GU Flashcards
1
Q
Urinary Tract System
A
kidneys, ureters, bladder (2 sphincters: internal & external/voluntary) and urethra
2
Q
Kidneys (anatomy)
A
- cortex is outside (contains glomeruli)
- medulla is inside (tubular & collecting ducts)
- glomerulus (encapsulated capillaries aka filtration membranes, allows components of the blood to filter through)
- afferent arteriole (blood enters here; dilates)
- juxtaglomerular apparatus (supplies blood to glomeruli & detects changes in BP)
3
Q
Pediatric urinary output
A
1mL/kg/hour
4
Q
Adult urinary output
A
1 liter per day
5
Q
Crystalloid fluid
A
- capable of passing thru a semipermeable membrane as in dialysis
- 1st choice in rapid volume replacement given in IV bolus of 10-20 mL/kg over 10 -15 minutes
- An increase in BP and decrease in HR indicate successful resuscitation
- LR & 5% dextrose
6
Q
Colloid fluid
A
- not capable of passing thru a semipermeable membrane
- contains protein
- remains in vascular space longer than crystalloids
- often administered to children in shock
- albumin
7
Q
Whole blood
A
- used only in incidents of known blood loss
- active bleeding or markedly decreased hematocrit
8
Q
Fresh frozen plasma (FFP)
A
- used to correct coagulopathies
- not for volume replacement
9
Q
Hemodialysis
A
- preferred method in most cases because protein loss less extensive than with peritoneal dialysis
- difficult in children less than 20 kg
- done via graft, fistula, or external access device
- preferred site is radial artery and forearm vein
- usually 3x/wk for 3-5 hours
- outpatient or hospital or dialysis facility
- home hemodialysis ideal for children waiting for transplants, living far from medical facilities, or those who have had more than one kidney transplant failure.
10
Q
Peritoneal dialysis
A
- for acute conditions
- quick & relatively easy to learn, safe to perform & requires minimum equipment/nurses
- slow, gentle process decreased pressure on organs
- great for limited vascular access, children with cardiac disease and neonates
- fewer dietary restrictions
- most often performed at home
- contraindicated for recent abdominal surgery, adhesion or scarring
- higher rate of infection
11
Q
Continuous venovenous hemofiltration
A
- used in acute care settings
- filtrates blood using special equipment at a very low setting
- fluid balance may be achieved within 24-48 hours
- used to remove excess fluid from patients with severe oliguria fluid overload
- successful in children who might not survive the rapid volume exchanges of hemodialysis and peritoneal dialysis
12
Q
Chronic renal disease and electrolyte imbalances
A
- potassium elevated
- phosphorus elevated
- calcium decreased
13
Q
Urinary tract infections
A
- inflammation, usually bacterial in origin, of the urethra (urethritis), bladder (cystitis), ureters (ureteritis), or kidneys (pyelonephritis)
- most common organism E. coli (80%)
- peak incidence, not structural, is 2-6 years old
- females have a 10-30x higher risk r/t shorter urethra (5-6% have first UTI by 1st grade)
14
Q
Intrinsic factors r/t UTI
A
- urine stasis (most important contributing factor), reflux, constipation, pregnancy
- neurogenic bladder
15
Q
Extrinsic factors r/t UTI
A
- poor hygiene, tight clothing/diapers, catheters, constipation, pregnancy
- antimicrobial agents
- bubble baths
16
Q
Altered urine and bladder chemistry r/t UTI
A
-decreased fluid intake
17
Q
Pathophysiology of UTI
A
- recurrent cystitis may produce anatomic changes in the ureter that leads to vesicoureteral valve incompetence and reflux of urine
- pyelonephritis can lead to acute and chronic inflammatory changes in the pelvis and medulla with scarring and loss of tissue
- recurrent or chronic infections results in increased fibrotic tissue
- controversy remains on whether or not cranberry juice helps prevent bacteria from sticking to bladder wall
18
Q
Clinical manifestations of UTI
A
- may be asymptomatic or nondescript symptomatology
- newborn - 2 yrs: fever or hypothermia, vomiting, FTT, abdominal distention, diarrhea, jaundice ( under 2 can’t concentrate their urine r/t immature renal function), may also have persistent diaper rash
- 2 to 12 yrs: enuresis, incontinence in a child previously not, fever, strong or foul-smelling urine, increased frequency, urgency
- adolescent: flank pain, fever, hematuria
19
Q
Goals of treatment with UTI
A
- guided by culture and sensitivity
- eliminate current infection –> antibiotic therapy
- identify contributing factors to reduce relapse –> parent teaching
- prevent urosepsis
- preserve renal function
20
Q
Diagnostic evaluation r/t UTI
A
- Urine culture (clean catch, catheter, suprapubic tab)
- suprapubic tap 1,000
- catheter >10,000 indicates UTI
- clean catch >100,000 indicates UTI
- ultrasonography
- voiding cystourethrogram (VCGU)
- intravenous pyelogram (IVP)
- dimercaptosuccinic acid scan (DMSA)
21
Q
Vesicoureteral reflux (VUR)
A
- retrograde flow of bladder, urine up the ureters
- primary reflux results from congenital abnormalities in insertion of ureters into the bladder; siblings need screened as there is a 36% chance they will have it as well (<2 yrs)
- secondary reflux results from UTI infections/stasis in the bladder and ureterovesicular junction incompetency due to edema, neurogenic bladder, dilation of ureters following surgical urinary diversion
22
Q
Pathophysiology of VUR
A
- it occurs when the pressure of a full bladder forces urine into the upper urethra
- as pressure is decreased, urine refluxes into the ureter, predisposing the child to UTI’s
- simple UTIs that begin in the bladder via an ascending urethral route are transmitted to the upper urinary tracts and kidney
- classified according to the degree of reflux (graded 1-5; grade 4-5 significant and warrant surgery with significant anatomic anomaly resulting in frequent UTIs or child from noncompliant family)
- important cause of renal damage; refluxed uring ascending into the collecting tubules of nephrons gives microorganisms access to the renal parenchyma, causing scaring
- reflux causing scarring will lead to loss of functioning nephrons and some degree of compromised function
- affects kidney growth
23
Q
Nursing considerations with VUR
A
- Tx with low dose antibiotics w/ frequent ua cultures
- parent education r/t medication administration
- parent teaching r/t collection of urine specimen
- preoperative teaching (antibiotics)
- postoperative care (cont. antibiotics, schedule renal US to r/o obstruction month out, d/c antibiotics if no obstruction, US and cystograms sometimes scheduled 6 months out but require catheter so some don’t like to do them and risk reintroducing bacteria.)
24
Q
Glomerulonephritis
A
A term that includes a variety of disorders, most of which are caused by an immunological reaction. It results in proliferative and inflammatory changes within the glomerular structure and destruction, inflammation, and sclerosis of the glomeruli of both kidneys.
25
Causes of glomerulonephritis
- inflammation of the glomeruli results from an antigen-antibody reaction produced from infection elsewhere in the body
- loss of kidney function develops
- immunological diseases
- streptococcal infection; group A beta hemolytic
- hx of pharyngitis or tonsillitis 2 to 3 wks prior to s/s.
26
Types of glomerulonephritis
- Acute: occurs 2 to 3 weeks after strep infection
| - Chronic: can occur after the acute phase or slowly over time
27
Glomerulonephritis complications
- renal failure
- hypertensive encephalopathy (very dangerous, monitor BP for rises)
- pulmonary edema
- HF
- Ascites (r/t low albumin & high protein)
28
Glomerulonephritis assessment
- child is pale, irritable, weak, and ANOREXIC
- mild/gross hematuria...UA is dark, smoky, cola-colored, or RED-BROWN
- proteinuria that produces persistent and excessive foam in the urine
- Oliguria or anuria (anuria is more common)
- urinary debris (sediment), mid-to-high SG (norm 10/20), low urinary pH
- increased BUN and creatinine (creatinine is most sensitive indicator)
- Azotemia
- abdominal/flank pain
- edema: face, periorbital area, feet, or generalized
- HTN (sudden onset --> seizures, encephalopathy, pulmonary & circulatory congestion)
- increased antistreptolysin O titer
- CXR to r/o cardiac enlargement & pulmonary congestion
- Serum complement levels (C3)
- headache
- chills and fever
- anroxeia, N/V
29
Glomerulonephritis implementation (nursing)
- monitor VS (BP!), weight, I&O, and the characteristics of the urine
- limit activity; provide safety measures
- monitor for edema and fluid overload, ascites, pulmonary edema, and CHF
- monitor for s/s of renal failure and urine output, cardiac failure, and hypertensive encephalopathy
- administer diuretics judiciously if significant edema and fluid overload present
- administer antihypertensive judiciously for hypertension; Captopril
- administer anticonvulsants judiciously for seizures associated with hypertensive encephalopathy; initiate seizure precautions as indicated
- administer antibiotics judiciously for the child with evidence of persistent streptococcal infections
30
Glomerulonephritis nutrition
- restrictions of fluids and sodium depend on the stage and severity of the disease, especially the EXTENT OF THE EDEMA, and the reduction in urine
- in uncomplicated cases, a regular diet is permitted but sodium is restricted to no added salt to foods
- moderate sodium restriction is prescribed for the child with hypertension or edema.
- foods high in potassium are restricted during periods of oliguria (increase of arrhythmias)
- protein is restricted if the child has severe azotemia resulting from prolonged oliguria
31
Glomerulonephritis implementation
- instruct the parents to report signs of bloody urine, headache, or edema
- instruct the parents that the child needs to obtain treatment for infections, specifically sore throats and upper respiratory infections
32
Nephrotic syndrome (MCNS)
- a set of clinical manifestations arising from PROTEIN WASTING (*massive protein dumping in urine) secondary to diffuse glomerular damage
- defined as massive proteinuria, hypoalbuminemia = decreased albumin, hyperlipemia, and edema
- the primary objective of therapeutic management is to reduce the excretion of urinary protein and maintain a protein-free urine.
33
Nephrotic syndrome assessment
- child gains weight
- edema and abdominal ascites --> lower extremity & scrotal/perineal edema
- significant pallor, irritability, fatigue, anorexic
- decreased urine output
- dark, frothy urine; hematuria may be present
- normal to low blood sugars & low protein
34
Nephrotic syndrome corticosteroid therapy
- prednisone is prescribed as soon as the diagnosis has been determined
- continued until the urine is free from protein and remains normal for 10 days to 2 weeks, then it is tapered to discontinuation; infection control with prednisone pts!!
- there is a tendency to relapse 1-2 x/yr. Therefore, low-dose, every-other-days schedule of corticosteroid therapy may be prescribed and may continue for 6 months to a year.
- Cytoxan for long term remission (may cause sterility, esp. in males, if continued for more than 2-3 months; watch labs for leukopenia)
- Cushing syndrome r/t long-term prednisone may occur
35
Nephrotic syndrome nutrition
- a regular diet is prescribed if the child is in remission but until then, sodium is restricted
- sodium restriction is prescribed during periods of massive edema
- normal protein intake is usually prescribed
36
Nephrotic syndrome implementation
- monitor vs
- monitor I&O / daily weights
- Monitor UA for SG and albumin
- monitor for edema
- prevent and monitor for s/s of infection particularly in the edematous child and the child receiving corticosteroid therapy
- maintain bed rest if severe edema is present; activity is not restricted during remission
- administer immunosuppressant therapy judiciously to reduce the relapse rate and induce long-term remission; may be administered n conjunction with the corticosteroid
- administer loop diuretic judiciously (may be prescribed if edema interferes with respiration)
- administer plasma expanders such as salt-poor human albumin to the severely edematous child
- administer antibiotics for infection
- instruct parents about testing urine for albumin, medication administration, and general care of the child
- instruct parents regarding s/s of infection and the need to avoid contact with other children who may be infectious
- instruct parents about the side effects of corticosteroid therapy (growth suppression, cataracts, bone demineralization, GI bleeding)
37
Enuresis
refers to a condition in which the child is unable to control bladder function although the child has reached an age at which control of voiding is expected.
-by age 5, most children are aware of bladder fullness and are able to control voiding
38
Primary nocturnal enuresis
- bed-wetting in a child who has never been dry for extended periods
- common in children, and most children will eventually outgrow bed-wetting without therapeutic intervention
- the child is not able to sense a full bladder and does not awaken to void
- the child may have delayed maturation of the CNS
39
Secondary or acquired enuresis
- the onset of wetting after a period of established urinary continence
- may occur during nighttime sleep (nocturnal), only during the waking hours (diurnal), or during both times of the day
- the child may complain of dysuria, urgency, or frequency
- the child should be assessed for UTI
40
Enuresis assessment
- normal voiding pattern (what's normal for them? How long has wetting been occurring?)
- hx of bed-wetting with no extended period of dryness in a child older than 5 years.
41
Enuresis implementation
- obtain UA and UA culture as prescribed to r/o infection or existing disorder
- assist family with identifying a tx plan that will best fit their needs
- limit fluid intake at night, and encourage the child to void just before going to bed
- involve the child in caring for the wet sheets and changing the bed, to assist the child to take ownership of the problem
- provide reward systems as appropriate for the child
- incorporate behavioral conditioning techniques
- encourage follow-up to determine the effectiveness of the treatment
- DDAVP nose spray
42
Cryptorchidism
-occurs when one or both testes fail to descent through the inguinal canal into the scrotal sac
43
Cryptorchidism assessment
-testes not palpable nor easily guided into the scrotum
44
Cryptorchidism impletmentation
- monitor during the first 12 months of life to determine if spontaneous descent occurs
- after age 1, medical or surgical tx may be instituted
- HCG, a pituitary hormone administered by injection that stimulates the production of testosterone, and hormone therapy with luteinizing hormone-releasing hormone (nasal spray) may be prescribed
- surgical correction, if needed, is done by orchiopexy before the child's second birthday if the testes do not descend spontaneously.
- monitor for bleeding & infection postoperatively
- instruct parents in postop care measures including preventing infection, pain control, and activity restrictions
- provide an opportunity for parental counseling if the parents are concerned about the future fertility of the child.
45
Epispadias and hypospadias
- congenital defects involving abnormal placement of the urethral orifice of the penis.
- Epispadias: urethral orifice located on the dorsal side of the penis; often occurs with exstrophy of the bladder
- Hypospadias: urethral orifice located below the glans penis along the ventral surface.
46
Epispadias and hypospadias surgical implementation
- done before the age of toilet training, preferable between 16 and 18 months of age (outpatient)
- the child should not be circumcised because the foreskin may be used in surgical reconstruction
47
Epispadias and hypospadias postoperative....
- child will have pressure dressing and may have some type of urinary diversion or a urinary stent while healing of the meatus occurs
- monitor vs
- encourage fluid intake to maintain adequate urine output and to maintain patency of the stent
- monitor I&O and the urine for cloudiness or odor
- notify dr if no urinary drainage for 1 hour because this may indicate kinks in the system or obstruction by sediment.
- provide pain meds and meds (anticholinergic) to relieve bladder spasms
- administer antibiotics
- instruct parents in care of the urinary diversion or stent
- instruct parents to avoid tub bath until stent is removed
- instruct parents re fluid intake, medication admin, s/s of infection, and the need for f/u for dressing removal approx. 4 days after surgery
48
Hemolytic uremic syndrome (HUS)
- 3 things: acute renal failure, hemolytic anemia, and thrombocytopenia
- occurs in white children 6 mos to 3 year old
- etiology is unknown however it is associated with URI or GI infections, particularly E. coli
- endothelial lining of the glomerular arterioles become edematous and occluded with platelets and fibrin cots causing RBCs to become damaged as they move through the arterioles
- these aberrant RBCs are then removed by the spleen causing a hemolytic anemia
- thrombocytopenia is produced by the platelet aggregation within the damaged arterioles.
49
Hemolytic uremic syndrome diagnosis
- diagnosis is made on physical findings:
- proteinuria
- hematuria
- casts (mineral deposits)
- elevated BUN/creatinine
- decreased H&H
- elevated reticulocyte count
50
Hemolytic uremic syndrome treatment
- supportive, prompt treatment, recovery is 95%
- fluid replacement, tx of HTN, correction of electrolytes, and acidosis
- early hemodialysis, peritoneal dialysis, ultrafiltration
- nursing care is the same as in acute renal failure
- family support
51
Acute renal failure (ARF)
- most common cause of ARF in kids is dehydration and poor perfusion, therefore these kids are sick to begin with
- characterized by oliguria lasting 10-14 days, azotemias, acidosis, f/e disturbances, edema, somnolence, circulatory congestion, arrhythmias from hyperkalemia
- no uremic frost, which indicates chronic
- usually reversible
- tx of underlying cause, prevent infection
- if due to poor perfusion, rehydrate and administer drugs that increase renal perfusion
- pediatric hemodialysis
