1. NURSING MANAGEMENT OF GENITOURINARY DYSFUNCTION: Theoretical Skills and Knowledge, Scientific Principles, Critical Thinking, Healthcare Promotion, Wellness and Illness, and Stress Adaptation

2. Lecture Objectives:
Describe common renal and urinary disorders that occur in children.
Assess a child for a renal or urinary tract disorder.
Formulate nursing diagnoses related to renal or urinary tract disorders.
Establish outcomes related to the care of a child with renal or urinary disorder.
Plan nursing care related to urinary or renal disorders.

3. Lecture Objectives (cont.)
Implement nursing care for the child with a renal or urinary disorder.
Evaluate outcomes for achievment and effectiveness of care.
Analyze methods for making nursing care of the child with a renal or urinary disorder more family centered.
Compare and contrast acute and chronic renal failure.
Discuss the types of renal dialysis.
Assess for signs of kidney transplant rejection.

4. Reading Assignment:
Wong, Perry & Hockenberry
Ch. 50; p

5. Renal System Assessment
Physical assessment
Palpation, percussion
Health history
Previous UTIs, calculi, stasis, retention, pregnancy, STDs, bladder cancer
Meds: antibiotics, anticholinergics, antispasmodics
Urologic instrumentation
Urinary hygiene
Patterns of elimination

6. Nursing Assessment of Urinary Tract Infection (UTI)
Nausea, vomiting, anorexia, chills, nocturia, frequency, urgency
Suprapubic or lower back pain, bladder spasms, dysuria, burning on urination

7. Nursing Assessment of Urinary Tract Infection (UTI)
Objective data
Fever
Hematuria, foul-smelling urine; tender, enlarged kidney
Leukocytosis, positive findings for bacteria, WBCs, RBCs, pyuria, ultrasound, CT scan, IVP

8. Diagnostic Studies Renal scan Cystogram Retrograde pyelogram
Ultrasound CT
MRI
Renal arteriogram UA
Urine C&S
BUN
Creatinine
KUB
IVP
VCG/VCUG

9. Normal Urinalysis pH: 5 to 9 Sp gr: 1.001 to 1.035
Protein: <20 mg/dl
Urobilinogen: up to 1 mg/dl
None of the following:
Glucose
Ketones
Hgb
WBCs
RBCs
Casts
Nitrite

10. Normal Characteristics of Urine
Color range
Clear
Newborn production—approx 1-2 ml/kg/hr
Child production—approx 1 ml/kg/hr
NB will produce 1-2 ml/kg/hr; after 1 mo. Approx 1 ml/kg/hr

11. Urinary Tract Infection (UTI)
Is it really that serious?
Concept of “asymptomatic bacteria” in urinary tract
Second most common bacterial disease
Account for more than 8 million office visits per year
Results in >100, 000 people hospitalized annually
>15% patients who develop gram-negative bacteria DIE
1/3 of gram-negative infections originate in urinary tract

12. Urinary Tract Infection (UTI)
Causes
Escherichia coli most common pathogen
Streptococci
Staphylococcus saprophyticus
Occasionally fungal and parasitic pathogens
Gram-negative bacilli from GI tract common cause
Fungal generally after multiple antibiotic courses;
Also more common w/ immunosuppressed or diabetics

13. Classification of UTI
Upper tract: involves renal parenchyma, pelvis, and ureters
Typically causes fever, chills, flank pain
Lower tract: involves lower urinary tract
Usually no systemic manifestations

14. Classification of UTI Lower tract Upper tract Cystitis Pyelonephritis
Urethritis
Glomerulo-nephritis
Upper tract
Pyelonephritis
VUR
Cystitis—Contained in bladder
Urethritis—Irritation>>infection; potential for ascending
Pyelonephritis—Inflam of upper urinary tract and may involve kidneys
Role of vesicoureteral reflux
VUR—w/ ea void, urine goes up into ureter and is opportunity for microbial proliferation
Glomerulonephritis—Immunologic disorder in the kidney proper; did not begin in the bladder and ascend; Generally follows other bacterial illness, esp strep

15. Classification of UTI Uncomplicated infection Complicated infections
Stones
Obstruction
Catheters
Diabetes or neurologic disease
Recurrent infections
Uncomplicated infection: occurs in otherwise normal urinary tract
Complicated Infections:
Stones
Obstruction
Catheters
Diabetes or neurologic disease
Recurrent infection

16. Types of UTIs Recurrent—repeated episodes
Persistent—bacteriuria despite antibiotics
Febrile—typically indicates pyelonephritis
Urosepsis—bacterial illness; urinary pathogens in blood
Recurrent is reinfection in person whose prior infection was successfully eradicated
Recurrent occurs because original infection not adequately eradicated
Unresolved bacteriuria: bacteria resistant or drug discontinued before bacteriuria is completely eradicated
Bacterial persistence: resistance developed or foreign body in urinary system serves as harbor and anchor for bacteria to survive despite therapy

17. Etiology and Pathophysiology of UTI
Physiologic and mechanical defense mechanisms maintain sterility
Emptying bladder
Normal antibacterial properties of urine and tract
Ureterovesical junction competence
Peristaltic activity
Explain what this means

18. Etiology and Pathophysiology of UTI
Alteration of defense mechanisms increases risk of UTI
Organisms usually introduced via ascending route from urethra
Less common routes
Bloodstream
Lymphatic system

19. Etiology and Pathophysiology of UTI
Contributing factor: urologic instrumentation
Allows bacteria present in opening of urethra to enter urethra or bladder
Sexual intercourse promotes “milking” of bacteria from perineum and vagina
May cause minor urethral trauma

20. Etiology and Pathophysiology of UTI
UTIs rarely result from hematogenous route
For kidney infection to occur from hematogenous transmission, must have prior injury to urinary tract
Obstruction of ureter
Damage from stones
Renal scars

22. Etiology and Pathophysiology of UTI
UTI is a common nosocomial infection
Often E. coli
Seldom Pseudomonas
Urologic instrumentation common predisposing factor

23. Clinical Manifestations of UTI
Symptoms
Dysuria
Frequent urination (>q2h)
Urgency
Suprapubic discomfort or pressure

24. Clinical Manifestations of UTI
Urine may contain visible blood or sediment (cloudy appearance)
Flank pain, chills, and fever indicate infection of upper tract (pyelonephritis)

25. Pediatric Manifestations
Frequency
Fever in some cases
Odiferous urine
Blood or blood-tinged urine
Sometimes NO symptoms except generalized sepsis

26. Pediatric Manifestations
Pediatric patients with significant bacteriuria may have no symptoms or nonspecific symptoms like fatigue or anorexia
So how do you find out?
This can also occur in adults as well
This is why when a child is admitted with FUO urine culture is done as part of the septic workup.

27. Diagnostic Studies of UTI
Dipstick
Microscopic urinalysis
Culture
Dipstick : to identify presence of nitrates, WBCs, and leukocyte esterase
Confirm w/ micro ua
Urine culture indicated in complicated or nosocomial, persistent bacteria, or frequently recurring (>2 episodes annually)
May be cultured if infection is unresponsive to empiric therapy or diagnosis is questionable

28. Diagnostic Studies of UTI
Clean-catch is preferred
U-bag for collection from child
Specimen obtained by catheterization or suprapubic needle aspiration has more accurate results
May be necessary when clean-catch cannot be obtained
Clean-catch is preferred
Specimen obtained by catheterization or suprapubic needle aspiration has more accurate results
May be necessary when clean-catch cannot be obtained

29. Diagnostic Studies of UTI
Sensitivity testing determines susceptibility to antibiotics
Imaging studies for suspected obstruction
IVP or Abd CT

30. Collaborative Care for UTI Drug Therapy: Antibiotics
Uncomplicated cystitis: short-term course of antibiotics
Complicated UTIs: long-term treatment
Antibiotic selected on empiric therapy or results of sensitivity testing

31. Collaborative Care for UTI Drug Therapy: Antibiotics
Trimethoprim-sulfamethoxazole (TMP-SMX) or nitrofurantoin
Amoxicillin
Cephalexin
Others
Gentamycin, carbenicillin ++
Pyridium (OTC)
Combination agents (e.g., Urised) used to relieve pain
Preparations with methylene blue tint
Sulfa : used to treat empiric uncomplicated or initial
Inexpensive
TMP-SMX taken bid
Pyridium is OTC that provides soothing effect on urinary tract mucosa
Stains urine reddish orange that can be mistaken for blood and may stain underclothing
Effective in relieving discomfort

32. Collaborative Care for UTI Drug Therapy
For repeated UTIs
Prophylactic or suppressive antibiotics
TMP-SMX administered daily to prevent recurrence or single dose before events likely to cause UTI
Suppressive therapy often effective on short-term basis
Limited because of antibiotic resistance ultimately leading to breakthrough infections

33. Etiology and Pathophysiology of Acute Pyelonephritis
Inflammation caused by bacteria, fungi, protozoa, or viruses infecting kidneys
Urosepsis: systemic infection from urologic source
Can lead to septic shock and death in 15% of cases

34. Etiology and Pathophysiology of Acute Pyelonephritis
Usually infection is via ascending urethral route
Frequent causes
E. coli
Proteus
Klebsiella
Enterobacter

35. Etiology and Pathophysiology of Acute Pyelonephritis
Commonly starts in renal medulla and spreads to adjacent cortex
Recurring episodes lead to scarred, poorly functioning kidney and chronic pyelonephritis

36. Clinical Manifestations of Acute Pyelonephritis
Vary from mild to “classic” and very severe
Presenting symptoms
N/V, anorexia, chills, nocturia, frequency, urgency
Suprapubic or low back pain, dysuria
Fever, hematuria, foul-smelling urine
Costovertebral tenderness
Symptoms often subside in a few days, even without therapy
Bacteriuria and pyuria still persist
Vary from mild fatigue to sudden onset of chills, fever, vomiting, malaise, flank pain, and lower urinary tract symptoms characteristic of cystitis
Costovertebral tenderness usually present on affected side, kidney usually palpated as enlarged
Acute Pyelonephritis Nausea, vomiting, anorexia, chills, nocturia, frequency, urgency
Suprapubic or lower back pain, bladder spasms, dysuria, burning on urination
Fever, Hematuria, foul-smelling urine, tender, enlarged kidney
Leukocytosis, positive findings for bacteria, WBCs, RBCs, pyuria,

37. Diagnostic Studies of Acute Pyelonephritis
Urinalysis
WBC casts
CBC
Imaging studies (IVP or CT)
Ultrasound
Urinalysis shows pyuria, bacteriuria, and varying degrees of hematuria
WBC casts indicate involvement of renal parenchyma
CBC will show leukocytosis with increase in immature bands
If bacteremia is a possibility, close observation and vitals monitoring are essential
Prompt recognition and treatment of septic shock may prevent irreversible damage or death

38. Collaborative Care of Acute Pyelonephritis
Hospitalization
Parenteral antibiotics
Hospitalization for patients with severe infections and complications such as nausea and vomiting with dehydration
Parenteral antibiotics to establish high serum levels

39. Collaborative Care of Acute Pyelonephritis
Relapses treated with 6-week course of antibiotics
Reinfections treated as individual episodes or managed with long-term therapy
Prophylaxis may be used for recurrent infections

40. Types of Glomerulonephritis
Most are postinfectious
Pneumococcal, streptococcal, or viral
May be distinct entity or
May be a manifestation of systemic disorder
SLE
Sickle cell disease
Others

41. Glomerulonephritis Symptoms
Generalized edema due to decreased glomerular filtration
Begins with periorbital
Progresses to lower extremities and then to ascites
HTN due to increased ECF
Oliguria

42. Glomerulonephritis Symptoms
Hematuria
Bleeding in upper urinary tract→smoky urine
Proteinuria
Increased amount of protein = increased severity of renal disease

43. Acute Post-Streptococcal Glomerulonephritis
Is a noninfectious renal disease
Autoimmune
Onset 5 to 12 days after other type of infection
Often group A ß-hemolytic streptococci
Most common in 6 to 7 years old
Uncommon in <2 years old
Can occur at any age

44. Diagnosing APSG
Diagnostics: UA, CBC, BUN, Serum creatinine, and albumin
Complement levels and ASO Titer
Renal Bx prn

45. Prognosis 95%—rapid improvement to complete recovery
5% to 15%—chronic glomerulonephritis
1%—irreversible damage

46. Nursing Management of APSG
Manage edema
Daily weights
Accurate I&O
Daily abdominal girth
Nutrition
Low sodium, low to moderate protein
Susceptibility to infections
Bed rest is not necessary
Most kids will normally restrict activity due to malaise

47. Nephrotic Syndrome
Most common presentation of glomerular injury in children
Characteristics
Proteinuria
Hypoalbuminemia
Hyperlipidemia
Edema
Massive urinary protein loss

49. Types of Nephrotic Syndrome
Minimal change nephrotic syndrome (MCNS)
AKA
Idiopathic nephrosis
Nil disease
Uncomplicated nephrosis
Childhood nephrosis
Minimal lesion nephrosis
Congenital nephrotic syndrome
Secondary nephrotic syndrome
MCNS is most common of these
Pathogenesis not known

50. Changes in Nephrotic Syndrome
Glomerular membrane
Normally impermeable to large proteins
Becomes permeable to proteins, especially albumin
Albumin lost in urine (hyperalbuminuria)
Serum albumin decreased (hypoalbuminemia)
Fluid shifts from plasma to interstitial spaces
Hypovolemia
Ascites

51. Nephrotic Syndrome Management
Supportive care
Diet
Low to moderate protein
Sodium restrictions when large amount edema present
Steroids
2 mg/kg divided into BID doses
Prednisone drug of choice ($$ and safest)
Immunosuppressant therapy (Cytoxan)
Diuretics

52. Family Issues Chronic condition with relapses Developmental milestones
Social isolation
Lack of energy
Immunosuppression/protection
Change in appearance due to edema
Self-image

53. Nursing Interventions
Aseptic technique during catheterizations
Avoid unnecessary catheterization and early removal of indwelling catheters
Prevents nosocomial infections
Wash hands before and after contact
Wear gloves for care of urinary system

54. Nursing Interventions
Routine and thorough perineal care for all hospitalized patients
Avoid incontinent episodes by answering call light and offering bedpan at frequent intervals

55. Nursing Interventions
Ensure adequate fluid intake (patient with urinary problems may think will be more uncomfortable)
Dilutes urine, making bladder less irritable
Flushes out bacteria before they can colonize
Avoid caffeine, alcohol, citrus juices, chocolate, and highly spiced foods
Potential bladder irritants

56. Nursing Interventions
Discharge to home instructions
Follow-up urine culture
Recurrent symptoms typically occur in 1 to 2 weeks after therapy
Encourage adequate fluids even after infection
Low-dose, long-term antibiotics to prevent relapses or reinfections
Explain rationale to enhance compliance

57. Hemolytic-Uremic Syndrome
Pathophysiology
Diagnostic evaluation
Therapeutic management
Prognosis
Nursing consideration

58. Wilms’ Tumor Etiology Diagnostic evaluation Therapeutic management
Surgical removal
Chemotherapy and/or radiation
Nursing considerations

59. Renal Failure
Acute renal failure (ARF)
Chronic renal failure (CRF)

60. Acute Renal Failure (ARF)
Definition: kidneys suddenly unable to regulate volume and composition of urine
Not common in children
Principal feature is oliguria
Associated with azotemia, metabolic acidosis, and electrolyte disturbances
Most common pathologic cause: transient renal failure resulting from severe dehydration

61. Acute Renal Failure (ARF)
Pathophysiology—usually reversible
Diagnostic evaluation
Therapeutic management
Nursing considerations

62. Complications of ARF Hyperkalemia Hypertension Anemia Seizures
Hypervolemia
Cardiac failure with pulmonary edema

63. Chronic Renal Failure (CRF)
Begins when diseased kidneys cannot maintain normal chemical structure of body fluids
Clinical syndrome called uremia

64. Potential Causes of CRF
Congenital renal and urinary tract malformations
VUR associated with recurrent UTIs
Chronic pyelonephritis
Chronic glomerulonephritis

65. CRF (cont’d) Pathophysiology Diagnostic evaluation
Therapeutic management
Manage diet, hypertension, recurrent infections, seizures
Nursing considerations

66. Dialysis
Peritoneal dialysis
Hemodialysis
Hemofiltration

67. Peritoneal Dialysis The preferred method of dialysis for children
Abdominal cavity acts as semipermeable membrane for filtration
Can be managed at home in some cases
Warmed solution enters peritoneal cavity by gravity, remains for period of time before removal

68. Hemodialysis
Requires creation of a vascular access and special dialysis equipment
Best suited for children who can be brought to facility 3 times/week for 4 to 6 hours
Achieves rapid correction of fluid and electrolyte abnormalities

70. Transplantation From living related donor From cadaver donor
Primary goal is LT survival of grafted tissue
Role of immunosuppressant therapy