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NURSING MANAGEMENT OF GENITOURINARY DYSFUNCTION:
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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.
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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.
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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
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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
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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
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Diagnostic Studies Renal scan Ultrasound CT MRI UA Urine C&S BUN
Creatinine KUB IVP
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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
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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
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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
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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
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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
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Classification of UTI Lower tract Upper tract Cystitis Pyelonephritis
Urethritis Glomerulo-nephritis Upper tract Pyelonephritis 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
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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
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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
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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
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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
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Etiology and Pathophysiology of UTI
Contributing factor: urologic instrumentation Allows bacteria present in opening of urethra to enter urethra or bladder
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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
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Etiology and Pathophysiology of UTI
UTI is a common nosocomial infection Often E. coli Seldom Pseudomonas Urologic instrumentation common predisposing factor
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Clinical Manifestations of UTI
Symptoms Dysuria Frequent urination (>q2h) Urgency Suprapubic discomfort or pressure
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Clinical Manifestations of UTI
Urine may contain visible blood or sediment (cloudy appearance) Flank pain, chills, and fever indicate infection of upper tract (pyelonephritis)
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Pediatric Manifestations
Frequency Fever in some cases Odiferous urine Blood or blood-tinged urine Sometimes NO symptoms except generalized sepsis
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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.
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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
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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
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Diagnostic Studies of UTI
Sensitivity testing determines susceptibility to antibiotics Imaging studies for suspected obstruction IVP or Abd CT
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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
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Collaborative Care for UTI Drug Therapy: Antibiotics
Trimethoprim-sulfamethoxazole (TMP-SMX) or nitrofurantoin Amoxicillin Cephalexin Others Gentamycin, carbenicillin ++ 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
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Collaborative Care for UTI Drug Therapy
For repeated UTIs Prophylactic or suppressive antibiotics Suppressive therapy often effective on short-term basis Limited because of antibiotic resistance ultimately leading to breakthrough infections
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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
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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
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Glomerulonephritis Symptoms
Hematuria Bleeding in upper urinary tract→smoky urine Proteinuria Increased amount of protein = increased severity of renal disease
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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
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Diagnosing APSG Diagnostics: UA, CBC, BUN, Serum creatinine, and albumin Complement levels and ASO Titer Renal Bx prn
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Prognosis 95%—rapid improvement to complete recovery
5% to 15%—chronic glomerulonephritis 1%—irreversible damage
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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
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Nephrotic Syndrome Most common presentation of glomerular injury in children Characteristics Proteinuria Hypoalbuminemia Hyperlipidemia Edema Massive urinary protein loss
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Types of Nephrotic Syndrome
Minimal change nephrotic syndrome (MCNS) 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
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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
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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
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Family Issues Chronic condition with relapses Developmental milestones
Social isolation Lack of energy Immunosuppression/protection Change in appearance due to edema Self-image
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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
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Nursing Interventions
Routine and thorough perineal care for all hospitalized patients Avoid incontinent episodes by answering call light and offering bedpan at frequent intervals
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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
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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
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Renal Failure Acute renal failure (ARF) Chronic renal failure (CRF)
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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 metabolic acidosis, and electrolyte disturbances Most common pathologic cause: transient renal failure resulting from severe dehydration
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Acute Renal Failure (ARF)
Pathophysiology—usually reversible Diagnostic evaluation Therapeutic management Nursing considerations
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Complications of ARF Hyperkalemia Hypertension Anemia Seizures
Hypervolemia Cardiac failure with pulmonary edema
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Chronic Renal Failure (CRF)
Begins when diseased kidneys cannot maintain normal chemical structure of body fluids Clinical syndrome called uremia
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Potential Causes of CRF
Congenital renal and urinary tract malformations Chronic pyelonephritis Chronic glomerulonephritis
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CRF (cont’d) Pathophysiology Diagnostic evaluation
Therapeutic management Manage diet, hypertension, recurrent infections, seizures Nursing considerations
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Dialysis Peritoneal dialysis Hemodialysis
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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
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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
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Transplantation From living related donor From cadaver donor
Primary goal is survival of grafted tissue Role of immunosuppressant therapy
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