Renal Flashcards
1
Q
Full term infant have the same number of…
A
nephrons as adults
2
Q
GFR in the newborn
A
30% that of the adult
3
Q
GFR does not reach adult level until…
A
3-5 years old
4
Q
Kidney’s and tubular system reach full size by…
A
adolescence
5
Q
Fluid turnover is..
A
7x greater than that of an adult
6
Q
Greater insensible H2O loss with illness such as…
A
- increaesed RR
- fever
- vomiting
- diarrhea
- and drainage from blood loss or tubes
7
Q
Altered fluid balance..
A
catastrophic consequences
8
Q
Until age 2…
A
- immature glomeruli, tubules, and nephrons of the kidney
- unable to conserve or excrete water and solutes effectively
- decreases ability to retain and concentrate urine
- immature homeostatic regulation (buffer) system
- weaker transport system for ions and bicarb equals risk for acid base imbalance
9
Q
Bladder capacity…
A
increases from 20-50 mls at birth to 700 mls by adulthood
-no bladder control under age 2 years due to immature nerves
10
Q
Renal excretion is dependent on
A
glomerular filtration, active tubular secretion, and passive tubular reabsorption
11
Q
Drugs dependent on…
A
renal excretion, like Pancuronium and Dig, can be markedly affected by immature kidney fx
12
Q
Kidneys receive a ______ percentage of CO than in adults
A
lower
13
Q
Hypodpadius
A
-urethral meatus located on ventral surface
14
Q
Epispadius
A
urethral opening located on dorsal surface
15
Q
Causes of hypospadius and epispadias
A
urethral folds fail to fuse completely over the urethral groove
16
Q
Medical Management of misplaced urethra
A
surgical repair
- usually during 1st year of life
- usually an outpatient procedure
- caudal nerve block
- anticholinergics
- urethral stent
17
Q
Nursing Management
A
- avoid stent removal
- I and O every hour
- pain control
- antibiotics until stent is removed
18
Q
UTI
A
-infection of bacterial, viral, or fungal origin that occurs in the urinary tract
19
Q
cystitis
A
lower UTI that involves the urethra or bladder
20
Q
pyleonephritis
A
upper UTI that involves the ureters, renal pelvis, renal parenchyma
21
Q
bacteriuria
A
presence of bacteria in the urine
22
Q
organisms causing UTIs
A
- E. coli most common
- staph aureus
- klebsiella
23
Q
Neonates
A
urinary tract more likely to be infected via the blood stream (boys more than girls)
24
Q
Older infants and children
A
(girls more than boys)
- peak age 2-6 years
- bacteria ascends the urethra
25
Causes of UTIs
- shorter urethra in females
- urinary stasis
- infrequent voiding
- incomplete emptying of the bladder
- vesicoureteral reflux
- poor personal hygiene
- indwelling catheter placement
- antimicrobial agents that alter the normal urinary tract flora
- sexually active adolescent females/sexually abused children
26
Clinical manifestations of UTI in infants
- unexplained fevers
- poor feeding
- failure to thrive
- vomiting
- strong-smelling urine
- irritable
- all children under 2 years with FUO should be tested for UTI
27
Clinical manifestations of UTI in older children
- dysuria
- urgency
- enuresis
- abdominal pain
- strong-smelling urine
- CVA tenderness
- chills
- high fevers with pyelonephritis
28
Urine C/S
- presence of bacteria
- collected via clean catch midstream, sterile cath, or suprapubic
- bagged urine only reliable when culture negative
29
Dipstick test (UA)
- leukocytes
- blood
- nitrite
30
If culture is positive,
- renal and bladder U/S (r/o scarring)
| - voiding cystourethrogram to r/o reflux
31
IVP
- IV pyleogram
- rare
- to r/o obstruction such as kidney stones
32
Nursing Management of UTIs
- admin antibiotics (amoxicillin, sulfa, cephalosporins)
- analgesia, comfort measures
- education on prevention of future UTIs and diagnostic tests
33
Enuresis
- repeated involuntary voiding by a child old enough to have bladder control
- nocturnal, diurnal or both
- primary: never had a dry night
- secondary: dry for at least 6 mths before bedwetting
34
Milestones in the Development of Bladder Control:
```
1.5 year
2 yrs
2.5 yrs
3 yrs
2.5 to 3.5 yrs
4 yrs
5 yrs
```
1.5 year: passes urine at regular intervals
2 yrs: child announces when he or she is voiding
2.5 yrs: child makes known the need to void and can hold urine
3 yrs: child goes to the bathroom by himself or herself, holds urge if preoccupied with play
2.5 to 3.5 yrs: child achieves nighttime control
4 yrs: child shows great interest in going to bathrooms when away from home
5 yrs: child voids approx. 5-6 times a day prefers privacy and is able to initiate emptying of bladder at any degree fulness
35
Treatment approaches
- fluid restriction before bed
- bladder exercises
- timed voiding
- enuresis alarms
- reward system
- medications
36
Vesicoureteral Reflux
- defined as retrograde flow of urine from bladder to ureters
- may result from faulty valve in bladder, anatomic implantation abnormality or acquired r/t scarring from recurrent UTIs
- left untreated, urine can retrograde into renal pelvis causing hydronephrosis and RF
37
VCUG
- examines the urethra and bladder while the bladder fills and empties
- radiopaque dye is placed in the bladder via catheter
- pictures are taken when the bladder via catheter
- reveals abnormalities of the inside of the urethra and bladder
- also determines whether urine flow is normal as bladder empties
38
Medical Management of Vesicoureteral Reflux
- mild cases: antibiotics, may outgrow or require surgery by endoscopy, STING
- severe cases: open surgery
- general anesthesia required for both
39
APIGN
acute post-infectious glomerulonephritis
- inflammation of the glomeruli of the kidneys
- usually occurs after a streptococcal infection (strep and impetigo)
- more common in boys
- highest incidence age 2-12 years
40
Pathophysiology of APIGN
- antibody-antigen complexes enter the glomeruli, leads to inflammation and obstruction
- glomerular filtration rate decreased
- vascular permeability increases leading to excretion of RBCs in urine
- sodium and H2O retained leads to edema
41
Clinical Manifestations of APIGN
- many children asymptomatic
- flank or mid abdominal pain
- irritability, malaise, fever
- HTN
- edema
- oliguria
- hematuria
- proteinuria
- fatigue, lethargy, anorexia
42
Nursing Management of APIGN
- fluid balance: monitor I/O, DW, assess edema, monitor electrolytes
- monitor VS and BP
- Medications: antihypertensives, diuretics, antibiotics, digitalis
- dialysis for severe cases
- diet: sodium, potassium, and fluid restrictions
- protein restricted if azotemia is severe
- bed rest during acute phase, prevent skin breakdown
- prevent infection
- provide emotional support to parents
- discharge planning teaching: medication regime, dietary restrictions, signs and symptoms of complications
43
Digitalis used to tx
circulatory overload
44
Antibiotics used to tx...
existing streptococcal infection, not APIGN
45
Prognosis of APIGN
- good for 90 percent of cases
- clinical signs resolve within few weeks
- renal function returns
46
Nephrotic Syndrome
-not a specific disease, but a clinical state
- characterized by:
- edema
- massive proteinuria
- hypoalbuminemia
- hypoproteinemia
- hyperlipidemia
- altered immunity
- more common in males, AA, hispanics
- peak age 2-7 years
47
Pathophysiology of Nephrotic Syndrome
- unknown etiology, but immune system role suspected--preceded by URI
- increased glomerular permeability allows albumin to cross into urine (proteinuria)
- proteinuria leads to decreased oncotic pressure and increased edema (fluid stays in interstitial areas, not pulled into vascular space)
- immunoglobulins lost, altered immunity
- anti-clotting factors lost, increased risk of blood clots
- liver increased lipid synthesis--hyperlipidemia
48
Clinical Manifestations of Nephrotic Syndrome
-edema develops slowly over several weeks
- AM: periorbital edema
- PM: edema in abdomen and ankles
- other S/S: HTN, irritability, anorexia, hematuria, decreased urine output, frothy urine, weight gain
- malnourishment results from proteinuria
- brittle hair
- pale, shiny skin
49
Criteria for diagnosis for Nephrotic Syndrome
- U/A: massive proteinuria
| - Blood: hypoalbuminemia
50
Medical Management of Nephrotic Syndrome
- goal is to decrease proteinuria, decreased edema, improve nutrition, prevent infection
- corticosteroids main treatment
- prednisone 2 mg/kg/dose 1-3 times per day until urine is protein free for 5-7 days
- continue prednisone once daily for 4 weeks, then give once every other day for 8 wks
51
Side effects of steroids
- growth suppression
- hyperglycemia
- obesity
- increased risk of infection
- HTN
- increased appetite
- mood swings
52
tx for patients unresponsive to steroids or with steroid toxicity
immunosuppressive therapy
- cytoxan
- prograf
- cyclosporine
53
IV albumin and diuretics for....
severe edema, monitor electrolytes
54
Dietary guidelines Nephrotic Syndrome
- decreased sodium
- decreased fat
- no need to decrease protein
55
Nursing Assessment for Nephrotic Syndrome
- physiologic assessment is crucial
- assess hydration status, edema
- strict I/O, DW
- abdominal girth
- V/s q 4 hrs
- monitor respiratory status
- test urine for specific gravity, proteinuria
- monitor for hypovolemia if on diuretics
56
Nursing Management of Nephrotic Syndrome
- admin meds
- prevent infection
- prevent skin breakdown
- dietary education
- promote rest
- provide emotional support
- discharge planning and home care teaching
57
Renal Failure
- occurs when kidney unable to excrete wastes, conserve electrolytes and concentrate urine
acute: occurs suddenly over days and weeks, may be reversible
chronic: occurs gradually and permanently over mths or years
- both types characterized by azotemia and oliguria
- anuria
58
Acute Renal Failure Clinical Manifestations
- dark urine or gross gematuria
- HA
- edema
- fatigue
- crackles
- gallop heart rhythm
- HTN
- hematuria
- lethargy
- N/V
- oliguria
- mass in flank area if a cyst, tumor, or obstructive lesion is present
59
Chronic Renal Failure Clinical Manifestations
- fatigue
- malaise
- poor appetite
- N/V
- failure to thrive or short stature
- may have oliguria or polyuria
- HA
- decreased mental alertness or ability to concentrate
- chronic anemia
- HTN
- edema
- fractures with minimal trauma
- rickets
- valgus deformity
60
Hyperkalemia in RF Clinical Manifestations
- peaked T waves, widening of QRS waves on ECG
- dysrhythmias
- muscle weakness
61
Hyponatremia in RF Clinical Manifestations
- ALOC
- muscle cramps
- anorexia
- abdominal reflexes, depressed DTR
- Cheyne-Stokes Respirations
- Sz
62
Hypocalcemia in RF Clinical Manifestations
- muscle tingling
- changes in muscle tone
- Sz
- Muscle cramps and twitching
- Positive Chvostek sign
63
Acute RF
- kidney fx abruptly diminishes
- rapid rise in BUN
- kidneys unable to regulate: extracellular fluid volume, sodium balance, acid-base homeostasis
64
Etiology of Acute RF
- dehydration from gastroenteritis
- hemorrhage
- sepsis
- acute glomerulonephritis
- hemolytic uremic syndrome
- poisoning
- 2 to 3 percent children in PICU
- 8 percent neonates in NICU
65
Medical Tx for Acute RF
- depends on underlying cause
- goals: minimize or prevent permanent renal damage and maintain fluid and electrolyte balance
- emergency tx for hypovolemia
- pulmonary edema, diuretics, dialysis if diuretics do not work
66
Hyperkalemia tx
tx with meds
- Kayexalate
- Calcium gluonate
67
Hypocalemia tx
-calcium gluconate
68
Metabolic Acidosis
sodium bicarb
69
HTN
anti-hypertensives
70
Infection tx with Acute RF
- tx with antibiotics
| - avoid nephrotoxic drugs--aminoglycosides
71
Hemorrhage/Anemia with Hgb less than 6 with ARF
transfuse with PRBCs
72
Chronic Renal Failure
- progressive, irreversible reduction in kidney function
- ultimately results in ESRD
- less than 10% renal function
- uremic syndrome
- anemia
- dialysis required for homeostasis
- higher in black children
73
Etiology of Chronic RF
- Developmental abnormalities of kidney
- Obstructed urine flow
- Urinary reflux
- Polycystic kidney disease
- Glomerulonephritis
- Hemolytic Uremic syndrome
74
Pathophys of Chronic RF
- healthy kidneys excrete excess acid body and regulate homeostasis
- renal failure disrupts the balance
- metabolic acidosis results
- retention of H2O and sodium results in HTN
- anemia results from decreased erythopoietin production
- osteodystrophy increase risk of fractures and rickets
- growth retardation secondary to:
* disturbed metabolism of calcium, phosphorus, and Vit D
* metabolic acidosis
* decreased caloric intake
75
Clinical Manifestations of Early RF
- polyuria
- pallor
- HA
- N
- fatigue
- decreased mental alertness
- anemia, resulting in tachycardia, tachypnea
76
Clinical Manifestations of Progressive RF
- HTN
- Anorexia
- Pul edema
- growth retardation
- osteodystrophy
- delayed fine and gross motor development
- delayed sexual maturation
77
Acidosis Medical Management
- sodium bicarb
| - sodium citrate
78
Anemia Medical Management
- diet: sufficient sources of iron and folic acid
- injectable iron may be required
- recombinant human erythropoietin--epogen, procrit
79
Medical Management HTN
- initial: low sodium diet, fluid restriction, and diuretics: thiazides, fursemide
- severe HTN--sodium restriction
- first line anti-hypertensive: ace inhibitors or angiotensin-receptor blockers ARB. both of these have shown a reduction in proteinuria
- combining the above is recommended for more significant HTN before trying other classes of medications, also shows a further reduction in protein excretion
80
Medical Management of Osteodystrophy
bone disease which results from kidneys inability to maintain normal phosphorus and calcium levels
- slows bone growth and causes deformities (rickets)
- increased serum phosphorus
- decreased serum calcium
81
Reduction of phosphorus
diet: milk, cheese, peas, beans, nuts, PB
- admin of phosphorus binding agent: calcium carbonate "Tums"
- admin of calcium with vit D
82
Growth Retardation
human growth hormone: especially before puberty
83
Nursing Management of RF
-identify complications of renal failure
- HTN
- Edema
- poor growth and development
- osteodystrophy
- metabolic acidosis
84
Monitor for side effects of medications
- diuretics: electrolyte imbalance, weakness, muscle cramps, dizziness, HA, N/V
- anti hypertensives: monitor BP, weight
85
Signs of infection
- elevated temp
- strong-smelling urine
- dysuria
- changes in respiratory pattern, productive cough
-good hand washing practice
