2. Nursing Care of Children with altered Genitourinary Function (2) Dr. Manal Kloub

3. Outline Nephrotic Syndrome Nephrotic Syndrome Renal Failure Renal Failure 1. Acute 2. Chronic

4. Nephrotic Syndrome ( Nephrosis )  It is a clinical state that includes massive Proteinuria, Hypoalbuminemia,hyperlipidemia and edema  The disorder can occur as 1. A primary disease known as idiopathic Nephrosis. Childhood Nephrosis, Minimal change nephritic Syndrome (MCNS). 2. A secondary disorder that occur as a clinical manifestation after or in association with Glomerular damage

5. Nephrotic Syndrome 3. Congenital form inherited as an autosomal recessive disorder. Nephrotic Syndrome occur in children between 2-7 years of age ; it is rare in children younger than 6 months of age Nephrotic Syndrome occur in children between 2-7 years of age ; it is rare in children younger than 6 months of age Patients with (MCNS) are twice as likely to be male. Patients with (MCNS) are twice as likely to be male.

6. Pathophysiology It is not understood It is not understood There may be a metabolic, biochemical, physiochemical or immune- mediated disturbances that cause the basement membrane of the glomeruli to become increasingly permeable to protein There may be a metabolic, biochemical, physiochemical or immune- mediated disturbances that cause the basement membrane of the glomeruli to become increasingly permeable to protein

7. Pathophysiology Renal Glomerular damage -----Proteinuria Renal Glomerular damage -----Proteinuria ( massive) ---- hypoprotienemia ( massive) ---- hypoprotienemia Hypoprotienemia– increased hepatic synthesis of protein and lipids --hyperlipidemia Hypoprotienemia– increased hepatic synthesis of protein and lipids --hyperlipidemia hypoprotienemia – deceased oncotic pressure hypoprotienemia – deceased oncotic pressure 1- edema 2- hypovolemia 1- edema 2- hypovolemia

8. Pathophysiology 1. Decreased renal blood flow --- Renin release ---- vasoconstriction 2. increased secretion of ADH and aldosterone --- Na+ and water reabsorption --- Edema

9. Assessment Clinical Manifestation Weight gain Weight gain Periorbital edema especially in morning from head dependent position Periorbital edema especially in morning from head dependent position abdominal cavity edema ( ascities ) abdominal cavity edema ( ascities ) Scrotal edema extremely marked Scrotal edema extremely marked anorexia,vomiting anorexia,vomiting Diarrhea caused by intestinal edema and poor absorption by edematous membrane Diarrhea caused by intestinal edema and poor absorption by edematous membrane Pleural effusion Pleural effusion Ankle/leg swelling. Ankle/leg swelling. Irritability, easily fatigued, lethargic Irritability, easily fatigued, lethargic

10. Diagnostic Evaluation  Blood pressure normal or slightly decreased  Susceptibility to infections  Urine alterations decreased volume and frothy  Laboratory studies reveal a. Marked Proteinuria ( +3 or higher ) which almost entirely albumin b. low serum protein concentration,reduced serum albumin significantly, elevated plasma lipids serum and platelets count may be elevated  Renal biopsy if the patient dose not respond to a 4-8 weeks courses of steroids

11. Management Dietary restriction includes a low salt diet and fluid restriction Dietary restriction includes a low salt diet and fluid restriction Diuretic therapy Diuretic therapy Sometimes infusions of 25% albumin are used Sometimes infusions of 25% albumin are used Acute infection are treated with appropriate antibiotics Acute infection are treated with appropriate antibiotics Corticosteroids are the first line of therapy for MCNS Corticosteroids are the first line of therapy for MCNS Relapse are treated with a repeated course of high dose steroid therapy Relapse are treated with a repeated course of high dose steroid therapy MCNS episodes often happen in conjunction with viral or bacterial infection MCNS episodes often happen in conjunction with viral or bacterial infection Relapses in children may continue over many years Relapses in children may continue over many years

12. Complications Infection peritonitis, cellulites and pneumonia Infection peritonitis, cellulites and pneumonia Circulatory insufficiency secondary to hypovolemia Circulatory insufficiency secondary to hypovolemia Thromboembolism Thromboembolism

13. Progn osis The prognosis for ultimate recovery in most cases is good The prognosis for ultimate recovery in most cases is good It is self limited disease It is self limited disease In children who respond to steroid therapy the tendency to relapse decreases with time In children who respond to steroid therapy the tendency to relapse decreases with time

14. Nursing care Daily monitoring of intake and out put Daily monitoring of intake and out put Weight the child daily Weight the child daily Examine urine daily for albumin Examine urine daily for albumin Measure abdominal girth daily Measure abdominal girth daily Assessment of edema (pitting, color& texture of skin Assessment of edema (pitting, color& texture of skin Monitor V/S to detect any signs of shock or infections( respiratory ) Monitor V/S to detect any signs of shock or infections( respiratory )

15. Nursing care Formulate a nutritionally adequate and attractive diet Formulate a nutritionally adequate and attractive diet Adjust activities according to children tolerance level Adjust activities according to children tolerance level Edema and fluids restricted during the edema phase and allowed when edema subsides. Edema and fluids restricted during the edema phase and allowed when edema subsides. Family support and home care ( urine examination, medication taken, prevent infection( Family support and home care ( urine examination, medication taken, prevent infection(

16. Renal Failure (RF) RF Is the inability of the kidney to excrete waste material, concentrate urine and conserve electrolytes. RF Is the inability of the kidney to excrete waste material, concentrate urine and conserve electrolytes. The disorder can be The disorder can be 1. Acute 2. Chronic Terms used in RF Azotemia : a accumulation of nitrogenous waste products within the blood Azotemia : a accumulation of nitrogenous waste products within the blood Uremia: retention of notoriousness products produce toxic symptoms often involve other body systems Uremia: retention of notoriousness products produce toxic symptoms often involve other body systems and its a life threatening and its a life threatening

18. Acute Versus Chronic Acute Acute –sudden onset –rapid reduction in urine output –Usually reversible –Tubular cell death and regeneration Chronic Chronic –Progressive –Not reversible –Nephron loss 75% of function can be lost before its noticeable 75% of function can be lost before its noticeable

19. Acute Renal Failure Most often occurs because of sudden body insult such as sever dehydration Most often occurs because of sudden body insult such as sever dehydration Resulted in Oliguria Resulted in Oliguria Azotemia Azotemia Acidosis Acidosis Diverse electrolytes disturbance Diverse electrolytes disturbance Causes Causes 1. Prerenal 2. Intrinsic renal 3. Post renal

20. Causes of ARF Pre-renal = Pre-renal = – vomiting, diarrhea, poor fluid intake, fever, use of diuretics, and heart failure – cardiac failure, liver dysfunction, or septic shock Intrinsic = Intrinsic = – Interstitial nephritis, acute glomerulonephritis, tubular necrosis, ischemia, toxins Post-renal = Post-renal = – prostatic hypertrophy, cancer of the prostate or cervix, or retroperitoneal disorders – neurogenic bladder – bilateral renal calculi, papillary necrosis, coagulated blood, bladder carcinoma, and fungus

22. Assessment Decrease urine output (70%) Decrease urine output (70%) Edema, esp. lower extremity Edema, esp. lower extremity Mental changes Mental changes Heart failure Heart failure Nausea, vomiting Nausea, vomiting Pruritus Pruritus Anemia Anemia Tachypenic Tachypenic Cool, pale, moist skin Cool, pale, moist skin

23. Diagnosis of Renal Failure Blood studies include Blood studies include 1. BUN and creatinine elevated 2. Hyperkalemia ( 6meq/l ) 3. Hypocalcaemia which leads to osteodystrophy 4. Increase phosphorus Urine creatinine clearance urine specific gravity decreased Urine creatinine clearance urine specific gravity decreased

24. Acute Renal Failure Management Treat life threatening conditions Treat life threatening conditions Identify the cause if possible Identify the cause if possible Treat reversible elements Treat reversible elements – Hydrate – Remove drug – Relieve obstruction

26. Hyperkalemia Symptoms Weakness Weakness Lethargy Lethargy Muscle cramps Muscle cramps Paresthesias Paresthesias Lowered blood pressure Lowered blood pressure Dysrhythmias Dysrhythmias

28. Hyperkalemia Treatment Calcium gluconate (carbonate) Calcium gluconate (carbonate) Sodium Bicarbonate Sodium Bicarbonate Insulin/glucose Insulin/glucose Kayexalate Kayexalate Lasix Lasix Hemodialysis Hemodialysis

29. Diet low in protein, potassium, sodium low in protein, potassium, sodium Increase Carbohydrates Increase Carbohydrates Restrict fluids Restrict fluids Daily weight Daily weight Accurate recording for intake & out put Accurate recording for intake & out put

30. Chronic Renal Failure It begins when the diseased kidneys can no longer maintain the normal chemical structure of body fluids under normal conditions It begins when the diseased kidneys can no longer maintain the normal chemical structure of body fluids under normal conditions Glomerular filtration rate decreased below 10 to 15 % of normal. Glomerular filtration rate decreased below 10 to 15 % of normal.

31. Chronic Renal Failure Causes The most common causes before 5 years are congenital renal and urinary tract malformation The most common causes before 5 years are congenital renal and urinary tract malformation such as renal hypoplasia, obstructive uropathy & such as renal hypoplasia, obstructive uropathy & Vesicoureteral reflux Vesicoureteral reflux Glomerular and hereditary diseases in children ages 5-15 years Glomerular and hereditary diseases in children ages 5-15 years Chronic pyelonephritis, chronic glomerulonephritis Chronic pyelonephritis, chronic glomerulonephritis Systematic diseases such as (Lupus erythematosus, anaphylactic purpura) Systematic diseases such as (Lupus erythematosus, anaphylactic purpura) Polycystic kidney disease Polycystic kidney disease Renal vascular disorder such as hemolytic Uremic syndrome (HUS) vascular thrombosis Renal vascular disorder such as hemolytic Uremic syndrome (HUS) vascular thrombosis

32. CRF Symptoms Malaise Malaise Weakness Weakness Fatigue Fatigue Neuropathy Neuropathy CHF CHF Anorexia Anorexia Nausea Nausea Vomiting Vomiting Seizure Seizure Constipation Constipation Peptic ulceration Peptic ulceration Anemia Anemia Pruritus Pruritus Abnormal hemostasis Abnormal hemostasis

33. Treatment 1. low protein, phos, & potassium diet 2. Daily fluid intake restriction 3. Low sodium intake such as ( chips) 4. Calcium supplement 5. anti- hypertension 6. blood transfusion 7. Human erythropoietin 8. Growth hormone may be given in some children 9. Dialysis 10. kidney transplant

34. Dialysis Patients with CRF eventually require dialysis Patients with CRF eventually require dialysis Diffuse harmful waste out of body Diffuse harmful waste out of body Control BP Control BP Keep safe level of chemicals in body Keep safe level of chemicals in body 2 types 2 types – Hemodialysis – Peritoneal dialysis

35. Hemodialysis 3-4 times a week 3-4 times a week Takes 2-4 hours Takes 2-4 hours Machine filters Machine filters blood and blood and returns it to returns it to body body

36. Peritoneal Dialysis Abdominal lining filters blood Abdominal lining filters blood types types – Continuous ambulatory – Intermittent

37. Thank you