Genitourinary Dysfunction Urinary Tract Infection

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Genitourinary Dysfunction Urinary Tract Infection Powered By Docstoc
					Genitourinary
Common Genitourinary Disorders
       • Enuresis

       • Urinary Tract Infection
       • Pyelonephritis

       •   Vesicoureteral reflux (VUR)
       •   Hydronephrosis
       •   Cryptorchidism
       •   Hypospadius
       •   Exstrophy of Bladder

       • Acute Glomerulonephritis
       • Nephrotic Syndrome
       • Acute Renal Failure
Voiding
Toilet Training
         • Myelination of spinal cord
           necessary before child can
           control bowel and bladder
           function; occurs between
           12-18 months
         • However, child is usually not
           ready until 18-24 months
         • Waiting until 24-30 months
           makes the job easier
Toilet Training: Average age of Continence is 3 years
                        of age

                       Expected Developmental Milestones

                       Age             Bladder Control
                    1.5 years          Urinates regularly
                     2 Years           Aware of voiding
                    2.5 years           Can hold urine
                     3 years            Daytime control
                    3.5 years          Nighttime control
Signs of Readiness for Toilet
Training
        • Physical Readiness
          – Child removes own clothes
          – Child is willing to let go of toy
          – Child is able to sit, squat, and walk well
          – Child has been walking for 1 year
        • Psychological Readiness
          – Child notices wet diaper
          – Child indicates need for diaper change
          – Child communicates need to go to the
            bathroom and can get there by self
          – Child wants to stay dry
• Parent Readiness
  – Requires many toileting sessions a day
  – Need to be able to give child undivided
    attention
  – Patience

  – Personal choice on toilet or free
    standing potty chair
Enuresis Involuntary voiding of urine > 6
yrs
          • Primary
             – Never achieved dryness for 3
               months
          • Secondary
             – Dry for 3-6 months then resumes
               wetness
          • Diurnal
             – Wetting occurs only in daytime
          • Nocturnal
             – Wetting occurs only in nightime
Etiology
           Organic
           •   Neurological delay
           •   UTI
           •   Structural disorder
           •   Chronic renal failure
           •   Disease with polyuria (DM)
           •   Chronic constipation
Etiology
           Non-organic
           • Sleep arousal problem
           • Sleep disorders from
             enlarged tonsils, sleep apnea
           • Psychological stress
           • Family history
           • Inappropriate toilet training
Diagnosis
       • Physical exam to r/o organic
         cause

       • Made by voiding diary
Treatment
      • Organic- treat underlying cause

      • Nonorganic- most will outgrow by
        late childhood
Impact on child
        • May avoid activities
          – Sports
          – Sleepovers
        • Great source of stress
        • Concealing wet clothing is difficult
        • Odor is a concern
Enuresis: Nursing Diagnosis
       • Situational Low Self-Esteem
         related to bed- wetting or urinary
         incontinence
       • Impaired Social Interaction related
         to bed- wetting or urinary
         incontinence
       • Compromised Family Coping
         related to negative social stigma
         and increased laundry load
       • Risk for Impaired Skin Integrity
         related to prolonged contact with
         urine
• Assess parent and child’s
  motivation and readiness

• If willing to be active participant
  then management includes:
  –   Alarms
  –   Timed voiding
  –   Bladder exercises
  –   Elimination diets
  –   Behavioral therapy
  –   Medications
Medication
       • DDAVP



       • Ditropan




       • Tofranil (Imipramine)
Infections
Urinary Tract Infection
(UTI) • Most common infection of GI tract
        • Fecal bacteria (E. coli) cause most
          UTI’s
        • Girls>boys after age 1
        • In males uncircumcised>circumcised

        • Can lead to renal scarring, high
          blood pressure, End Stage Renal
          Disease
Conditions that Predispose
Infants and Children to UTIs
 • Urinary tract obstructions
 • Voiding dysfunction resulting in
   urinary stasis
 • Anatomic differences in younger
   children
 • Individual susceptibility to infection
 • Urinary retention while toilet-training
 • Bacterial colonization of the prepuce
   of uncircumcised infants
 • Infrequent voiding
 • Sexually active adolescent girls
Symptoms

    • Infants
      – Nonspecific
      – Fever or
        hypothermia
        (neonate)
      – Irritability
      – Dysuria (crying
        when voiding)
      – Change in urine
        odor or color
      – Poor weight gain
      – Feeding difficulties
Symptoms
      • Children
           –   Abdominal or suprapubic pain
           –   Voiding frequency
           –   Voiding urgency
           –   Dysuria
           –   New or increased incidence of enuresis
           –   Fever
           –   Malodorus urine
           –   Hematuria
Pyelonephritis
          Infection travels to kidneys

    Symptoms
    • Same s/s of UTI plus:
    • Higher fever
    • Back or flank pain (CVAT)
    • Nausea & vomiting
    • Look sick
Diagnostic tests
        • Urinealysis (UA)
          – Macro
          – Micro
          – 24 hour
        • Culture and Sensitivity (C & S)

        • Specimen collection
          –   Clean catch
          –   Pediatric urine collector
          –   Straight cath
          –   Foley cath
Diagnosis
       • UA (Urinalysis)
            – Bacteriuria
            – Pyuria
       • Urine C&S: colony count = 100,000

       • Pyelonephritis
            – Above plus
            – Elevated WBC
            – Elevated ESR
            – Increased CRP
Management of Both
  • 7-10 day course of ABX
  • Dehydrated child and very
    young often require IV and hosp
  • Increase PO fluids
  • Analgesia
  • Antipyretics
  • Repeat urine C&S 3-5 days
    after tx
Prevention
  • Proper toilet training
  • Teach proper wiping
  • Avoid tight clothing
  • Wear cotton underwear
  • Encourage children to avoid “holding”
    urine
  • Avoid bubble baths
  • Don’t force cranberry-increases acidity
  • Adolescent: urinate immediately after
    intercourse
Structural Defects
Vesicoureteral reflux (VUR)
       •Malformed valves at ureters and
       bladder
       •Allows a backflow of urine up the
       ureter into the kidney

       •Can be congenital abnormality,
       graded 1-5
       •Grade 5: massive ureteral and renal
       pelvis dilation
Etiology and symptoms
       • Genetic origin
       • Girls>boys
       • Symptoms
         – Frequent UTI’s (most common)
         – Enuresis
         – Flank pain
         – Abdominal pain
Vesicoureteral reflux (VUR)
       Treatment:
       • Grades 1-3: will usually resolve
         on own
       • Grades 4-5: valve repair
       • Prophylactic ABX
       • Teach child to double void
       • Urine C&S q 2-4 months until 3
         negative
Hydronephrosis
     • Enlargement of the pelvis of
       the kidney secondary to a
       congenital narrowing of the
       ureteropelvic junction
     • May also be acquired
       secondary to kidney stones,
       tumors, blood clots
Symptoms


      • Usually free of symptoms initially
      • May have repeated UTI’s (urinary
        stasis)
      • Polyuria
      • Frequency
      • Flank pain
      • Increased BP
      • Abdominal palpation reveals a mass
Hydronephrosis
     Diagnosis:
     • If congenital, usually diagnosed in
       utero
     • IVP shows enlarged renal pelvis &
       site of obstruction

     Management:
     • If untreated can destroy nephrons
     • Surgical correction of the obstruction
Cryptorchidism (UDT)
      •One or both testes fail to descend through
      the inguinal canal into the scrotal sac
      •Testis may be retractable
      • In 85% right testis is affected
      •The affected side or bilateral scrotum
      appears flaccid or smaller than normal

      •Unknown why this fails
        –Increased abd pressure
        –Hormonal influences
Cryptorchidism (UDT)
      • Common in the premature infant and
        LBW infant
      • Incidence decreases with age
      • Many resolve spontaneously by 12
        months age
      • If still present at age 1, descent
        usually does not occur
      • Associated with lower sperm
        production
      • Increased risk for malignant testicle
        turoms in adulthood
Management
      • Observation for first year
      • HCG- stimulates testosterone
        production and helps with
        descent
      • If testis fail to descend
        between 1-2 years of age
        then surgical treatment:
        Orchiopexy
Surgical Management: usually outpatient

          • Post op instructions:
             –Loose clothing
             –Incision Care
             –Monitor for infection
             –Analgesia
             –Ice
             –Discuss future fertility & cancer
              risk
Hypospadius
  – Congenital malformation
  – Urethral opening is below normal
    placement on glans of penis (ventral
    surface-underside)
  – May also have short chordee (fibrous
    band of the penis, will cause it to curve
    downward)
  Epispadius
  – dorsal placement of urethral opening
Hypospadius, epispadius,
chordee
Etiology and Symptoms
       • Cause is unknown
       • Defects in testosterone is possible
       • Possible genetic origin

       Symptoms
       • Urinary stream deflected downward
       • Prepuce is small-Penis appears to look
         circumcised
       • May have chordee, undescended
         testes and inguinal hernia
Management of both
      • Out patient surgery to
        lengthens urethra
        (meatomy), position
        meatus at penile tip,
        release the chordee
      • Performed btw 12-18 mos
        of age
      • No circumcision
Post-op:
• Stent for urinary drainage and
  patency
• Double Diapering
• Strict I&O
• Pain Management
• Monitor for Infection
• No Hip-Holding, ride-on toys
• Possible fertility problems
Exstrophy of Bladder

   • Bladder lies open and exposed on abdomen
     (defect in abdominal wall)
   • Pelvic bone defects (non-closure of pelvic
     arch)
   • Bladder is bright red & unable to contain
     urine, may also have defects in urethra
     (epispadius)
   • Surgical closure of abdominal wall,
     reconstruction of bladder, urethra and
     genitalia “continent urinary reservoir”
Management
   Preop:
   •Prevent infection
   •Protect skin integrity
   •Protect exposed bladder
   •Parental education
   (straight catheterization)
   •Keep infant’s legs flexed
Goals of Surgery
       • Closure of the bladder and
         abdominal wall
       • Urinary continence, with preservation
         of renal function
       • Creation of functional and normal-
         appearing genitalia
       • Correction to promote later sexual
         functioning
• Post Op
•Suprapubic catheter-if unable to
restore function
•Immobilized Pelvis
•Strict I&O
•Antispasmotics: Probanthine
(Pyridium)
•Analgesics
•Parental Emotional Support
Summary-Nursing Role
      Structural Disorders of GU System

      • Many children are discharged with stents
        or catheters.

      • Teach parents how to change dressings,
        double diaper, care for catheters, assess
        pain and give analgesics, and recognize
        signs of possible obstruction or infection.

      • Parents should encourage the child to
        participate in age-appropriate activities.
Disorders of the Kidney
Pediatric Normal Value age 2-12 yr
        • Chemistry Panel
          –   Potassium: 3.5-5.8
          –   Sodium: 135-148
          –   Urea Nitrogen: 3.5-7.1
          –   Creatinine: 0.2-0.9
          –   Calcium: 2.2-2.7
          –   Albumin: 3.2-4.7
        • Blood Gases
          – Bicarbonate: 18-25
        • Urinalysis
          – Protein: None
          – Specific Gravity: 1.001-1.030
Acute Glomerulonephritis (AGN)
   • Sudden inflammation of the glomeruli of the
     kidney resulting in acute renal failure
   • Peak age 5-10 years, boys>girls
   • Capillary walls of kidney become permeable;
     allows red blood cells and protein to pass into
     urine
   • Usually seen 7-10 days after a strep infection
     (immune response to strep), may be other
     organisism
     – APSGN (Acute Post Streptococcal
       Glomerulonephritis)
Signs & Symptoms
  • URI preceding symptoms
  • Sudden onset of hematuria (smokey or
    tea-colored urine)
  • Proteinuria (+1 to +4)
  • Edema (worse in the morning) of
    eyelids and ankles; sodium and fluid are
    retained
  • Oliguria: < 1 ml/kg/hr = impending
    renal failure
Signs & Symptoms
  • Hypertension (due to decreased
    glomerular filtration rate) can be
    severe
  • HTN may lead to pulmonary
    edema (listen for crackles)
  • Fever, malaise, abdominal pain,
    HA, vomiting- feel sick
Diagnosis

 • Presenting symptoms
 • Urinalysis
   – proteinuria +1 to +4,
   – 24h urine 1 gram protein
   – hematuria
 • Increased BUN, creatinine
Diagnosis
  • Electrolytes Imbalance (from inadequate
    glomerular filtration)
     – high serum potassium
     – low serum bicarbonate


  • BP may increase, if > 160/100 can lead
    to encephalopathy
  • ASO Titer (antistreptolysin): indicates
    presence of antibodies to streptococcal
    bacteria
Management
• No specific treatment- supportive
• Manage S&S (adequate rest- main tx)
• Monitor renal dysfunction
• Anti-hypertensive therapy (limit sodium &
  water or by diuretics & anti-hypertensive
  meds)
• Prognosis is excellent
• Daily weight, accurate I & O until fully
  resolved (2 mos)
• Diuresis signals the beginning of resolution
Nursing Care- AGN/ASPGN
      • Monitoring fluid status- hypovolemia
        – I&0, VS, Electrolytes
      • Preventing infection-ARF risk for
        infection
        – Hand hygiene, screen visitors, watch
          CBC
      • Preventing skin breakdown
        – Bed Rest is the Treatment
        – Check dependent areas
        – Sheets tight, free of crumbs, sm toys
Nursing Care- AGN/ASPGN
      • Meeting nutritional needs
        – ARF anorexia is common
        – no added salt, low protein diet
        – Encourage food from home
        – Age appropriate quantity


      • Providing emotional support to the
        child and family
        – Guilt is common from untreated strep
Nephrotic Syndrome

     • Immune response to systemic
       infection alters the structure of the
       glomeruli to become permeable to
       protein
     • resulting in:
       – Massive urinary protein loss
       – Generalized tissue edema
Assessment
    • Highest incidence at age 3
    • Generalized Edema
      –Periorbital edema
      –Abdominal edema
      –Scrotal edema
    • Poor nutrition
    • Growth retardation
    • Renal failure
Laboratory Findings
       • Proteinuria (24h urine 15
         grams)
       • Hypoalbuminemia
       • Hyperlipidemia
       • Urine appears dark and
         frothy
       • Negative ASO titer
Treatment
      •   Reduce edema
      •   Protect skin from FVE
      •   Protect from Infection
      •   Prevent Hypovolemia
Reduce edema
• Prednisone 2mg/kg/day for 4-8 weeks
  – Long term steroid use is concern

  – Treat until child is in remission (zero to
    trace urine protein for 5-7 consecutive
    days)
• Diuretic therapy used only if poor
  response to steroids
• May need IV albumin (helps restore
  normal plasma osmotic pressure)
• Give parental support and education re:
  urine protein checks
Risk for impaired skin integrity
r/t edema & decreased
circulation.

    • Frequent position changes q2h
    • Loose clothing
    • Semifowler’s for sleeping, elevate
      edematous body parts
    • Maintain good hygiene (daily baths, dry
      completely)
    • Promote physical activity if able
      (promote circulation)
Risk for infection r/t
immunosuppressive therapy/treatment
of edema.

• Screen visitors for s/s of infection
• Administer ABX as ordered given
  for peritonitis prophylaxis
• Good handwashing for staff and
  family
• Monitor child for s/s infection
Fluid volume excess (ECF) r/t
decreased excretion of sodium and
fluid retention.
       • Monitor I & O
       • Obtain accurate daily weights
       • Adhere to no-added salt diet
       • Monitor BP at least once each shift
       • Administer diuretics (potassium
         intake)
       • Monitor pulmonary status (watch for
         fluid overload, pulmonary edema)
Risk for fluid volume deficit r/t effects of diuretics.

             • Watch for low BP & increased pulse
               => hypovolemia
             • Report if child has output of less than
               1 ml/kg/hr of urine
             • Increased Hbg, Hct and platelets
               may indicate hemoconcentration or
               low intravascular volume
             • Observe for s/s dehydration r/t use of
               diuretics
Compare and Contrast
  AGN                        Nephrotic Syndroms

  School age child           Young child
  Dark Urine                 Dark Urine
  Oliguria                   Oliguria
  Strep Infection            Negative Strep
  Mild proteinuria           Severe proteinuria
  Serum protein unaffected   Hypoalbuminemia
  Hyperkalemia               Hyperlipidemia
  Increased BUN, Cr          Severe edema
  Mild edema                 Normal or low BP
  HTN                        Tx-prednisone, diuretics, IV
  TX- BP meds                albumin
Acute Renal Failure
  kidney is unable to excrete
  wastes and concentrate urine
Acute Renal Failure (ARF)
        • Sudden onset of impaired renal
          function
        • Boys>girls
        • More common age < 5 years
        • Usually occurs secondary to
          infection
        • Most children regain renal
          function
        • Can be life threatening
Types of ARF
       Prerenal
         – Sudden decrease in renal blood flow result
           from dehydration, hypovolemia, shock,
           burns, CHF
       Intrarenal
         -damage to kidney tissue from
         antibiotic use and other nephrotoxic
         drugs, contrast dye, or infections of the
         kidney
       Postrenal
         – Urine is obstructed between the kidney and
           meatus causing back up of urine in kidney
           and diminishes renal function. Structural
           abnormality, tumor or calculi are the cause
Acute Renal Failure
       Signs & symptoms:
       •Oliguria (< 1ml/kg of weight)
       •HTN may be malignant
       •Dehydration
       •Pallor, listlessness
Laboratory Findings ARF
       •Hyperkalemia
       •Hyponatremia
       •Hypocalcemia
       •Increased BUN & creatinine

       •Azotemia (increased serum
       nitrogen)
       •Uremia (azotemia plus cerebral
       irritation)
Treatment: Mild ARF
       • Increase renal perfusion and
         restore electrolyte balance
       • Depends on Cause
       • General Treatment Includes:
         – Fluid restriction
         – Daily weight
         – TPN to minimize protein catabolism
       • Kayexalate for hyperkalemia
         – I & O (Foley)
Practice Questions!
     The nurse is teaching the parents of a preschooler
     information about urinary tract infections and ways
     to reduce their recurrence. Statements from the
     parents that indicate an understanding of ways to
     prevent UTI’s include (select all that apply)

1.   “I should try to get her to drink a lot of water”
2.   “I will buy her cotton underwear”
3.   “Soaking in a bubble bath will reduce her
     irritation”
4.   “If I notice her wetting the bed, I need to have
     her checked for UTIs”
5.   “I should avoid giving her cranberry juice as it
     has been shown to make urine more acidic”
The parent of a 2 ½ year old child
asks the nurse about potty training.
Which assessment question should
the nurse ask to assess the child’s
developmental readiness?
1. “Can you child hold urine
   voluntarily?”
2. “Can you child urinate on command?”
3. “Is your child dry at night?”
4. “Does your child know when he is
   voiding?”
   The nurse would include which of the
   following in the care of a child with
   acute glomerulonephritis?
   (select all that apply)

1. Careful handling of edematous
   extremities
2. Observing the child for evidence of
   HTN
3. Provide fun activities for the child on
   bedrest
4. Monitor for hematuria
5. Encouraging salty foods
   The newborn has been diagnosed
   with cryptorchidism. The MD has
   ordered HCG to be administered. The
   mother asks the nurse why the baby
   is receiving the drug. The nurse
   explains it will:

1. Maintain an adequate temperature
   around the testes
2. Prevent infection in the undescended
   tests
3. Prevent the development of cancer
4. Promote descent of the testes
• View the diagram below. Where is the
  site of malformation in a child with
  VUR?
               A




   B

                            C


       D
• Am 18.4 kg child urinated 43.68ml.
  The last void was 3 hrs ago. The
  nurse evaluates this output to be:

1.   Oliguria
2.   Polyuria
3.   Normal output
4.   Anuria
• The following results are from a
  chemistry panel on a 5-year-old
  child. Which of the following labs
  confirm the child is in
  APSGN/AGN (Select all that
  apply)
1.Potassium 5.9
2.Urea Nitrogen 7.4
3.Albumin 3.8
4.Creatinine 0.6
5.15 g 24/hr proteinuria
• Answer 1,2,3

1.Potassium 5.9 (hyperkalemia)
2.Urea Nitrogen 7.4 (Inc BUN)
3.Albumin 3.8 (Normal)
4.Creatinine 0.6 (should be inc)
5.15 g 14/hr proteinuria (way to
  high)
• The nurse is treating a 33 lb child
  with Nephrotic Syndrome. The
  nurse calculates the appropriate
  dose of prednisone to be:
• 1. 10 mg qd
• 2. 20 mg qd
• 3. 30 mg qd
• 4. 40 mg qd

				
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