UNIT 3 GU Flashcards
Wht are different types of GU tract disorders and defects?
- UTI
- VUR
- Obstructive uropathy
- External defects
Kidneys start developing when and finish developing when?
Kidneys start developing 1 week in embryo but dont finish until about a year after birth
What should we know bout the incidences of UTI in children?
- Females are still more susceptiable than males due to the shorter urethras
- Uncircumcised maless less than 3 months of age and females younger than 12 months have the highest prevalence of UTI’s
- Unexplained fever should be evaluated
Anytime a child has an unexplained fever we should r/o a…
UTI
What is the biggest culprut of UTIs
E. Coli– due to the proximity of the anus and urethra
What is the single most important factor of UTIs in children?
Urinary stasis
What are clinical manifestations of UTI’s?
Depends on the age of the patient
- Common in children
- Incontinence in the toliet trained (enuresis)
- Strong-smelling urine
- Urinary frequency or urgency
- Pain with urination (dysuria)
- Fever
- Hematuria (all ages)
- Newborn to infants
- Crying/fussy, not eating, difficult to console, crying when pottying, fever, diahrrea, jaundice, odor in urine, blood tinged
- Toddler
- Expresses that it hurts or hold themself
How do we dx a UTI in children since there is no specific s/s that indicates UTI?
Need a UA– looking for nitrates, leukocytes, blood, cooudy, odor
What are different methods of collecting urine specimens in children?
- ** Cotton ball in diaper **
- Place cotton ball around the area that they would excrete the urine. Wait for the child to pee. This method will not work if child poops in diaper. Once you have a specimen you place the cotton ball into a syringe and squeeze pee out
- ** Bagged specimen **
- Similar to a ziplock bag but velcrows. Take the sticky part and attach to private area and when child voids the speciment will go into the bag. Empty into speciment cup. Easily contaminated and doesnt stick well
- Older children can ** midstream clean catch **
- ** Sterile catheter specimen **
- **Suprapubic aspiration ** – MD does this if unable to straight cath. Done in the PICU
- ** Bladder catheterization ** (Straight cath)
What is a normal PH level in a UA?
4.8-7.8
What is a normal protien, glucose, ketone, leukocyte esterase, nitrites level in a UA?
Negative
What is a normal RBC & WBC level in a UA?
<1 or 2
What is a normal bacteria level in a UA?
Negative to few
What is a normal cast level in a UA?
Occasional
When do you get the results of your UA with culture and sensitivity?
Prelim: 24 hours
Final: 72 hours (3days)
How is cycstitis normally treated
(Inpatient or outpatient)
Orally– outpatient
How is polynephritis usually treated
(IV or Oral)
IV
How is urosepsis usually treated (inpatient or outpatient)
Inpatient with lots of meds
What are the goals of UTI treatment?
- Eliminate infection
- Identify contributing factiors
- Prevent systemic spread
- Preserve renal function
What scan might be done if a child has recurrent UTIs and what info regarding do that scan should we know?
VCUG… Before a child gets dye we must check there kidney function (BUN & CR) make sure they have no allergies to shelfish or iodine.
okay to void on table
After imaging we need to encourage fluids to wash out dyes
What education should we provide patients with UTI’s
- Wipe front to back
- Avoid bubble baths
- Wash hands
- Finish antibiotics
- Pee after sexaul intercourse
- Double void
What is the antibiotic of choice to treat UTI’s
- Penicillin
- Sulfonmide
- Cephlosporins
What is VUR
Vesicoureteral Reflux
It is the abnormal flow of urine from the bladder into the ureters
What are the different types of reflux?
- Primary
- Seen the most it is caused by the congenital abnormality of incorrect insertion of the ureters into the bladder
- Secondary
- Usually seen with a neurogenic bladder. The brain and bladder are not talking. Bladder gets full and brain doesnt tell it too empty.. Causing to to reflux
Kids with VUR have frequent ___1___ infections
- Kidney infections (pylonephritis)
What is a voiding cystourethrogram?
VCUG
Images taken of the kidneys before during and after voiding to visulize the possible urine reflux…using contrast medium that is injected into the bladder through a catheter
Kids may have to be sedated for this exam. If they are awake reassure them its okay to have an accident on the exam table…
Ask allergies to shelfish and iodine… post hydration is important in riding kidneys of die.
What do we need to know about the VCUG grading scale?
Primary thing to know is that grade 1 is the least and 5 is the worst.
Grade 1: Reflux is only into the ureter
**Grade 2: ** Reflux into the renal pelvis
**Grade 3: ** Reflux into the renal pelvis w/mild hydropnephrosis
Grade 4: Reflux into the renal pelvis with moderate hydronephrosis
**Grade 5: ** Severe hydronephrosis and can cause ureter to twist and cause obstruction.
Conservative treatment of VUR consists of?
- Daily low dose antibiotic therapy-prophylactic
- Liberal fluids
- Regular voiding and double voiding
- Routine urine culture (every 2-3 months or anytime they have a fever)
- annual VCUG
Concervative treatment of VUR is reserved for grades….
1-3
What is the goal of concervative treatment in VUR?
- Prevent any bacteria from reaching kidneys
Surgical treatment of vur is reserved for what stages?
4 & 5
Why is concertative treatment used in grades 1-3?
Typically as the child grows the bladder stretches up making the ureters more on top so less reflux.
Surgical treatment of VUR includes?
- Ureteral reimplantation
Indications for surgery in VUR include?
- Severe forms of VUR
- Significant anatomic abnormaltiy
- Noncompliance with medical therapy
- antibiotic intolerance
- Infrequent access to health care system
Severe forms of VUR are at risk for damaging the kidney permentaly… usually doesnt resolve on its own like grade 1-3. This put them at risk for renal scaring
What is obstructive uropathy?
Structural or functional abnormality of the urinary system that obstructs the normal flow of urine, producing renal disorders. Obstruction can occur at any level of the urinary tract
Can be unilateral or bilateral, congenital or acquired and is more prevalant in boys.
What is the patho obstructive uropathy?
- Obstruction–>
- Damage to the distal nephrones (UTI)–>
- altered ability to concentrate urine —>
- increased urine flow—>
- decreased excretion of acid–>
- Urine pools—>
- Hydronephrosis —>
- UTI which goes back to #2
Understand that urine backs up which damages the kidney causing hydronephrosis
What is a inguinal hernia?
Protrusion of abdominal contents through inguinal canal into the scrotum
Usually seen on a sonogram… fairly common seen more often in preterm infants
Typically painless unless their is some kind of strangulation of content
What is hydrocele?
Fluid in the scrotom
How is a hydrocele trated?
- Typically self-resolving
- Surgical repair if not resolved in 1 year (hydrocelectomy)
In older children Hydrocele can be caused from….
Trauma
How can we differentiate between a soild mass in the scrotum and fluid in the scrotum?
Basically we candle the bottom of the scrotum using a penlight. If light is seen then its fluid. If no light passes its a mass
After surgical repair of a hydrocele what should we teach parents?
- Swelling is normal
- Anythime there is a surgery in the perineal area… kids cannot use straddle toys while healing minimum of 2-4 weeks
- limit strenous activity, esp in older children
What is Phimosis?
Narrowing or stenosis of the opening of foreskin resulting in the inability to retract forskin
Appears like a tight ring or tubber band around tip
How is phimosis treated?
1.Resolves as the child grows but can obstruct urine flow…
- If urine flow is obstructed parents may report dribbling stream or balloning of fore skin
2. Mild not forcible: manual forskin retraction (NOT FORCIBLE)
3. In Severe cases: Circumcsion or vertical division of foreskin
4. Steroid cream 2x a day for a month… then they will have an option of a circumcison in severe cases.
What is a hypospadias?
Urethral opening located below or behind glans penis or anywhere along ventral surface of penile shaft
What is the treatment of a hypospadias?
Surgical correction– repair usually happens around 6-12 months. Surgery will allow the boy to stand to pee and have a functioning sexual reporducing organ. Sperm wont be able to reach if undreneath
What education do you need to provide a parent of a child that has a hypospadias?
Make sure parents understand that the chld cannot have a circumsision until after surgery because they may need extra the extra skin
avoid straddle toys… while healing (2-4 weeks min)
What is cryptochidism?
Failure of one or both testes to descend normally through inguinal canal into scrotum
How do you treat cryptochidism?
Orchiopexy
1. Surgical release of the undesended testicles into the scrotum… done outpatient
2. If not corrected increased risk for maligency and fertility repairment
3. Might have a button
For our external defects what are the nursing considerations?
- Routine preop/postop care
- Tub baths are discouraged for a few days up to weeks depending on physicans orders
- Possibly cath care– teach parents how to care and teach child not to pull on
- Activity restriction– no straddle toys, rough play, pushing, pulling
- Parental support
What is nephrotic syndrome (glomerular disease)
Disorder characterized by increased glomerular permeability to plasma protien, which results in massive urinary protien loss
Typically membranes in the glomeruli are not permable but in this process they become more permable esp. to albumin which leads to massive protien loss in the urine
What causes Nephrotic syndrome (Glomerular disease)
- 80% of the time it is idiopathic – aka idiopathic nephrosis, childhood nephrosis or MCNS (minimal change nephrotic syndrome)
- Can be caused by clinical manifestations
- If there is glomeular damage then thats going to be the presumed cause esp. in systemic diseases like lupus
- Other causes can be toxins… drugs or other toxins that damage the kidney.. these are referred to as secodnary disorders
- Congenital (inherited autosomal defect)-rare
True or false: Males are 2x more likely to have nephrotic syndrome (glomerular disease)
True
Patho of nephrotic syndrome (glomerular disease)
1.Glomerular membrane becomes more permeable to protiens, esp albumin
2.Protiens are lost in the urine—> hypoprotienemia and massive protienuria
3.Serum albumin level decreases—> Hypoalbuminemia
4.Osmotic pressure in capillaries decrease
5.Vascular pressure exceeds the pull of osmotic pressure
6.Fluid accumulates in the intersitial spaces—> Edema
7.Shift of fluids from plasama to intersitiual spaces reduces vascular volume —> Hypovolemia
8.Renin-angiotensin system is stimulated
9.ADH & Aldosterone are secreted
10.Reabsorption of sodium & water in an attempt to increase intravascular volume
What are clinical manifestations of nephrotic syndrome (glomerular nephritis)
- Weight gain in a healthy child “puffy apperance”
- Edema
- Massive protienuria
- Hypoalbuminemia
- Hyperlipemia–liver rapidly manufactureing lipids to replace protiens
- Anorexia
- Irritability
- decreased activity
- Increaed infection due to the lose of immunoglobulins which are important to immune response
What should we know about edema in nephoritic syndrome (glomular nephritis)
Edema
- Pattern: gerneralized esp. in periorbital and facial area. Worse in the morning but goes down during the day.
- May be gaining weight but losing true body weight
- ascites
- pleural effusion– fluid in lungs may present with fever, chest pain, syspnea, & non productive cought.
What might we see on a UA with a patient who has nephrotic syndrome?
- Decreaed volume
- Dark and frothy in apperance
2. Massive protienuia- Greater than 2+
- May have a few RBC’s
- Greater than 2+
- Dark and frothy in apperance
How is nephrotic syndrome dianosed?
- Based on history
- Clinical manifestations
- Massive protienuria in urine
True or false: GFR is typically not effected with nephrotic syndrome?
True
What two main labs will we look at besides a UA for nephrotic syndrome?
BUN & CR
How do we treat nephrotic syndrome?
- 1st line: corticosteriods
- Prednisone 2mg/kg/day x6 weeks, then 1.5 mg/kg every other day x6 weeks. High dose and long term.
- Cyclophosphamide or cyclosporine
- For chidren who cannot tolerate prednisone or who have repeated relapses
- Possibly furosemide– only going to provide temporary relief from edema. The patient is still going to lose protiens so they will continue to swell
- to provide temporary relief from edema
- Possibly 25% albumin
- Decrease edema (hopefully)
- Increases plama volume
What are the goals of treatment for nephrotic syndrome?
- Reduce urinary protien
- Reduce fluid retention
- Preventing infection
- Minimize complication r/t tx and therapy
What can trigger a replase of nephrotic syndrome?
- Relapses can be triggered by allergies, immunizations viral or bacterial infection up to 2/3 of children with this syndrome will have a replase
How do you treat relapses in nephrotic syndrome?
- dx early parents are tught to do @ home dipsticks that look for protient (2+ protien in urine is not good)
- Relapse tx w/ repeate & shorter doses of high steriords
What are some nursing considerations for nephrotic syndrome?
- Strict I&O plus daily weight
- VS-lung heart sounds (watch for chest edema)
- Prevention of infectoin
- Thermoregulation
- Assessment of edema
- Measure abdominal circumference
- Level/location of swelling
- degree of pitting
- Loss of appetitie/diet
- Long-term steriod use
- Home care for relapse
- Sodium restricted diet/short term fluid restrictions
- Long term corticosteriods s/s- insomnia, male hair growth, growth retardation, hypertention, gi bleed, bone malformation, infection risk, increased blood sugar.
What do we need to educate parents of patiens with nephrotic syndrome to do with diapers?
Make sure parents know not to trash diaper or flush urine. Daily urine protien check are going to happen. We will use the cotton ball method if child is not potty trained
Which method or urine collection should we avoid in children who have nephrotic syndrome?
Sticky bag method– risk of skin breakdown is high due to edema.. infection risk if skin breakdown occurs
What is acute glomerulonephritis?
- Group of kidney disorders characterized by inflammatory injury in the glomerulus , most caused by an immunological reaction
What is the main culprut of acute glomerulonephritis?
Strep in the winter/spring
Impetigo in the fall and summer
can also be a autoimmune disease response
What causes acute glomerulonephritis?
- Immunological/autoimmune disease
- Following strep infection of pharynx or skin
- Acute: 2-3 days after infecton
- Chronic: after the acute phase or slowly over time
History of pharyngitis or tonsillitis 2-3 weeks before symptoms b
What is the patho of glomerulonephritis?
- Immune complexes deposited in glomerular basement membrane
- Increased glomerular basement membrane permability to RBC’s & Protiens—> Hematuria protienuria
- Glomeruli become edematous & infiltrated with leukocytes
- Capillary lumen becomes occluded
- Decreased capillary flow & decrease in plasma filtration
- Excessive accumulation of waer & retention of sodium
- Interstital fluid & plasma volumes expand
- Circulatory congestsion —> Edema & HTN
Why would a throat culture be negative in glomerulonephritis?
We see the trigger from the strep infection 10-21 days post infection… throat culture would be negative since antibiotics have already been given
What are clinical manifestations of glomerulonephritis?
1.Non-specific complaints– headache,tired, irritable, decreased appetite?
2.Edema- especially periorbital
3.Urine:
- Cloudy, tea/cola-colored
- Parallell, protienuria & hematuria….2+protienuria =2+ hematuria
4. Azotemia will show increased BUN & CR (this doesnt happen in nephrotic syndrome)
5. ASO titer
- If strep is believed to be the reason… this will measure against the antibodies. So if strep was present antibodies that the infection would still be present
Is HTN present in glomerulonephritis?
True
How do we treat gloomerulonephritis?
- Dietary restrictions
- Moderate sodium restrictions (regular diet with no added salt)
- Possible fluid restriction
- Restrictions of foods with substantial potassium during periods of oliguria
- fluid volume overload s/s
- Antihypertensives & diuretics
Why do we restrict potassium during periods of oliguria in glomerulonphritis?
If the kidneys are not filtering k+ out then we are retaining k+ in the blood. We do not want to add more and they become hyperkalemic which we know would affect the heart
What is the prognosis of glomerulonephritis?
Usually good w/complete recovery but there are some cases in which the child will go into acture renal failure
What are some nursing considerations of acute glomerulonephritis?
- VS, strict I&O, daily weight
- blood pressure monitoring will be important
- Monitor for dehydration in fluid-restricted pts
- Offer appealing meal choices
- Will not be hungry but try to offer them choices within their appropriate dietary needs
- Allow for frequent rest periods
- Typically done on their own will due to not feeling well.
- Restricted contact sports
When do we provide supportive measures as a treatment for acute glomerulonephritis?
If they are normotensive and have normal urine output… they can be treated at home…
If they start to have increased bp or urine output they will have to be admitted.
Parental education r/t follow up & home care of acute glomerulonephritis includes?
- frequent ua and vp monitoring for signs of progression of the disease
- 1st sign of renal failure is decreased urine output… report decreased urine output
Acute glomerulonephritis can lead to what syndrome
Nephrotic syndrome
Causes
Acute glomerulonephritis vs. Nephrotic syndrome
Acute glomerulonephritis: Follow streptococcal infection
Nephrotic syndrome: Idiopathic in most cases
Additional physical symptoms
Acute glomerulonephritis vs. Nephrotic syndrome
Acute glomerulonephritis: Anorexia, lethargy, headache
Nephrotic syndrome: Fatigue, susceptible to infection
Acute glomerulonephritis vs. Nephrotic syndrome
EDEMA
Acute glomerulonephritis: Mild to moderate, Primarly periorbital
Nephrotic syndrome: Severe, facial and generalized, ascites
Acute glomerulonephritis vs. Nephrotic syndrome
BP
Acute glomerulonephritis: Mild to severe HTN
Nephrotic syndrome: Generally normotensive
Acute glomerulonephritis vs. Nephrotic syndrome
Urine Appearance
Acute glomerulonephritis: Cloudy, tea/cola-colored
Nephrotic syndrome: dark and frothy
Acute glomerulonephritis vs. Nephrotic syndrome
Urine Protein
Acute glomerulonephritis: Generally mild to moderate; parallels hematuria
Nephrotic syndrome: Massive protienuria (3+ and higher)
Acute glomerulonephritis vs. Nephrotic syndrome
Urine Blood
Acute glomerulonephritis: Up to gross amounts
Nephrotic syndrome: Few RBCs
Acute glomerulonephritis vs. Nephrotic syndrome
ASO titer
Acute glomerulonephritis: Positive
Nephrotic syndrome: Negative (if tested)
Acute glomerulonephritis vs. Nephrotic syndrome
TREATMENT
Acute glomerulonephritis: Supportive, moderate dietary restrictions, antihypertensives & Diuretics pRN, Abx to treat caustive agent
Nephrotic syndrome: Corticosteriods, dietary restrictions, possibly diuretics & albumin
What is enuresis?
Intentional or involuntary passage of urine into bed (usually at night) in children who are beyound the age when voluntary bladder control should be normally acquired
More common in boys than girls
What factors play a role in enuresis?
- Small bladder
- Persistent UTI
- Severe Stress
- Developmental delay that interferes w/toliet training
What are the different types of Enuresis?
- Primary: Bedwetting in children who have never been dry for an extended period
- Secondary: The onset of wetting after a period of established urinary continence– may be caused by stress
How do we treat enuresis?
Behavioral 1st
1. 1st must rule out organic cause(s)
2. Restrict or eliminate fluids after dinner
3. Avoidance of caffeine & sugar-containing drink after 1600
4. Purposeful interruption of slee to void
5. Motivation therapy(bribery)
6. Bed alarm
This continues until there is 14 days of no bed wetting.
What medications can be used to treat enuresis?
Imipramine (tofranil) and desmopressin are most commonly used
Trycyclic antidepressants/anticholenergic meds… remember these are going to dry mouth, headache, cause constipation, and trycyclic antidepressants can become cardiac toxic if there is an overdose.
What is hemolytic uremic syndroe (HUS)
Uncommon, acute renal disease that occurs primarily in infants and small children between the ages of 6 months and 5 years
What causes HUS
Bacterial toxins, viruses & chemicals… typically e.coli, bad meat, juice or dairy products, swimming in pools and lakes contaminated with feces
What are clinical features of HUS
Hemolytic anemia
Thromboytopenia
Renal Injury
What is the patho of HUS?
- Toxin damages endothelial lining of glomerular arterioles
- Glomerular arterioles become swollen & occluded with depositis of platelets & fibrin clots
- RBCs are damaged as they attmpt to move through partially occluded vessels—> acute hemolytic anemia
- Damaged cells are removed by the spleen —> thrombocytopenia
What are clincal manifestations of HUS?
- Preceded by illness
- Gastroenteritis
- Upper resp. infection
- Vomiting
- irritability
- lethargy
- pallor r/t low rbc anemia
- hemorrhagic manifestation r/t thrombocytopenia
- oliguria or anuria
- CNS involvment
- high bp
- swelling of hands, face or entire body
What is the treatment of HUS?
- Goals of therapy are early diagnosis & agressive care of renal failure & hemolytic anemia
-
Most consistently effective treatment is dialysis
- any child anuric x 24 hours or oliguric w/uremia or HTN & seizures
- FFP, plasmapheresis
- PRBC
What are the nursing consderations for HUS?
- Strict I&Os
- Management of dialysis in PICU
- Thermoregulation
- reduction of anxiety
- Closely monitor for fluid overload
What is the prognosis of HUS?
- 95% of the time that a child goes into acute remal failure they will make a full recovery
- 10-50% chance they will have residual renal impairment & will live the rest of their life without healthy kidneys
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