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Pedi Exam 2 > Renal/GU > Flashcards

Renal/GU Flashcards

1
Q

GU alterations in children

A

Infants and toddlers have a lower GFR than adults
They are less able to concentrate urine and absorb amino acids, which leads to increased risk for dehydration.
A kidney does not become mature in function until 2y/o

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2
Q

Defects in development: Renal/GU

A

Bladder exstrophy
Hypospadias and Epispadias
Enuresis

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3
Q

Urinary tract infections

A

Cystitis: infection of the bladder
Pyelonephritis: Infection of the kidney

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4
Q

Urinary tract infections: Caused by

A

Ascending bacteria
E. coli is the most common
Others: group B strep, K. pneumoniae, Protus, Enterobacter, Enterococcus, Staph
Viruses and fungi can cause infections

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5
Q

What inhibits bacterial growth in male urethra

A

Longer male urethra and the antibacterial properties of the of the prostatic secretions inhibit the entry and growth of pathogens

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6
Q

Urinary tract infections: Single most important factor in cause

A

Urinary stasis where the bladder isnt completely emptied out and urine stays in the bladder or it refluxes back ip the ureter and stays in the ureter, so teach parents to have children go on a schedule

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7
Q

Urinary tract infections: Clinical manifestations

A

Kids have atypical symptoms and show unrelated signs. Tell-tale signs: incontinence in toilet trained children, foul smelling urine, frequency, urgency

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8
Q

Urinary tract infections: Clinical manifestations in Infants

A 
Non-specific and resembles symptoms fo a child with a GI tract disorder
Fever or hypothermia in neonate
Irritability 
Poor feeding 
Vomiting
Signs of dysuria (constant squirming and irritability or screaming when urinating or urinating more frequently than has in the past)
Change in urine color or odor
Constant diaper rash
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9
Q

Urinary tract infections: Clinical manifestations: Children

A 
Abdominal, back, or suprapubic pain 
Frequency, urgency 
Dysuria
New or increased incidence of enuresis, daytime incontinence who have been toilet trained already 
Fever
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10
Q

Urinary tract infections: Clinical manifestations: Adolescents

A

Hematuria
Frequency with painful and small urinations
Fever with upper tract

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11
Q

Urinary tract infections: Diagnosis

A 
Obtain history and physical
Urinalysis and culture (children: get midstream urine, younger children (not toilet trained): catheterization because will need to be sterile) 
Looking for WBC, RBC, or protein.
Do not encourage drinking large amounts of fluids as this could dilute the sample and not show the bacteria
Presence of nitrites on a dipstick if a good predictor and you can start treating sooner before culture is back. 
Cloudy urine, fishy smell
Suprapubic aspiration 
Blood test
Catheterization 
VCUG 
IVP
DMSA
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12
Q

Urinary tract infections: Diagnosis: Suprapubic aspiration

A

Done in some children
Most accurate way to obtain urine samples in children who are <2 y/o.
You insert a needle just above the symphysis pubis into the bladder and you aspirate urine back into the syringe

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13
Q

Urinary tract infections: Diagnosis: VCUG (voiding cystourethrogram)

A

Recurrent UTI
Further investigation is done using radiology exams
Catheter is placed into the bladder, a contrast is used to fill up the bladder through the catheter
X-ray are taken to see if the contrast is going back up through the ureter and into the kidney. So we can confirm that the urine does flow back up and cause kidney infection. The goal is to get the children to void during the xray so you can see the contrast going through the urethra. looking for any type of structural defects

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14
Q

Urinary tract infections: Diagnosis: IVP (intravenous pyelogram

A

Xrays are taken after the child has been injected through his vein with contrast. So youll see the contrast in the kidneys and in the ureter as the nephrons filter the contrast, and into the bladder. The goal here as well is to get the child to void while there is an Xray being done. Look for contrast coming through the ureter and look for structural defect

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15
Q

Urinary tract infections: Diagnosis: DMSA

A

Scan used to identify anatomical abnormalities that contribute to the development of the infection and any changes that have occured from recurrent infections

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16
Q

Urinary tract infections: Therapeutic management: Goal

A

Eliminate infection
Identify contributing factors to reduce recurrence risk
Prevent systemic spread
Preserve renal function

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17
Q

Urinary tract infections: Therapeutic management: Abx therapy

A

7-10 day specific to organism
We start with something broad until culture comes back (24-72hr)
Start with PCN, Bactrim, Cephalosporins, Nitrofurantoin, Tetracyclines
Possible IV abx in hospital if UTI worsens (not recommended)
Cranberry juice has been shown to have some beneficial properties

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18
Q

Urinary tract infections: Therapeutic management: Follow up

A

Teach parents how to take care of a child with a UTI to prevent further infections that can result in renal damage and reflux
Urine samples are done monthly for 3 mo then every 3 mo then every 6 mo

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19
Q

AAP guidelines for UTI: Children 2-24 mo: Diagnosis

A

Based on cathed or suprapubic urine that shows 50,000 WBC
Bagged urine is no longer acceptable for UTI diagnosis or it can also be diagnosed during a urine sample of 50,000/mL with a child that has fever, an US of kidney/bladder showing anatomical abnormalities or VCUG- US shows hydronephrosis for VUR or recurrence of febrile UTI

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20
Q

Education to avoid UTIs

A 
Wiping/cleaning from front to back and avoid constipation
Good fluid intake
Void frequently 
Avoid bubble baths
Wear cotton underwear
Prophylactic abx (recurrent UTI, given at night time since there will be less frequent voiding)
Void after sexual activity 
Follow up appointments
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21
Q

Vesicoureteral Reflux (VUR):

A

Backflow or reflux or urine from bladder into the ureter and possible the kidneys
With each void, urine is pushed up the ureters so it doesn’t come out until the next void
High incidence of UTI (primarily pyelonephritis- sx: more sick and fever)

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22
Q

Vesicoureteral Reflux (VUR): Secondary UTI

A

Results form stones or obstructions such as a tumor, stricture or psychological

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23
Q

Vesicoureteral Reflux (VUR): Diagnostic evaluation

A

VCUG
Renal scan
Urodynamic studies for voiding dysfunction

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24
Q

Vesicoureteral Reflux (VUR): Diagnostic: Renal scan

A

look for scarring and functional abnormality. Scarring from infection from reflux

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25
Q

Vesicoureteral Reflux (VUR): Diagnostic: Urodynamic studies for voiding dysfunction

A

Child is observed as they void to see what the pressures of the urinary stream are, or to see if there are any abnormalities with the wat his urine is streamed
Children will normally outgrow

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26
Q

Vesicoureteral Reflux (VUR): Therapeutic management

A

Low-dose prophylactic abx
Labs (BUN, Cr) for kidney function
Urine culture done every 2-3 mo or when the child has a fever

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27
Q

Vesicoureteral Reflux (VUR): Repair/surgery

A

Re-implantation of the ureter into the bladder. The ureter opening at birth isn’t sitting on the right side of the bladder, which is on top. Or the ureteral valve isn’t fully developed and can’t close properly, then surgery is done. Its performed with recurrent UTIs, severe forms of VUR, non compliance of meds, or if the child has an intolerance of abx

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28
Q

Vesicoureteral Reflux (VUR): Sub trigeminal injection

A

New procedure

Gel is injected around the ureter to make sure the ureters are longer and created a bulge to narrow the passage

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29
Q

Vesicoureteral Reflux (VUR): Post op

A

Child will have long skinny tubes or catheters coming from each kidney to keep ureter patent until it heals. These come out into the bladder through the urethra and taped to a foley bladder catheter. Each catheter will have its own bag to measure the urine. Its important to monitor each catheter separately to determine its output. When it heals the urine will stop in the urethral caths and they will be discontinued and you will see all the urine coming in through the foley

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30
Q

Obstructive uropathy: Hydronephrosis

A

Enlargement of the kidney develops with obstruction of the ureter
Backup of urie above the obstruction causing dilation of the renal pelvis and destruction of the renal parenchyma
Dilation of the ureters from a reservoir that reduces the effect on the kidneys for a long time.
The ureteral obstruction can cause backup of urine up into the kidneys
The problem may also be stenosis of the ureter that doesn’t allow for urine to come down the bladder.

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31
Q

Obstructive uropathy: Links

A

Boys are more affected
Ear defect, you’ll see them lowset and will suspect kidney function problem
Or it could be a chromosomal anomaly

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32
Q

Obstructive uropathy: Nursing considerations

A

Urinary diversion
Maintaining urine flow (goal)
Fluids are thus encourages
Body image

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33
Q

Obstructive uropathy: Nursing considerations: Urinary diversion

A

If we have damage such as stricture in the ureter, then the ureter will be cut above the stricture and will be diverted to a pisch made form a segment of bowel. Implant the uterus into that segment of bowel and tie it up/close it odd, make it into a pouch and form a stoma that comes to the skin

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34
Q

Bladder Exstrophy: Congenital anomaly

A

Bladder wall is outside of the body through a defect in lower abdominal wall, upon birth.
In utero, the bladder wall and abdominal fail to close. This is an exposed and everted bladder that is bright red with constant seeping of urine form exposed ureteral or uerethral orifices. It can be malodorous and susceptible to infection. IT can have tissue ulceration and renal damage. Requires a great deal of surgery to get the bladder back inside to where it has to be. Our job is to keep the bladder moist and intact

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35
Q

Bladder Exstrophy: Clinical manifestations

A

Exposed bladder mucosa
Displaced anal opening
Widened symphysis pubis (bones don’t close in utero like they were supposed to)
Defects of external genitalia

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36
Q

Bladder Exstrophy: Therapeutic management

A

Cover with non-adhering plastic wrap to keep it from drying, because the bladder mucosa is needed to stay intact for surgery
Do not use petroleum jelly or gauze as it tends to damage the bladder mucosa

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37
Q

Bladder Exstrophy: Therapeutic management: Surgery

A

Usually >1 procedure
There will not be a sphincter until the bladder growns and a second surgery to correct epispadia and create a urethral opening sphincter. Another surgery may be needed to create an umbilicus
They may also have a stoma as the new sphincter created constriction problems. Or the bladder may be removed if it too small or defective. The ureters then connect to the intestines to create a urinary reservoir accessed by a stoma. A mitrofanoff is procedure where the stoma exits through the appendix

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38
Q

Bladder Exstrophy: Assessment

A

Determine parents understanding
Newborn: Patency of anus, urine output, condition of bladder mucosa, testes
Older children: urinary continence, history of UTIs, self perception, social interaction

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39
Q

Bladder Exstrophy: Nursing Implementation: Goal

A

To preserve renal function, attain urinary control, reconstructive repair, and improve sexual functionality, especially in the mials

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40
Q

Bladder Exstrophy: Nursing Implementation

A

Focus on maintaining integrity of bladder
Provide emotional support to family
Encourage verbalization of fears, concerns
Lab values
UA
Older children: psychosocial implications

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41
Q

External defects: Hypospadias

A

COngenital anomaly where meatus is below normal placement on glans of penis (ventral surface)

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42
Q

External defects: Chordee

A

Downward curvature of penile shaft. We need to release the constriction thats causing the binding

43
Q

External defects: Epispadias

A

Dorsal placement of urethral opening, so when he voids, he squirts up instead of at the end of the urethra

44
Q

External defects: Other anomalies

A

Undescending testes and inguinal hernias. The abdominal content can protrude through the inguinal wall into the scrotum (inguinal hernia)

45
Q

Hypospadias & Epispadias: Therapeutic management

A

Surgical intervention should be done before potty training (<18mo) and before child has developed body image

46
Q

Hypospadias & Epispadias: Management Goal

A

Make urinary and sexual function as normal as possible

The outcome of surgery is a sexually adequate organ that can void standing up in a normal fashion

47
Q

Hypospadias & Epispadias: Assessment

A

Assess urinary function: checking for UTI, urinary stream, dribbling, family history of GU problems
Family understanding
Usually these children aren’t circumcised at birth. During surgery the foreskin is used to create the urethral tube (older surgery)
New procedure does not require the foreskin

48
Q

Hypospadias & Epispadias: Implementation

A 
Pre/post op teaching
Care of catheter/stent
Increase fluid intake 
VS 
Observe urine for cloudiness
Diversional activities and pain relief
49
Q

Hypospadias & Epispadias: Implementation: Care of catheter/stent

A

Catheter/Stent is in place to keep the meatus or urethra open. There is a lot of swelling that goes along with surgery and we do not want it to swell closed. There is a tube in place during healing. Teach the parents how to care for the stent of catheter
No baths, swimming, sand box play or rough activities

50
Q

Enuresis

A

Child cant control bladder function at age expected (5yr)

51
Q

Nocturnal Enuresis

A

Bed wetting at night
Incontinence must not be related to direct physiological effects of a substance such as diuretics or general medical conditions such as DM, DI, Spina bifida, seizures, sickle cell anemia

52
Q

Nocturnal Enuresis: Primary

A

Not dry night for long periods of time

53
Q

Nocturnal Enuresis: Secondary

A

Bedwetting occurs after control attained

54
Q

Enuresis: Diagnostic evaluation

A

History and clinical symptoms (find out why this is happening, is it structural? or is it infection? do they have spina bifida- cant feel bladder is full)
Happens most often in little bodys ages 6-8 yr
Many don’t have coexisting psychopathology. But some do have developmental disorders, or learning problems, behavioral difficulties such as increased motor activity and aggression

55
Q

Enuresis: Risk of

A

Infection: UA for C/S

56
Q

Enuresis: Therapeutic management

A

If found to be behavioral issue, have the child take part in caring for wet sheets, but remember it’s not a punishment
Do not put a diaper on child
Limit nighttime fluid intake and have child void before going to bed
Imagery: keep a diary
Rewards
Behavioral conditioning (reduce shame and guilt of child, don’t make it be a manipulative behavior)
Medications

57
Q

Enuresis: Medications

A

Imipramine hydrochloride
Oxybutynin (reduces bladder contractions)
Anti-diuretics- ADH/Vasopressin (DDVAP) (help to decrease the nighttime urinary volume to less than functional bladder capacity, can be administered as a nasal spray at night, it relapse occurance is high after it has been stopped)

58
Q

Enuresis: Medication: Imipramine Hydrochloride

A

Antidepressant - Because it has anticholinergic action in bladder that inhibits urination. it can be given at bedtime. Once enuresis has stopped or cured, you can withdraw. Sometimes relapse happens

59
Q

Enuresis: Assessment

A

Get parents understanding of problem and types of interventions tried. Primarily its an alteration of the neuromuscular bladder functioning. It is benign and self limiting. It is temporary, regressive behaviors from birth of sibling, trauma, ADHD children who have accidents as they get too involved in their play
Get UA specimen and history of the number of episodes for diagnosis and to measure effectiveness of treatment

60
Q

Enuresis: Implementation

A

Provide correct info to family so they choose best treatment to meet their needs
Follow-up to determine effectiveness
Watch for child abuse in these children

61
Q

Nephrotic syndrome:

A

Most common glomerular injuries in children

Can be congenital or inherited

62
Q

Nephrotic syndrome: Characterized by

A

Proteinuria
Hypoalbuminemia
Hyperlipidemia (decreased protein in the blood the liver synthesizes more proteins to make up for the loss so it breaks down more lipids)
Edmea

63
Q

Nephrotic syndrome: Primary

A

Disorder with in the glomerulus. It is the most common type found in children

64
Q

Nephrotic syndrome: Secondary

A

From a systemic disease

65
Q

Nephrotic syndrome: Etiology

A

Increased glomerular permeability to plasma protein which results in large urinary protein loss
Primarily seen in children between 2-7y/o
Rarely seen in children <6mo
Unusually seen in children over 8y/o
Often males are affected more

66
Q

Nephrotic syndrome: Pathology

A

Thought to be some glomerular injury in that the basement membrane of the glomerulus becomes increasingly permeable to proteins like albumin. It’s supposed to be tight and not let proteins through. This reduces the amount of albumin in the serum, decreasing the colloidal osmotic pressure in the capillaries. This causes fluid to accumulate in the interstitial spaces causing edema in the body cavities particularly in the abdomen called ascites. This reduces the vascular fluid volume causing hypovolemia from third spacing.
Large amounts of fluid, but dehydrated as the fluid is in the interstitial spaces

67
Q

Nephrotic syndrome: Mnemonic

A 
P=Protein in urine
R= Really tried and not in good spirit 
O= Oliguria
T=Terrible appetite N/V/D
E=Edema, worse in the morning 
I= Increased wt. gain
N=Normal BP
68
Q

Nephrotic syndrome: Clinical manifestations

A 
Edmea (facem eyes, ankles, gonadal and lower extremity and generalized edema) 
Pallor
Fatigue 
Anorexia
Abd pain
Recent URI
Wt gain
Clothes feel tight from the edema/ascites
Normal BP
Decreased urinary output
69
Q

Nephrotic syndrome: Diagnostic Evaluation

A 
Clinical presentation 
Age of child (2-8yr)
Lab results (massive proteinuria- 3+ on dipstick)
Hyperalbuminuria
Hypoalbuminemia
Hypovolemic
Usually no hematuria
70
Q

Nephrotic syndrome: Goals of therapy

A

Decrease excretion of urinary protein
Decrease fluid retention in tissues
Prevention of infection (challenging due to long term steroid use)
Minimize complications

71
Q

Nephrotic syndrome: Therapeutic management

A

May be hospitalized for edema, tests, start steroid therapy
No added salt diet or greater restriction (prevent further edema)
Prophylactic abx
Diuretic therapy to help decrease edema
May receive SPA (serum albumin infusion, if protein too low in blood)
Prednisone 2mg/kg/day (max of 60mg), taper down, First line therapy

72
Q

Nephrotic syndrome: Steroid use

A

Used for 4-6 wks, then tapered down for 3 months
May be steroid resistant and need kidney biopsy
Steroid dependent: relapse when dose is tapered, may need to use another immunosuppressant

73
Q

Nephrotic syndrome: Nursing care

A

VS
I&O
Wt
Assess for edema
Abd girth
Check urine for protein
Give appetizing foods
Support edematous areas: such as legs, scrotum, abd
Cleanliness is important for these children
Family understanding of disease and treatment

74
Q

Nephrotic syndrome: Education

A

Home monitoring and SE of steroid medication (growth retardation, immunosuppression so be weary of URI) Recovery is good. Self-limiting disease. We’ll start to see diuresis as urinary protein excretion diminishes within 7-21 days after starting steroid. But again remember they can relapse

75
Q

Glomerulonephritis:

A

Group of kidney diseases where the glomerulus is injured. Capillaries of glomerulus are inflamed, so we will see blood in urine

76
Q

Glomerulonephritis: Occurs from

A

Infection, systemic disease process, primary defect in glomerulus itself

77
Q

Glomerulonephritis: Most common cause

A

Acute post-streptococcal glomerulonephritis (APSGN)
hematuria, proteinuria, edema, renal insufficiency. This is a reaction that occurs 1-3 wks after a strep infection
Primarily effects children 6-7yr

78
Q

Glomerulonephritis: APSGN

A

Is an immune reaction to strep infection of throat or skin. Usually occurs 1-3 wk after strep infection has already resolved. The thought is that after strep infection, it followed by the release of membrane like material from this specific organism, gets into the circulation. Its antigenic antibody formation. An immune-complex reaction occurs after the appropriate period of time. these become trapped in the glomerulus capillary loop. These swell and decrease the filtration of plasma leading to excessive water accumulation and Na retention. this is why we see HTN and edema

79
Q

Glomerulonephritis: Clinical manifestations

A 
Hematuria (smoky or tea colored blood in the urine) 
Proteinuria (so an increased SG, BUN, Cr)
Edema (face, periorbital, worse in the morning, spreads to the extremities and abdomen)
ANorexia
Decreased urine output
HTN
Fever (maybe)
Fatigue
Pallor
Irritable 
Cardiomegaly 
Pulmonary edema
Pleural effusion
80
Q

Glomerulonephritis: Diagnostic evaluation

A

History
Presenting symptoms
Lab results (blood, BUN, CR)

81
Q

Glomerulonephritis: Therapeutic management

A

No specific treatment
Heals on its own in 4-10 days up to 2-3wks
Recurrence is not common
Follow up weekley and then monthly until resolved
Treating symptoms/degree of renal dysfunction
Prognosis excellent for APSGN

82
Q

Glomerulonephritis: Will be hospitalized for…

A

Acute renal failure: F&E imbalance, May need a diuretic and K to prevent complications from fluid volume overload

83
Q

Glomerulonephritis: Antihypertensive

A

Limit fluids/Na; diuretics and antiHTN meds

Monitor and treat HTN as this can be life threatening

84
Q

Glomerulonephritis: Assessment

A 
Ongoing 
Watch for F&E, I&O promote rest
VS
Daily wts
Lab values
Understanding of illness/hospitalization
85
Q

Glomerulonephritis: Signs of improvement

A

Increased urine output with decreased weight. Child begins to feel better. BP will fall. Appetite will return, BUN and Cr will return to normal ranges. Hematuria my decrease or may be present for 2-8wk afterwards. Watch for any type of renal failure (acute or chronic renal failure where the child has to be on dialysis)

86
Q

Glomerulonephritis: Nursing care

A 
Regular diet (no salt added, low Na foods)
Fluid restriction (insensible loss + urine volume = what child is allowed to have)
Parent education 
Once we get the BP and urinary output under control, treatment can be continued at home and he can return to clinic for us to monitor his progress. If the child has edema, HTN, hematuria, oliguria then they need to be treated in the hospital
87
Q

Dialysis

A

Observe for changes in the color of the dialysate draining from the child. The spent solution should be clear. If the color is cloudy, notify the provider immediately

88
Q

AAP guidelines for UTI: Children 2-24 mo: Treatment

A

7-14 days abx

89
Q

NB bladder

A

30ml then increases to about 90ml at 1yr

90
Q

Hydrocele

A

Presence of peritoneal fluid in the scrotum between the parietal and visceral layers. Most common cause of painless scrotal swelling in children and adolescents, along with nonincarcerated inguinal hernia

91
Q

Hydrocele: Communicating

A

Usually developed when the processus valginalis does not close during development, allowing for communication with the peritoneum
May change in size during the day or with straining

92
Q

Hydrocele: Noncommunicating

A

Have no connection to the peritoneum with fluid coming from the mesothelial lining
Not reducible and do not change size with crying or straining

93
Q

Hydrocele: Newborn

A

Often resolve spontaneously by 1yr

94
Q

Hydrocele: Older children

A

Noncommunicating may be idiopathic or a result of trauma, epididymitis, orchitis, testicular torsion, torsion of the appendix testis or appendix epididymis or tumor

95
Q

Hydrocele: Surgery

A

Repair is indicated for communicating, persisting past 1 yr because there is a risk of development of incarcerated inguinal hernia
Straddle toys are to be avoided for 2-4 wks and strenuous activities in older boys may be avoided for 1 month

96
Q

Hydrocele: Idiopathic

A

Repaired if symptomatic, and reactive hydrocele usually resolves with treatment of underlying cause such as epididymitis

97
Q

Hemolytic Uremic syndrome

A

Acquired AKI

98
Q

Hemolytic Uremic syndrome: Classic Signs

A

Anemia, thrombocytopenia, renal failure

99
Q

Hemolytic Uremic syndrome: Causes

A

Bacterial toxins, chemicals, viruses (E. coli from undercooked meat, unpasteurized milk, fruit juice, alfalfa sprouts, lettuce, salami)

100
Q

Hemolytic Uremic syndrome: Patho

A

Endothelial lining of small glomerular arterioles

Damages passing RCBs which are removed by spleen

101
Q

Hemolytic Uremic syndrome: Clinical Manifestations

A 
Vomiting, irritability, lethargy
Pallor, bruising, petechiae, jaundice, bloody diarrhea
Oliguria, anuria
Renal failure
CNS (seizures, stupor, coma)
102
Q

Hemolytic Uremic syndrome: Goal

A

Catch early

Supportive care

103
Q

Hemolytic Uremic syndrome: Treatment

A

Fresh frozen plasma, plasmapheresis
Blood transfusion
Medications to treat symptoms
Hemo/peritoneal dialysis (anuria for 24hr)

Pedi Exam 2 (6 decks)

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