Renal/GU Flashcards
GU alterations in children
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
Defects in development: Renal/GU
Bladder exstrophy
Hypospadias and Epispadias
Enuresis
Urinary tract infections
Cystitis: infection of the bladder
Pyelonephritis: Infection of the kidney
Urinary tract infections: Caused by
Ascending bacteria
E. coli is the most common
Others: group B strep, K. pneumoniae, Protus, Enterobacter, Enterococcus, Staph
Viruses and fungi can cause infections
What inhibits bacterial growth in male urethra
Longer male urethra and the antibacterial properties of the of the prostatic secretions inhibit the entry and growth of pathogens
Urinary tract infections: Single most important factor in cause
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
Urinary tract infections: Clinical manifestations
Kids have atypical symptoms and show unrelated signs. Tell-tale signs: incontinence in toilet trained children, foul smelling urine, frequency, urgency
Urinary tract infections: Clinical manifestations in Infants
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
Urinary tract infections: Clinical manifestations: Children
Abdominal, back, or suprapubic pain Frequency, urgency Dysuria New or increased incidence of enuresis, daytime incontinence who have been toilet trained already Fever
Urinary tract infections: Clinical manifestations: Adolescents
Hematuria
Frequency with painful and small urinations
Fever with upper tract
Urinary tract infections: Diagnosis
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
Urinary tract infections: Diagnosis: Suprapubic aspiration
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
Urinary tract infections: Diagnosis: VCUG (voiding cystourethrogram)
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
Urinary tract infections: Diagnosis: IVP (intravenous pyelogram
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
Urinary tract infections: Diagnosis: DMSA
Scan used to identify anatomical abnormalities that contribute to the development of the infection and any changes that have occured from recurrent infections
Urinary tract infections: Therapeutic management: Goal
Eliminate infection
Identify contributing factors to reduce recurrence risk
Prevent systemic spread
Preserve renal function
Urinary tract infections: Therapeutic management: Abx therapy
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
Urinary tract infections: Therapeutic management: Follow up
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
AAP guidelines for UTI: Children 2-24 mo: Diagnosis
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
Education to avoid UTIs
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
Vesicoureteral Reflux (VUR):
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)
Vesicoureteral Reflux (VUR): Secondary UTI
Results form stones or obstructions such as a tumor, stricture or psychological
Vesicoureteral Reflux (VUR): Diagnostic evaluation
VCUG
Renal scan
Urodynamic studies for voiding dysfunction
Vesicoureteral Reflux (VUR): Diagnostic: Renal scan
look for scarring and functional abnormality. Scarring from infection from reflux
Vesicoureteral Reflux (VUR): Diagnostic: Urodynamic studies for voiding dysfunction
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
Vesicoureteral Reflux (VUR): Therapeutic management
Low-dose prophylactic abx
Labs (BUN, Cr) for kidney function
Urine culture done every 2-3 mo or when the child has a fever
Vesicoureteral Reflux (VUR): Repair/surgery
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
Vesicoureteral Reflux (VUR): Sub trigeminal injection
New procedure
Gel is injected around the ureter to make sure the ureters are longer and created a bulge to narrow the passage
Vesicoureteral Reflux (VUR): Post op
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
Obstructive uropathy: Hydronephrosis
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.
Obstructive uropathy: Links
Boys are more affected
Ear defect, you’ll see them lowset and will suspect kidney function problem
Or it could be a chromosomal anomaly
Obstructive uropathy: Nursing considerations
Urinary diversion
Maintaining urine flow (goal)
Fluids are thus encourages
Body image
Obstructive uropathy: Nursing considerations: Urinary diversion
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
Bladder Exstrophy: Congenital anomaly
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
Bladder Exstrophy: Clinical manifestations
Exposed bladder mucosa
Displaced anal opening
Widened symphysis pubis (bones don’t close in utero like they were supposed to)
Defects of external genitalia
Bladder Exstrophy: Therapeutic management
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
Bladder Exstrophy: Therapeutic management: Surgery
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
Bladder Exstrophy: Assessment
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
Bladder Exstrophy: Nursing Implementation: Goal
To preserve renal function, attain urinary control, reconstructive repair, and improve sexual functionality, especially in the mials
Bladder Exstrophy: Nursing Implementation
Focus on maintaining integrity of bladder
Provide emotional support to family
Encourage verbalization of fears, concerns
Lab values
UA
Older children: psychosocial implications
External defects: Hypospadias
COngenital anomaly where meatus is below normal placement on glans of penis (ventral surface)
External defects: Chordee
Downward curvature of penile shaft. We need to release the constriction thats causing the binding
External defects: Epispadias
Dorsal placement of urethral opening, so when he voids, he squirts up instead of at the end of the urethra
External defects: Other anomalies
Undescending testes and inguinal hernias. The abdominal content can protrude through the inguinal wall into the scrotum (inguinal hernia)
Hypospadias & Epispadias: Therapeutic management
Surgical intervention should be done before potty training (<18mo) and before child has developed body image
Hypospadias & Epispadias: Management Goal
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
Hypospadias & Epispadias: Assessment
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
Hypospadias & Epispadias: Implementation
Pre/post op teaching Care of catheter/stent Increase fluid intake VS Observe urine for cloudiness Diversional activities and pain relief
Hypospadias & Epispadias: Implementation: Care of catheter/stent
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
Enuresis
Child cant control bladder function at age expected (5yr)
Nocturnal Enuresis
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
Nocturnal Enuresis: Primary
Not dry night for long periods of time
Nocturnal Enuresis: Secondary
Bedwetting occurs after control attained
Enuresis: Diagnostic evaluation
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
Enuresis: Risk of
Infection: UA for C/S
Enuresis: Therapeutic management
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
Enuresis: Medications
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)
Enuresis: Medication: Imipramine Hydrochloride
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
Enuresis: Assessment
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
Enuresis: Implementation
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
Nephrotic syndrome:
Most common glomerular injuries in children
Can be congenital or inherited
Nephrotic syndrome: Characterized by
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
Nephrotic syndrome: Primary
Disorder with in the glomerulus. It is the most common type found in children
Nephrotic syndrome: Secondary
From a systemic disease
Nephrotic syndrome: Etiology
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
Nephrotic syndrome: Pathology
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
Nephrotic syndrome: Mnemonic
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
Nephrotic syndrome: Clinical manifestations
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
Nephrotic syndrome: Diagnostic Evaluation
Clinical presentation Age of child (2-8yr) Lab results (massive proteinuria- 3+ on dipstick) Hyperalbuminuria Hypoalbuminemia Hypovolemic Usually no hematuria
Nephrotic syndrome: Goals of therapy
Decrease excretion of urinary protein
Decrease fluid retention in tissues
Prevention of infection (challenging due to long term steroid use)
Minimize complications
Nephrotic syndrome: Therapeutic management
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
Nephrotic syndrome: Steroid use
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
Nephrotic syndrome: Nursing care
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
Nephrotic syndrome: Education
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
Glomerulonephritis:
Group of kidney diseases where the glomerulus is injured. Capillaries of glomerulus are inflamed, so we will see blood in urine
Glomerulonephritis: Occurs from
Infection, systemic disease process, primary defect in glomerulus itself
Glomerulonephritis: Most common cause
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
Glomerulonephritis: APSGN
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
Glomerulonephritis: Clinical manifestations
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
Glomerulonephritis: Diagnostic evaluation
History
Presenting symptoms
Lab results (blood, BUN, CR)
Glomerulonephritis: Therapeutic management
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
Glomerulonephritis: Will be hospitalized for…
Acute renal failure: F&E imbalance, May need a diuretic and K to prevent complications from fluid volume overload
Glomerulonephritis: Antihypertensive
Limit fluids/Na; diuretics and antiHTN meds
Monitor and treat HTN as this can be life threatening
Glomerulonephritis: Assessment
Ongoing Watch for F&E, I&O promote rest VS Daily wts Lab values Understanding of illness/hospitalization
Glomerulonephritis: Signs of improvement
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)
Glomerulonephritis: Nursing care
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
Dialysis
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
AAP guidelines for UTI: Children 2-24 mo: Treatment
7-14 days abx
NB bladder
30ml then increases to about 90ml at 1yr
Hydrocele
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
Hydrocele: Communicating
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
Hydrocele: Noncommunicating
Have no connection to the peritoneum with fluid coming from the mesothelial lining
Not reducible and do not change size with crying or straining
Hydrocele: Newborn
Often resolve spontaneously by 1yr
Hydrocele: Older children
Noncommunicating may be idiopathic or a result of trauma, epididymitis, orchitis, testicular torsion, torsion of the appendix testis or appendix epididymis or tumor
Hydrocele: Surgery
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
Hydrocele: Idiopathic
Repaired if symptomatic, and reactive hydrocele usually resolves with treatment of underlying cause such as epididymitis
Hemolytic Uremic syndrome
Acquired AKI
Hemolytic Uremic syndrome: Classic Signs
Anemia, thrombocytopenia, renal failure
Hemolytic Uremic syndrome: Causes
Bacterial toxins, chemicals, viruses (E. coli from undercooked meat, unpasteurized milk, fruit juice, alfalfa sprouts, lettuce, salami)
Hemolytic Uremic syndrome: Patho
Endothelial lining of small glomerular arterioles
Damages passing RCBs which are removed by spleen
Hemolytic Uremic syndrome: Clinical Manifestations
Vomiting, irritability, lethargy Pallor, bruising, petechiae, jaundice, bloody diarrhea Oliguria, anuria Renal failure CNS (seizures, stupor, coma)
Hemolytic Uremic syndrome: Goal
Catch early
Supportive care
Hemolytic Uremic syndrome: Treatment
Fresh frozen plasma, plasmapheresis
Blood transfusion
Medications to treat symptoms
Hemo/peritoneal dialysis (anuria for 24hr)
