Genitourinary Flashcards
Exam 2
Anatomy and physiology of GU
Kidney:
Urethra:
Reproductive organs:
Anatomy and physiology: Kidney
Kidney: large in relation to the stomach; prone to injury.
Anatomy and physiology: Urethra
Urethra: shorter; risk for bacteria into bladder (UTI).
Anatomy and physiology: Glomerular filtration rate:
slower in infant; risk for dehydration.
Anatomy and physiology: Bladder capacity:
Bladder capacity: 30 mL in newborn; increases to adult size by 1 year.
Anatomy and physiology: How are reproductive organs?
Reproductive organs: immature at birth until adolescence.
Anatomy and physiology:
What occurs in genitourinary tract?
Urine Formation
Excretion of waste products
Regulation of electrolytes- Blood Pressure
Control of water balance
Control of acid-Base balance
Regulation of Red Blood cell Production
Synthesis of vitamin D to active form
Regulation of calcium and phosphorus
Renal Clearance
Significant Data When Assessing Past Medical History for GU Disorders:
Past medical history
Neonatal history
Family history
Significant Data When Assessing Past Medical History for GU Disorders:
Past Medical History
Maternal polyhydramnios, oligohydramnios,
diabetes,
hypertension, or
alcohol or cocaine ingestion.
Significant Data When Assessing Past Medical History for GU Disorders:
Neonatal history
Presence of a single umbilical artery,
abdominal mass,
chromosome abnormality, or
congenital malformation.
Significant Data When Assessing Past Medical History for GU Disorders
Family history
Renal disease or uropathology,
chronic UTIs,
renal calculi,
or a history of parental enuresis.
Fluid and Electrolyte Balance:
Who is at a greater risk of fluid and electrolyte imbalance?
Children at greater risk for fluid and electrolyte imbalance
Fluid and Electrolyte Balance:
Why do children have a greater risk for fluid and electrolyte imbalance
Have a proportionately greater amount of body water
Require more fluid intake
Excrete more fluid
Fluid and Electrolyte Balance:
Caring for child with fluid and/or electrolyte imbalance
What to monitor?
Monitor for signs of:
Fluid deficit
Fluid excess
Electrolyte imbalance
What does emergent care require (F and E balance)
Emergent care sometimes required with IV replacement of fluids and electrolytes
Fluid and Electrolyte Balance
Fluid Balance:
Fluid balance: intake and output of fluid in 24-hour period is approximately the same
Fluid and Electrolyte Balance
Fluid deficit occurs when fluids are lost by:
Diaphoresis
Vomiting
Diarrhea
Hemorrhage
Fluid and Electrolyte Balance: How does fluid overload occur?
Fluid overload occurs from conditions that create impaired fluid excretion
Fluid and Electrolyte Balance: Conditions that cause impaired fluid excretion?
Kidney disease
Congestive heart failure
Administration of excessive amount of intravenous fluids
Types of Dehydration:
Isotonic dehydration
Hypotonic dehydration
Hypertonic dehydration
Types of Dehydration: Isotonic dehydration
Electrolyte and water deficits in balanced proportions
Types of Dehydration: Isotonic dehydration
How are serum sodium levels?
Serum sodium remains in normal limits (130–150 mEq/L)
What is the most common type of dehydration?
Isotonic dehydration
What is the greatest concern with isotonic dehydration?
Hypovolemic shock is greatest concern
Types of Dehydration: Hypotonic Dehydration
Electrolyte deficit exceeds water deficit
Types of Dehydration: Hypotonic Dehydration
How is serum sodium levels?
Serum sodium concentration is < 130 mEq/L
Types of Dehydration: Hypotonic Dehydration
How are physical signs?
Physical signs more severe with smaller fluid losses
Types of Dehydration: Hypertonic dehydration
What is likely to occur?
What are serum sodium levels?
Sodium serum concentration > 150 mEq/L
Seizures likely to occur
Types of Dehydration: What is the most dangerous type of dehydration?
Most dangerous type; water loss in excess of electrolyte loss
Hypertonic dehydration
Urinary and Renal Disorders:
What are structural disorders include:
Bladder exstrophy
Obstructive uropathy
Hydronephrosis
Vesicoureteral reflux
Kidney formation disorders:
Renal developmental abnormalities account for what percent of ESRD in children?
Renal developmental abnormalities account for 30-50% of End Stage Renal Disease (ESRD) in children.
Kidney formation disorders: About half cases are secondary to what?
About half of these cases are secondary to abnormalities of the lower urinary tract.
Kidney formation disorders:
Are collectively known as?
These disorders are collectively known as congenital anomalies of the kidney and urinary tract (CAKUT)
Obstructive uropATHIES include?
Uretero-pelvic junction (UPJ)
Uretero-vesical junction (UVJ)
Ureterocele
Posterior urethral valves (PUV) - Males only
Vesicoureteral reflux
Urine normally flows downward from kidneys; in vesicoureteral reflux (VUR), urine backflows from bladder to ureters, and sometimes back to kidneys; this occurs at vesicoureteral junction
What are signs and symptoms of VUR?
Most common presentation: recurrent UTI
Flank pain, abdominal pain, and enuresis may coexist
Fever
Nausea/vomiting
UTI symptoms
What is a common cause of UTIs in children?
VUR is a common cause of UTIs in children
Urinary tract infections: What are they caused by?
Caused by bacterium, virus, or fungus
Urinary tract infections: Where do they start?
Most often start distally and ascend at urethral area, causing urethritis or cystitis
Urinary and Renal Disorders include:
UTI
Hematuria
Proteinuria
Acute glomerulonephritis
Nephrotic syndrome
Enuresis
Hemolytic-uremic syndrome
Renal failure (acute and chronic)
Urinary tract infections: If origin in the upper tract, what may result?
If origin in upper tract, ureteritis and pyelitis or pyelonephritis may result
Cystitis
Cystitis = lower UTI involving the urethra and or the bladder
Pyelonephritis
upper UTI that involves the ureters, renal pelvis – usually affects both kidneys
Urinary tract infections:
How is a diagnosis made?
Based on urine culture and sensitivities
Also indicated by suprapubic aspiration (SPA) or catheterization with 50,000/mL bacterial growth
Urinary tract infections:
With intensely ill children, what is a choice?
With intensely ill child, catheterization or SPA is choice in all age groups to detect UTIs
Urinary tract infections:
Administer medications:
What types of meds are used for UTIs?
IV fluids or antibiotics may be required
Parenteral and oral antibiotics are used to treat UTIs
Urinary tract infections:
What type of antibiotics are recommended for children with toxic symptoms, dehydration, vomitting or noncompliance?
Parenteral antibiotics are recommended for children with toxic symptoms, dehydration, vomiting, or noncompliance
Urinary tract infections:
What kind of antibiotics are given and how long are they given to toxic children or those with pyelonephritis?
IV antibiotics are usually given for 14 days to toxic children or those with pyelonephritis
Urinary tract infections:
What kind of antibiotics are given for uncomplicated cases?
Oral antibiotics for uncomplicated cases
Uti symptoms - developmentally:
Neonates:
Failure to thrive
Jaundice
Hypothermia
Vomitting or diarrhea
Cyanosis
Abdominal distention
Lethargy
Sepsis
Uti symptoms - developmentally:
Infants:
Poor feeding
Fever (esp. related to pyelonephritis)
Vomitting or diarrhea
Malodor
Dribbling urine
Ab pain/colic irritability
Malaise
Poor weight gain
Uti symptoms - developmentally:
Toddler/Preschool
Abdominal pain
Vomiting or diarrhea
Flank pain
Fever (especially pyelonephritis)
Malodor
Altered voiding pattern
Diaper rash
Enuresis
Malaise
Uti symptoms - developmentally:
School Age/Adolescent
Enuresis
Malodor
Classic dysuria with frequency, urgency, and discomfort
Fever/chills (especially related to pyelonephritis)
Abdominal pain
Flank pain
Malaise
Vomiting or diarrhea
Urinary tract infections - education
What is key?
Education/discharge instructions- Prevention is key!
Urinary tract infections - education
What are you teaching?
Teach signs of infection
Urinary tract infections - education
What are you emphasizing the importance of?
Emphasize importance of hand washing
Urinary tract infections - education
What are you teaching techniques for?
Teach wipe technique – front to back, cotton underwear
Urinary tract infections - education
What are you teaching teenagers?
Teenagers- avoid tight jeans, urinate frequently
(females void after intercourse and change tampons/pads frequently.)
Urinary tract infections - education
What should you teach is an increased cause of infection?
Explain fecal soiling and constipation as an increased cause of infection
Urinary tract infections - education
What should you encourage?
Encourage collaboration with health-care provider to prevent constipation:
Urinary tract infections - education
How would you prevent constipation?
Increased dietary and fluid intake
Administration of stool softeners and laxatives
Teaching child to establish normal bowel habits
Hematuria:
What can be the first sign of renal disease?
Although rare, microscopic hematuria can be the first sign of renal disease
Hematuria:
What does gross hematuria in children indicate?
Gross hematuria in children is more serious, indicating a possibility of:
IgA nephropathy
hypercalciuria with or without calculi,
post-streptococcal glomerulonephritis,
renal trauma,
coagulopathy,
hydronephrosis,
epididymitis,
and tumor
Hematuria
What are signs and symptoms?
Microscopic blood in urine
Macroscopic blood in urine
Hematuria:
Microscopic blood in urine
(Not visible to the naked eye)
Hematuria:
Macroscopic blood in urine
(Gross hematuria)
Proteinuria: What is it associated with?
Disorder associated with upright activities during daytime hours
Proteinuria:
What test may be used to discover loss of proteins?
Routine office urinalysis may discover loss of proteins, such as albumin or globulins, in urine
Proteinuria:
What is diagnosis based on?
Diagnosis Based on serial first-voided (first urine of morning) specimens for urinalysis at least 3 times over 2-week span
Proteinuria:
How does it range?
Proteinuria ranges from simple and reversible etiologies to complex, life-threatening causes
Proteinuria:
What is else is it associated with?
Proteinuria is associated with progressive renal disease
Proteinuria:
May be a cause of what?
Proteinuria may be a cause of renal injury
Proteinuria: May be a risk factor for what?
Proteinuria may be a risk factor for cardiovascular disease
Proteinuria:
What are signs and symptoms?
Commonly asymptomatic
Dipstick shows 1+ (30 mg/dL) or higher level of proteinuria
Proteinuria may also be noted in infected urine, often along with leukocytes, hematuria, and positive nitrates
Proteinuria:
Signs and symptoms: What does dipstick show?
Dipstick shows 1+ (30 mg/dL) or higher level of proteinuria
Acute glomerulonephritis
Inflammation of the glomeruli
Acute glomerulonephritis:
What does interference with glomeruli filtering lead to?
Interference with the glomeruli filtering waste products from the blood gives rise to acute and chronic clinical manifestations
Acute glomerulonephritis:
Very dangerous Signs and Symptoms?
OLIGURIA
EDEMA
HYPERTENSION
CIRULATORY OVERLOAD
HEMATURIA
PROTEINURIA
Acute glomerulonephritis: Signs and Symptoms?
Gross hematuria, either tea-colored or red urine
Edema, which may be seen in periorbital region
Child may develop hypertension and headache
Severe disease causes ascites, due to fluid shifting
Acute glomerulonephritis:
Diagnosis: Most children are healthy until what?
Most children are healthy until the strep infection of throat or skin– edema is moderate and difficult to detect.
Acute glomerulonephritis: How long does it take renal disease to manifest?
Renal disease manifests weeks after the infection
Acute glomerulonephritis: What must be present in urinalysis?
U/A-hematuria and proteinuria – increased BUN, Cr, increased BP
Acute glomerulonephritis:
What does ASO titer indicate?
Serum antistreptolysin titer (ASO titer) will indicate exposure to bacteria if child has not had diagnosed streptococcal infection in past 2 weeks
Acute glomerulonephritis:
How is Serum complement?
Serum complement (C3) may be positive
Acute glomerulonephritis:
How long is urine microscopic hematuria present?
Urine microscopic hematuria may still be noted up to 1 year after disease resolves
Acute glomerulonephritis:
What labs assess renal function?
Laboratory tests (BUN, creatinine) assess renal function
Acute glomerulonephritis: If children does not fully recover, what may develop? What would be required?
If child does not fully recover, nephrotic syndrome may develop, and renal biopsy may be required
Acute glomerulonephritis: Collaborative care (cont’d)
What would be done about infectious sources?
Treat infectious sources (e.g. streptococcus) with appropriate antibiotics
Acute glomerulonephritis:
Collaborative care (cont’d)
What do fluid imbalances require?
Fluid imbalances require monitoring of fluid intake and output, as well as possible treatment with diuretic medications and antihypertensive drugs
Acute glomerulonephritis:
What may severe glomerulonephritis require?
Severe glomerulonephritis may require peritoneal dialysis or hemodialysis
Acute glomerulonephritis:
What may be useful to manage the acute process?
Corticosteroids may be useful to manage the acute process
Acute glomerulonephritis: Other than meds, what is needed to treat this?
Rest
Daily weights *best indicator to monitor fluid status
Acute glomerulonephritis: What is the prognosis?
Good Prognosis
Acute glomerulonephritis: What is the best indicator of fluid status?
Daily weights *best indicator to monitor fluid status
Most common cause of acute renal failure (ARF) in children:
Hemolytic uremic syndrome (HUS)
Hemolytic uremic syndrome (HUS): What is it most commonly associated with?
most commonly associated with children ingesting beef contaminated with Escherichia coli, although other organisms have been implicated
Hemolytic uremic syndrome (HUS):
Signs and Symptoms: What are classic signs?
Thrombocytopenia
Anemia
Acute renal failure
Hemolytic uremic syndrome (HUS):
Other signs and symptoms include
Gastroenteritis with abdominal pain, vomiting, and bloody diarrhea
Potential upper respiratory infection
Hematuria
Proteinuria
Pallor
Lethargy
Irritability
Decreasing urine output
Hepatosplenomegaly
Dehydration
Possible seizures
Consciousness alteration
Anemia with high reticulocyte count
Thrombocytopenia
Hemolytic uremic syndrome (HUS)- What is the hallmark sign?
Bloody diarrhea
Henoch-Schönlein Purpura:
What does it include?
Henoch-Schönlein purpura (HSP) includes a range of mild to severe glomerulonephritis and renal insufficiency
Henoch-Schönlein Purpura:
What is it classified as?
Classified as vasculitis due to component of inflammation in the arteries
Henoch-Schönlein Purpura:
What does it typically follow?
Typically follows an upper respiratory tract infection
Henoch-Schönlein Purpura:
What are signs and symptoms?
Hematuria
Hypertension
Bloody diarrhea
Crampy abdominal pain
Rash with palpable purpura (raised purpura), features found especially on the lower extremities and buttocks
Joint pain and swelling
Scrotal swelling in males
Henoch-Schönlein Purpura:
Where are Rash with palpable purpura usually found?
features found especially on the lower extremities and buttocks
Henoch-Schönlein Purpura: How is diagnosis made?
Based on clinical findings;
history of classic symptoms of rash,
gastrointestinal complaints or hematuria,
and arthritis are present
Henoch-Schönlein Purpura: Diagnosis is dependent on what?
History?
Henoch-Schönlein Purpura: What are lab results?
Elevated serum IgA level, sedimentation rate, platelet count, and WBC counts may be present
Urinalysis may show hematuria
Stool guaiac test may be positive
Nephrotic Syndrome: WHat is it?
Congenital, Idiopathic, Secondary
Nephrotic Syndrome: Why could it be congenital, idiopathic or secondary?
Congenital (rare) before 1 year old,
Idiopathic (most common Minimal Change Disease) by age 6,
Secondary (SLE, DM, HSP)
Nephrotic Syndrome: what is it characterized by?
Proteinuria
Hypoalbuminemia
Edema
Hypercholesterolemia
Nephrotic Syndrome: Risks include?
Anemia
Infection – because of altered immunity
Poor growth
Ascites
Peritonitis
Thrombosis
Renal failure
Nephrotic Syndrome: What are the three classic signs?
Proteinuria, hypoalbuminemia, edema.
What happens in Nephrotic Syndrome:
How does proteinuria occur?
The glomerular membrane that is usually impermeable to albumin and other proteins becomes permeable to proteins which leak through the membrane and are lost in the urine = proteinuria
This in turn reduces the serum albumin level leading to hypoalbuminemia This leads to edema especially in the abdomen (ascites). This shift in fluid causes hypovolemia. Hypovolemia triggers the RAA system causing vasoconstriction.
What happens in Nephrotic Syndrome:
How does hypoalbuminemia occur?
Proteinuria –> This in turn reduces the serum albumin level leading to hypoalbuminemia
What happens in Nephrotic Syndrome:
How does edema occur?
hypoalbuminemia–> This leads to edema especially in the abdomen (ascites).
This shift in fluid causes hypovolemia. Hypovolemia triggers the RAA system causing vasoconstriction.
What happens in Nephrotic Syndrome:
Edema leads to what? What does that lead to?
This shift in fluid causes hypovolemia. Hypovolemia triggers the RAA system causing vasoconstriction.
Nephrotic Syndrome: What is used to diagnose?
Urinalysis may show
Nephrotic Syndrome: What may urinalysis show?
Protein levels of 2+ or greater
Hyaline or granular casts
Microhematuria
High specific gravity
Nephrotic Syndrome: How are cholesterol, serum albumin levels?
Cholesterol levels may be elevated
Serum albumin levels may be low
Nephrotic Syndrome: What may be required?
Kidney biopsy may be required
Nephrotic Syndrome: What may be needed if disease is severe?
Hospitalization may be needed if the disease is severe
Nephrotic Syndrome: What should you monitor?
Fluid and electrolyte balance
Weight
Degree of edema
Nephrotic Syndrome:
What must you be aware of?
Be aware of disease manifestations and need for possible kidney biopsy
Nephrotic Syndrome: How should you treat?
Treat with diuretics and albumin replacement if indicated early on
Enuresis: What are the types of enuresis?
Primary enuresis:
Secondary enuresis:
Diurnal enuresis:
Nocturnal enuresis:
Primary enuresis:
enuresis in the child who has never achieved voluntary bladder control.
Secondary enuresis:
Secondary enuresis: urinary incontinence in the child who previously demonstrated bladder control over a period of at least 3 to 6 consecutive months.
Diurnal enuresis:
daytime loss of urinary control.
Nocturnal enuresis:
nighttime bedwetting.
Renal trauma:
In what percent of abdominal trauma situations is it present?
Kidney trauma is present in 8–10% of abdominal trauma situations
Renal trauma:
What does History of injury relate to?
History of injury relates to blunt and penetrating abdominal injury
Renal trauma:
What does kidney injury occur more often from?
Kidney injury occurs more often from blunt trauma; kidneys
Renal trauma:
What are kidneys known for rupturing from?
kidneys are known for rupturing from blunt trauma.
Renal trauma: Penetrating trauma injuries are often caused by:
Penetrating trauma injuries are often caused by animal bites, gunshot wounds, or stabbings
Renal trauma:
With critical injuries involving renal trauma, children show the following and signs and symptoms:
Grey Turner’s sign (ecchymosis localized in flank area and flank tenderness)
Palpable mass
Hematuria
Acute kidney injury (AKI)- WHat does it result in?
resulting in a treatable condition manifesting as an increase in nitrogenous waste products and lack of homeostasis regulation by the kidney
Acute kidney injury (AKI): Signs and symptoms;
Pre-renal causes are associated with:
hypovolemia signs
Acute kidney injury (AKI):
Signs and symptoms relative to extracellular fluid indications from decreased renal circulation from vasodilation or cardiovascular disease include:
Edema
Ascites
Weight gain
Increased central venous pressure (CVP) and pulmonary artery wedge pressure (PAWP)
Acute kidney injury (AKI): Signs and symptoms
Pre-renal causes are associated with hypovolemia signs and are evidenced by:
Tachycardia
Dry mucous membranes
Poor peripheral perfusion
Poor skin turgor
Flat jugular veins
Weight loss
Acute kidney injury (AKI):
Intrarenal or intrinsic AKI is evidenced by:
Peripheral edema
Rales
Cardiac gallop
Potential presence of a rash and arthritis, suggesting systemic lupus erythematosus or Henoch-Schönlein purpura
Acute kidney injury (AKI):
Post-renal findings include
Palpable flank masses, which might indicate renal vein thrombosis, tumors, cystic disease, or urinary tract obstruction
Aki diagnosis: How is it made?
Take careful history, analysis of symptoms, and physical examination to determine if cause is prerenal, intrarenal, or postrenal
Aki diagnosis: How does collecting previous history help?
Previous history helps to determine any previous infections, such as acute glomerulonephritis or neurogenic bladder
Aki diagnosis: What can be uncovered?
Genetic problems (e.g., horseshoe-shaped kidney, only one kidney) can be uncovered
AKI diagnosis: What are common lab tests
Common laboratory data include
urinalysis,
blood chemistry,
blood urea nitrogen,
serum creatinine, and
pH
Aki diagnosis: How else can it be diagnosed? (having to do with toxins?)
Can also be diagnosed by finding toxins in blood caused by exposure to heavy metals or organic solvents, which can cause acute tubular necrosis
AKI diagnosis:
Other epidemiological nephrotoxic agents include treatment with
aminoglycosides, amphotericin B, contrast, or chemotherapeutic agents
AKI diagnosis:
What can renal biopsy be used for?
Renal biopsy can be used to determine causation
Chronic kidney disease:
What terms have replaced it? Who does it exclude?Why?
The term chronic kidney disease (CKD) has replaced the term chronic renal failure or chronic renal insufficiency,
but excludes children under 2 years whose quick response to treatment cannot be estimated by the glomerular filtration rate alone
Chronic kidney disease:
How is GFR for kids greater than 2?
For those > 2 years, the glomerular filtration rate progressively deteriorates through four separate stages
Chronic kidney disease:
Signs and symptoms?
Failure to thrive or anorexia
Nausea
Vomiting
Loss of appetite
Lethargy
Headaches
High blood pressure
Reduced urine output
Polyuria and polydipsia
Bedwetting
ESRD and Renal Replacement Therapy:
Condition in which the kidneys cannot concentrate urine, conserve electrolytes, or excrete waste products.
ESRD and Renal Replacement Therapy :
How can ESRD present?
May be acute or chronic
ESRD and Renal Replacement Therapy :
How is acute renal failure when it progresses?
When acute renal failure continues to progress, it becomes chronic (also known as end-stage renal disease [ESRD]).
ESRD and Renal Replacement Therapy :
What is treatment for ESRD?
Dialysis and kidney transplantation are treatment modalities used for ESRD.
ESRD and Renal Replacement Therapy:
What is RRT?
Renal replacement therapy (RRT) is the treatment option for end-stage renal disease (ESRD) and is also used for acute kidney injury
ESRD and Renal Replacement Therapy:
Signs and symptoms
Swelling and edema
Anemia
Weakness and fatigue
Shortness of breath
Changes in urination
Rash or itchy, dry skin
Elevated BUN and creatinine
Uremia: build-up of waste
Altered electrolytes
Hypertension
Tachycardia
Tachypnea
Dialysis and transplant:
What are the types of dialysis available? What is another treatment?
Peritoneal Dialysis
Hemodialysis
Transplant
Dialysis and transplant:
Peritoneal Dialysis
Uses child’s abdominal cavity as a semipermeable membrane to help remove excess fluids and waste products.
Dialysis and transplant:
Hemodialysis
Removes toxins and excess fluid from the blood by pumping the child’s blood through a hemodialysis machine and then reinfusing the blood into the child.
Hemofiltration:
In the pediatric setting, hemofiltration, or CRRT, is a process that removes water by filtration through an extracorporeal system
Hemofiltration:
What should you do prior to Hemofiltration?
Collaborate with the health-care provider about:
Goals of stabilizing fluid balance
Assessing BUN, creatinine, glucose, and PTT
Check patency of all circuits carefully, look for clots
Monitor analysis of PTT and clotting studies every 1 to 3 hours
Hemofiltration:
What should you do when hemofiltration begins?
Monitor vital signs and fluid balance every 30 minutes
Assess ultrafiltration rate every hour with replacement fluid set by nephrologist
Hemofiltration:
Education/discharge instructions
What should you teach parents?
Teach parents to monitor for complications related to continuous arteriovenous hemofiltration (CAVH)
Hemofiltration:
What do you need to teach parents to monitor for related to CAHV?
Fluid and electrolyte imbalances
Bleeding/thromboembolic events (e.g., anemia and hypovolemia)
Hemofiltration:
Education/discharge instructions
What do you need to emphasize importance of?
Emphasize importance of nutritional needs and involvement of a dietitian
Peritoneal Dialysis : What does it utilize?
Peritoneal dialysis (PD) utilizes the peritoneal membrane to filter and purify blood
Peritoneal Dialysis : What is put in the child’s abdomen?
Dialysis solution, consisting of dextrose sugar and other minerals in water, is instilled into the child’s abdomen through an abdominal catheter
Peritoneal Dialysis: Signs and symptoms of complications
Potential peritonitis
Catheter dysfunction and obstruction
Pain
Pulmonary complications
Fluid and electrolyte imbalance
Hemodialysis- WHat is the purpose?
To prevent accumulation of unwanted fluid and toxins, hemodialysis (HD) removes unwanted products by extracorporeal circulation through a dialyzer
For U.S. adolescents and children with ESRD, what dialysis is preferred?
For U.S. adolescents and children with ESRD, HD is preferred
hemodialysis:
Side effects
Hypotension (low blood pressure)
Weakness, dizziness, and nausea from the hypotension
Muscle cramps secondary to electrolyte imbalances
hemodialysis: Collaborative care
Keep AV fistula, AV graft, or venous catheter clean and safe
Keep access site clean and use only for hemodialysis
Maintain fluid and dietary restrictions between dialysis sessions
hemodialysis:
Keep access site clean and use only for hemodialysis: how?
Child cannot wear jewelry near site
Child cannot have a blood pressure taken on affected arm
Do not bruise site
Renal transplant: WHo is referred for it?
Children with progressive renal disease leading toward ESRD are referred for a kidney transplant evaluation
Renal transplant: Collaborative care
2- to 3-day inpatient evaluation prior to transplant
Obtain complete history and physical
Perform psychosocial assessment
Notify financial counselor
Perform lab tests:
Perform diagnostic tests:
Perform thorough nursing assessment related to possible infection, imbalance of fluid and electrolytes, and rejection
Maintain proper nutrition with protein-restricted diet to avoid overloading kidneys
Renal transplant: Collaborative care
2- to 3-day inpatient evaluation prior to transplant
Perform lab tests:
Cross match, HLA/PRA markers, ABO, tissue typing
CBC, PT/PTT, INR, CMP
Hepatitis B, C, CMV, EBV, HSV, VZV, HIV, VDRL
Hemoglobin A1C
PPD
Renal transplant: 2- to 3-day inpatient evaluation prior to transplant (cont’d)
Perform diagnostic tests:
Chest x-ray, ECG, 2-D echo, abdominal CT, abdominal US, and vascular studies
Cardiology stress test and/or cardiac catheterization
Urological system evaluation
Pulmonary function tests
Co-morbidity clearance and consulting
Renal transplant: 2- to 3-day inpatient evaluation prior to transplant (cont’d)
Candidate phase:
patient is waiting to be put on transplant list
Reinforce treatment options provided to patient/family and complete medical history of child and parents
Renal transplant: 2- to 3-day inpatient evaluation prior to transplant (cont’d)
Candidate phase: What is being done?
Encourage good nutritional support pre- and post-transplant in collaboration with dietitian
Conduct comprehensive physical assessment of child
Coordinate multiple diagnostic studies to be completed and ensure that any problems are corrected prior to listing child as transplant candidate
Ensure that living donor is healthy and compatibility ensured through HLA matching
Conduct a psychosocial assessment of parent and child to ensure compliance
Assess that histocompatibility testing is done
Organize care and schedule tests needed prior to transplant
Answer questions; reinforce lifestyle commitments and changes
Administer standard immunizations minimum of 6 weeks prior to transplant
Measure viral titers prior to transplantation to ensure vaccination adequacy
Renal transplant:
Collaborative care (cont’d)
Renal transplant phase: WHat is it?
actual transplant, pre- and post-operative
Provide education about medications and treatments
Monitor respiratory and cardiac functions with immediate detection and referral to transplant team if any abnormalities
Renal transplant:
Renal transplant phase: actual transplant, pre- and post-operative (cont’d)
Monitor for:
Bleeding
Infection or indications that kidney is functioning abnormally
Oliguria
Wound infection
Increased blood pressure
Renal transplant:
Renal transplant phase: actual transplant, pre- and post-operative (cont’d)
Monitor for:
Monitor fluid status for either hypovolemia or hypervolemia
Monitor:
Hourly intake urine and output
Serum electrolytes and liver enzymes
Vital signs and central venous pressure
Administer IV fluids, diuretics, and, if needed, dialysis or continuous venovenous hemofiltration
Monitor laboratory studies
Assess for surgical complications
Assess for urologic complications
Monitor for obstruction
Monitor for urine leakage
Administer immunosuppression medications
Female Reproductive Organ Disorders:
Labial adhesions
Vulvovaginitis
Pelvic inflammatory disease
Sexually transmitted infections
Menstrual disorders
Labial adhesions-
Fusion of the labia minora due to inflammation, infection, trauma, estrogen deficit
Labial adhesions- who is it common in?
Most common in girls 3 months to 6 years old
Labial adhesions: Signs and symptoms
Thin film develops over labia, from posterior to anterior aspect
Vaginal introitus and urethral meatus are not visible
Dysuria
Urinary incontinence
Labial adhesions: Diagnosis
Based on signs and symptoms and common associated problems
Labial adhesions: Diagnosis
Based on signs and symptoms and common associated problems-include:
Dysuria
Incontinence if urine is trapped; dribbling after voiding in toilet-trained girls
Vulvovaginitis
Inflammation of the vulva and vagina
Bacterial or yeast overgrowth.
Vulvovaginitis- caused by what
Chemical factors such as bubble bath, soaps, or perfumes found in personal care products.
Poor hygiene.
Tight clothing may cause a heat rash in the perineal area.
Vulvovaginitis: What may lead to irritation of superficial skin?
Persistent scratching of the irritated area may result in the complication of superficial skin infection.
Vulvovaginitis- most common cause?
Candidiasis, a yeast organism, is the most common source of this disorder
Vulvovaginitis: Signs and symptoms
Discharge can vary
Glutinous gray-white
Purulent
Blood-tinged
Foul-smelling and brown or green
Thick white curd
Vulvovaginitis- Diagnosis
Diagnosis is based on patient history, clinical findings, and pH testing of vaginal secretions
Pseudohyphae (branching yeast organisms) may be found on microscopy where pH is < 4.5
Clue cells (large epithelial cells with bacteria) may indicate bacterial vaginosis; trichomonads may indicate trichomoniasis
Other organisms may be found on Pap smears in adolescents (Candida or trichomonads)
Manifestations of Pelvic Inflammatory Disease (PID)
Long-term complications
Chronic pelvic pain,
ectopic pregnancy, and
infertility related to scarring.
Manifestations of Pelvic Inflammatory Disease (PID)
Fever
Abdominal pain
Pain with intercourse
Dysmenorrhea (painful menstrual cycles)
Abnormal uterine bleeding
Long-term complications
Vulvovaginitis - Treatment
If caused by vaginal candidiasis, medicate with over-the-counter antifungal cream applied topically
Miconazole (Monistat)
Clotrimazole (Gyne-Lotrimin)
Vulvovaginitis - Treatment
If caused by vaginal candidiasis, medicate with over-the-counter antifungal cream applied topically
Miconazole (Monistat)
Clotrimazole (Gyne-Lotrimin)
Amenorrhea
The absence of menses; categorized as primary or secondary
Amenorrhea = primary
Delayed puberty
Tanner stages of sexual characteristic development show delay
Amenorrhea = secondary
Signs and symptoms of pregnancy
Mastalgia (breast tenderness) or breast enlargement
Nausea and vomiting
Urinary frequency
Enlarged uterus
Chadwick’s sign
Male Reproductive system issues
Phimosis and paraphimosis
Hypospadias and Epispadias
Cryptorchidism
Hydrocele and varicocele
Testicular torsion
Epididymitis
Sexually transmitted infections
Phimosis
Condition in which the foreskin is so tight it cannot be retracted over the glans penis
Phimosis can be a result of what?
Can be result of infection or inflammation underneath foreskin, or can be congenital
Phimosis Signs and symptoms
Possible infection or inflammation of penis
Presence of paraphimosis
Dysuria
Pain
Abnormal, intermittent urine stream
Inability to retract foreskin
Pinpoint opening of foreskin
Paraphimosis
Condition in which the foreskin is retracted and cannot be returned to its normal position
Paraphimosis who is is common in?
More common in adolescents and can occur after masturbation, forceful retraction, or sexual abuse
Paraphimosis s/s
Bluish discoloration of glans and foreskin
Edema of glans and foreskin
Risk of necrosis of penis
Paraphimosis- how is diagnosis made?
Diagnosis
Based on:
Patient history
Physical examination findings
Hypospadias and Epispadias
Congenital conditions, possibly genetic, characterized by an abnormal positioning of the urethral meatus
Hypospadias
the meatus is inferior to its usual position
Epispadias
In epispadias, the meatus is superior to its usual position; surgical correction with possible penile urethral lengthening may be necessary
Signs and symptoms of hypospadias include:
Opening of urethra below tip on bottom side of penis
Incomplete foreskin
Curvature of penis during erection
Abnormal position of scrotum in relation to penis
Cryptorchidism
Absent, undescended, or ectopic testicles
WHat is the most common male congenital anomaly?
Most common male congenital anomaly, noted in 2–4% of all newborn males
Cryptorchidism results from what?
May result from hormonal, anatomical, or chromosomal variations; prematurity increases the chances.
Cryptorchidism
Signs and symptoms:
A retractile testis has descended but retracts with exam and physical stimulation
An ectopic testis is outside of the normal pathway (e.g., in the groin, abdominal wall, or perineum)
After 1 year of age, it is uncommon for the testes to spontaneously descend
In 85% of cases, the undescended testis is unilateral and on the right
Cryptorchidism - treatment?
Explain orchiopexy
Surgical repair usually done at age 6–12 months
circumcision Benefits
Decreased incidence of UTI, sexually transmitted infections, AIDS, and penile cancer, and in female partners a decreased occurrence of cervical cancer.
circumcision. Complications
Alterations in the urinary meatus, unintentional removal of excessive amounts of foreskin, or damage to the glans penis.
Varicocele
Abnormal dilations in the testicular veins, normally unilateral and affecting the left testicle
