1. Nursing care of children with altered genitourinary function Dr. Manal Kloub

2. Outline Introduction Nursing assessment Diagnostic tests Congenital anomalies of genitourinary function (hypospadias, epispadias) Urinary tract infection Acute glomerulonephritis Nephrotic syndrome Renal failure

3. Introduction The kidneys are essentially regulatory organs which maintain the volume and composition of body fluid by filtration of the blood and selective reabsorption or secretion of filtered solutes.

5. Alterations in Renal Function

6. Introduction Urinary tract is a sterile system, the slightly acidic urine creates hostile environment for most alkaline microorganisms First line of defense is expulsion via bladder flushing or increase frequent voiding

7. N  The Glomerular Filtrate rate(GFR) is the rate at which substances are filtered from the blood to the urine.Usually it is ( 120 ml/min) blood at the end confirmed to urine tubule excreted rate 1ml/min * Urine amount depend on the :fluid intake,kidney function and age  urine normally execrated ( urea, ammonia & creatinine)  if kidney disease we can found. 1.albumin 2. sugar 3. blood 4. casts 5. bile pigments

8. Developmental and Biological Variances All nephrons are present at birth Kidneys and tubular system mature throughout childhood reaching full maturity during adolescence. During first two years of life kidney function is less efficient.

9. Renal development in early Infancy Develop first weeks of embryonic life but not completed until the end of the first year after birth. Nephrones are immature and less efficient than later ages Glomerular filtration and absorption are relatively low and do not reach adult values until 2 years/old The loop of Henle is short which reduces the ability to reabsorb sodium and water therefore produce very dilute urine. Urea synthesis & excretion are slower so new born retain large quantities of nitrogen 24 hrs urine volume is low but it rapidly& steadily increase with normal growth.

10. Bladder Bladder capacity increases with age 20 to 50 ml at birth 700 ml in adulthood

11. Urinary Output Urinary output per kilogram of body weight decreases as child ages because the kidneys become more efficient. Infants1-2 mL/kg/hr Children0.5 – 1 mL/kg/hr Adolescents40 – 80 mL/hr

12. Clinical manifestation Depends on the age and maturation of the child In newborn urinary tract disorders are associated with a number of malformation as low set ears and urinary tract anomalies

13. Clinical manifestation  Neonatal period / birth to 1 month). Poor feeding Vomiting Failure to gain weight Rapid respiration ( because of acidosis ) Respiratory distress Spontaneous pneumothorax Frequent urination

14. Clinical manifestation Neonatal period / birth to 1 month). Screaming on urination Poor urine stream Dehydration Other anomalies By ultrasound : enlarged kidney or bladder

15. Clinical manifestation From 1- 24 months Poor feeding Vomiting Failure to gain weight Excessive thirst Frequent urination Straining or screaming on urination Foul –smelling urine

16. Clinical manifestation From 1- 24 months continued Pallor Fever Persistent diaper rash Seizers ( with or without fever ) Dehydration Enlarged kidney or bladder

17. Clinical manifestation Childhood period ( 2-14 year)  Vomiting  Growth failure  Excessive thirst  Enuresis, incontinence, frequent urination  painful urination  Swelling of face  Seizures  Pallor,fatigue,blood in urine  Abdominal or back pain  Edema,hypertension,tetany

18. A Childe average UOP /24hr AgeAmount (ml) 6month - 2 years540-600 2-5 years500-780 5-8 years600-1.200 8-14years1.000-1.500 Over 14 years1500 and more

19. Diagnostic test: 1 Urine Analysis Normal urine analysis finding ColorPale yellow Appearanceclear PH4.6-8 Specific gravity1.003-1.030 ProteinZero RBC & WBCLess than 1

20. 2. Creatinine Clearance Rate (CCR) depends on GFR – it is measured by the amount of creatinine excreted in 24 hrs in the urine normal CCR 100ml/min A venous blood sample is taken during 24 hrs period and compared with the urine findings Normal urine creatinine 0.7-1.5 mg/100ml and the serum creatinine rarely exceeds 1mg/ dl 3. Urine culture 4. Blood studies ( BUN 5- 20mg/100ml)

21. Diagnostic test 5. X-ray studies a. KUB ( Kidney,Ureter,Bladder ) b. Intravenous pyelogram (IVP) study the upper urinary tract c. Voiding Cystourthrogram (VCUG) study the lower urinary tract 6.Cystoscopy: direct examination of bladder and Ureter with cyst scope introduced to the urethra 7. Renal Biopsy 8. CT scan 9. Renal angiography

22. VCUG

23. IVP

24. Intra Venous Pyelogram Kidney function analyzed Watch for allergic reaction to dye.

25. Renal Biopsy

26. Cystoscopy

27. CT Scan

28. Structural Abnormality of the Urinary Tract 1 Hypospadias. urethral defect in which urethral opening is not at the end of the penis but on the ventral ( lower ) aspect of the penis. It is fairly common occur in 1-300 male newborn Epispadias : It is similar defect in which the opining is one the dorsal surface of the penis.

29. Hypospadias

30. Tight Chordee

31. Structural Abnormality of the Urinary Tract 2 Assessment chordee ( fiber band that causes the penis to curve down ward) Undescending test ( cryptorchidism)

32. Therapeutic treatment 3  Males with hypospadias shouldn’t be circumcised  A meatotomy – a surgical procedure to extend the urethra to a normal position  at age 12-13 months adherent chordee may be released. The surgery may be delayed until age 3-4 y after surgery keep folly's catheter for ( 3- 7days).  Testosterone cream to encourage penis growth to make the procedure easy. or receive daily testosterone injections.  - If left uncorrected infertility

33. Hypospadias Repair

34. Cryptorchidism Hidden testicle 3 to 5% of males High incidence in premature infants Goals of treatment:  Preserve testicular function  Normal scrotal appearance

35. Multidisciplinary Interventions Most testes spontaneously descend. Surgical procedure, orchiopexy, if testicles do not descend into the scrotal sac by 6 to 12 months of age Hormone therapy – human chorionic gondadotropin Slightly higher risk of testicular cancer if untreated In the teen or adult the testicle would be removed

36. Testicular Exam Monthly testicular self-examination is recommended for all males beginning in puberty, but is essential in males with history of undescended testicle.

37. Urinary Tract Infections UTI 1 Description Bacterial colonization of urine or bacterial invasion of any structural component of urinary tract ( Symptomatic, Asymptomatic ). Cystitis : the most common type of urinary tract infection (UTI) is infection to the bladder Urethritis : inflammation of the urethra Pyelonephritis : inflammation of the upper urinary tract and kidney

38. Urinary Tract Infections UTI 1 Bacteria reach parenchyma either by the ascending route from the bladder hematogenous seeding from a bacteremia Urosepsis : febrile urinary tract infection coexisting with systematic signs of bacterial illness. Blood culture reveals presence of urinary pathogens.

39. Etiology Escherichia coli which found in the GI tract is the responsible bacteria for 80-90% of pediatric UTI Gram positive organisms 10-15% Viruses infrequently may cause UTI associated with hemorrhagic cystitis. Candida species with immuno compromised patients

40. Risk factors Female gender Uncircumcised male Family history of vesicoureteral Reflux (VUR) Neurogenic bladar Urinary tract malformation ( strictures, posterior urethral valves,calculi) Chronic constipation Poor hygiene Catheterization of the urinary tract

41. Assessments Newborn s have non-specific symptoms fever, anorexia,Jaundice frequently leading to sepsis Infants toddlers and preschoolers have specific symptoms as fever, vomiting diarrhea and abdominal pain Children and adolescents have more classic adult symptoms a. Cystitis : frequency, urgency, dysuria, b. Pyelonephritis : fever,flank pain,costovertebral angle (CVA) tenderness c. History of prior UTI

42. Diagnostic tests Urine analysis and culture. First morning specimen is preferable because bacterial count decrease with hydration during the day Suprapubic aspiration ( in children younger than 2 years ) IVP, Scan.

43. Treatment The objectives are : 1. To eliminate current infection 2. To identify contributing factors to reduce the risk of recurrence 3. To prevent systematic spread of the infection 4. To preserve renal function

44. Treatment Antibiotic therapy third generation cephalosporin recommended 10 days for uncomplicated UTI /cystsis and 14 for pyelonephritis ( usually need hospitalization ) Repeated urine specimen should be collected 72hours after initiation of medication (3 urine specimens must be obtained to prove the absence of bacteria). Surgical correction of anatomic defect as primary reflux or bladder neck obstruction to prevent recurrent infection Cranberry juice to make urine more acidic

45. Nursing interventions Adherence to full course of the antibiotic therapy Increased fluid intake: up to 1000 cc for the older child to dilute and washed out endotoxins and tissue debris Give mild analgesic such as acetaminophen Bladder irritants such as chocolate and caffeine rich should be avoided Bathtub of warm water if there is any pain during urination

46. Nursing interventions IV therapy: nursing care directed toward V/S, intake and output monitoring Make urine analysis to be sure there is no UTI Urge to urinate every 4hr to prevent urine stasis Wear cotton underwear Child and family teaching include aspects of disease progression and management, handling of medication

47. Acute Glomerulonephritis  The glomeruli become inflamed and impair the kidney's ability to filter urine  Tissue damage result from immune complex and glomerular deposition.  Ischemic change –lead to decrease GFR –increased Na & water retention and allow protein to be filter

48. Causes  It may primary event or manifestation of systematic disorder such as 1. Systemic lupus erythematosus (SLE). 2. Henoch-Schönlein purpura 3. Sickle cell Anemia 4. Polyarteritis 5. Bacterial endocarditis  Disease can be range from minimum to sever

49. Post-Infectious Glomerulonephritis It is the most common form of glomerulonephritis in children A common cause is from a streptococcal infection, such as upper respiratory infection. Usually from group A beta-hemolytic streptococci

50. Post-Infectious Glomerulonephritis Usually occurs more than one week after an infection and referred to as acute post-streptococcal glomerulonephritis, APSGN The post-streptococcal glomerulonephritis is primarily a disease of children, 6 to 7 years of age The onset is usually abrupt, with a latent period of 10 to 14 days between infection of the throat and the development of clinical manifestations

51. Common initial clinical manifestations of post- streptococcal glomerulonephritis Hematuria Edema Hypertension Oliguria Proteinuria

52. Generally, Symptoms may include Dark brown-colored urine (from blood and protein) Sore throat Diminished urine output Fatigue Lethargy Increased breathing effort Headache High blood pressure Joint pain

53. Symptoms Seizures (may occur as a result of high blood pressure) ECG changes (T wave inverted, prolonged P-R interval Pale skin color Fluid accumulation in the tissues (Periorbital edema)

54. Diagnosis Thorough physical examination Complete medical history Urine tests (reveal hematuria, proteinurea, increased specific gravity). Blood tests reveal 1. Normal electrolytes & co 2 level 2. elevated blood urea nitrogen (Azotemia)& creatinine level. Electrocardiogram (ECG) - to detects heart muscle damage

55. Diagnosis Serological tests : Antibody responses to previous streptococcal infection such as 1. ASO titer, streptokinase. 2. Serum complement level (C 3 ) it is decreased initially and returns to normal 8 to 10 weeks after the onset). Chest x-ray Renal biopsy

56. Treatment Antibiotics if glomerulonephritis is caused by a streptococcal infection Fluid restriction Decreased protein diet Decreased salt and potassium diet If heart failure occur 1. put the child in semi fowler’s position 2. digitalization 3. O2 therapy

57. Treatment Medication, such as : 1. Diuretics :Lasix helpful for edema 2. Antihypertensive drugs if DBP rise to more than 90mmhg 3. Anticonvulsant therapy for seizures 4. Phosphate binders - medications to decrease the amount of the mineral phosphorus in the blood Dialysis: used for short-term or long-term therapy to remove wastes and additional fluid from the blood after the kidneys have stopped functioning

58. Nursing Care Management Regular monitoring for V/S including BP The volume and Characteristics of urine are noted Monitor any signs of cerebral complication Body wt daily and closed monitor I&O. Bed rest with quiet play activities Diet ( low salt, protein ) Follow up visits and evaluation In most patients hematuria disappears by 6 months but proteinuria may persist for a years in a third of patients which frightening the parents

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