixed
- prep for procedure
- post-op watch
- protect and care for catheter
- teach home care (wound and cath care)
Vesicoureteral reflux (VUR) and complications
- regurgitation of urine from bladder into ureters and kidneys
- graded 1-5
- inc pressure can lead to HTN, renal insufficiency, failure, or scarring
- primary reflux is familiar and usually outgrown
Vesicoureteral reflex types
- Primary reflux–result of incompetent valvular mech at ureterovesical jxn
- Secondary reflux–from acquired condition like UTI or holding it in
signs of VUR
- repetitive UTIs
- 1 UTI in boys
- fam hx of VUR (screen early using VCUG)
VUR tx
- antibiotics until reflux resolves (long-term course)
- grade 4/5 almost always (sometimes 3) get surg; reimplantation of ureter
VUR NC, preop
- infx prevention (compliance with abx (best before bed)
teach child to empty bladder completely (esp before bed), teach good hygiene - have siblings screened
- age appropriate prep for procedures
VUR NC post-op
- care for cath and stent
- administer analgesics for incision pain and antispasmodics for bladder spasms
- teach home care; prophylactic abx for 1-2 post-surg
Hernias
Protrusion of a part of organs thru an abnormal opening
- danger arises when: protrusion is constricted, circ impaired, interference with fxn or dev of other structures
- common herniation areas in kids include (diaphragmatic, ab wall, inguinal canal)
Diaphragmatic hernia
Hole in diaphragm that allows ab contents to be sucked up into cavity
- severity depends on how early it happened (affects heart more if happens earlier)
Congenital diaphragmatic hernia s/s
- s/s often is detected in utero
- s/s after birth–resp distress, cyanosis, scaphoid ab, impaired CO
Congenital diaphragmatic hernia tx
- intubation
- GI decompression
- IVF
- will need surg ASAP after stabilizing
Congenital diaphragmatic hernia surg NC
- monitor resp and fluid, acidosis, thermoreg, cardiac output, sedation, gastric decompression
- tube in stomach for decompression
- promote bonding and reassurance
- postop–continue ventilation (slowly weaned), watch for acidosis, I&O, GI decompression, TPN and liquids, thermoregulation, sedation, pain control, CO
Umbilical hernia
Incomplete fusion of the umbilical ring where umbilical vessels exit ab wall
- usually ok in 3-5Y
- can be fixed in surg but usually not needed (just monitor)
- inc in size with cough, bearing down
- parents should press down on it and feel air and fluid–go to ER
Inguinal hernia
Opening on lower abdominal wall, leaving opening for abdominal contents to poke through
- hernia more visible with cry, strain, having BM
- need surgery
Most important NC for inguinal and umbilical hernia
Press on area and should feel air and fluid; if feel something else, go to ER
Urinary tract infection
Bacterial infx including urethritis (urethra), cystitis (bladder), and pyelonephritis (kidneys)
UTI epidemiology
- E. coli most causes in females
- more common in females bc short urethra
- uncircumcised males more likely
- very common in kids before age 6
UTI risk factors
- constipation
- soak in bubble bath (bubbles can irritate urethra)
- pinworms
- dysfxn voiding; urinary stasis
- dec fluid intake
- VUR
- urologic abnormalities
- indwelling catheterizaion
- neurogenic bladder (often poor muscle tone, prob with CNS)
- sex abuse and intercourse (investigate cause with more than one UTI)
UTI CM: infants
- fever
- irritable
- poor appetite—FTT
- wt loss
- smelly urine
- v/d
- cry w/ urination
- NOT urgency—can’t discern that
UTI CM in kids
- dysuria
- freq, urgency, incontinence
- foul smelling urine, maybe hematuria
- ab pain
- fever
UTI diagnostics
- urine screening (+ nitrites, + RBCs, + WBCs)
- urine culture > 100k colonies of a single bac
UTI therapeutics
- cure infx
- ID predispose fx (tight underwear, poor wiping, sex activity)
- prevent recurrent infx
UTI NC
- specimen handling
- adequate admin of abx
- push fluids
- promote comfort
- adequate follow-up cultures
- teach preventative measures like promote freq bladder emptying, hydration, avoid tight pants, avoid colas and caffeine, chx period products freq
Enuresis
involuntary passage of urine by a child over age of 5
- primary or secondary
- diurnal or nocturnal
Enuresis etiology
Primary
- fam tendency
- dec bladder capacity (age + 2 in oz)
- heavy sleep
- nocturnal polyuria theory
- dev or maturational lag
- sleep dx
Secondary
- psych fx (divorce, bully)
- abuse
- UTI
- diabetes
- sickle cell anemia
Enuresis dx/tx
- hx and physical
- urine sample (check for UTI)
- hx of bed wetting
- wait for maturation (most kids outgrow by age 10)
- tx the cause
- retention/control exercise
- drug therapy: oxybutynin, imipramine, DDAVP for special situations like sleepovers ($$$)
- moisture alarm–beeps or vibrates
- behavior mods–positive reinforcement is key
Enuresis NC
- don’t punish child
- child not lazy or doing on purpose
- recc books (Dry ALL night, waking up dry)
- limit choc and caffeine
- limit fluids after dinner
- use bed pads and 2 sets of sheets
- use pull ups only on sleepovers–wick moisture away but we want kids to get used to getting up after feeling moisture
- void schedule and gradually inc to get kids used to peeing not in bed
- teach use of alarms
- support and encouragement
What is normal urine output
1-2 mL/kg/hr
Desired urine pH
4.5-8
