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Pediatric Genitourinary Disorders

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Secondary reflux repeated UTI's cause scarring of valve ... Girls who have more than three UTI's, and boys with first UTI should be referred ... – PowerPoint PPT presentation

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Title: Pediatric Genitourinary Disorders


1
PediatricGenitourinary Disorders
2
Structural Defects
  • Exstrophy of the Bladder
  • Hypospadius / Epispadius

3
Bladder Exstrophy
  • The bladder wall extrudes through the abdominal
    wall.

p. 1630
4
Exstrophy of the Bladder
  • Treatment Surgical Reconstruction
  • Usually done 24 - 48 hours after birth
  • Goals
  • Bladder and abdominal wall closure
  • Preserve urinary function and continence
  • Creation of normal appearing genitalia
  • Improvement of sexual functioning

5
Exstrophy of the Bladder
  • Pre-op Nursing Care
  • Prevent infection and trauma to bladder
  • Nursing Interventions
  • Cover bladder mucosa with plastic dressing
  • Daily cleansing of skin around area

6
Exstrophy of the Bladder
  • Post-operative nursing care
  • Care of the surgical site
  • Observe for signs of obstruction
  • Positioning / alignment
  • Neurovascular assessment of lower extremities
  • Monitor renal function
  • Promote comfort
  • Discharge teaching

7
Hypospadias
Epispadias
8
  • Hypospadias
  • Congenital urethral defect in which
  • the uretheral opening is on the
  • lower aspect of the penis and not
  • on the tip.

9
  • Epispadias
  • Congenital urethral defect in which the uretheral
    opening is on the upper aspect of the penis and
    not on the end

10
Etiology and Pathophysiology
  • Epispadias rare and often associated with
    extrophy of bladder.
  • Hypospadias
  • Occurs from incomplete development of urethra in
    utero.
  • Occurs in 1 of 100 male children. Increased risk
    if father or siblings have defect.
  • Defect ranges from mild (meatus is just below
    tip) to meatus on the perineum between scrotum,
    ventral foreskin lacking
  • May have accompanying chordee (a fibrous band
    that causes the penis to curve downward),
  • Undescended testes found in conjunction with
    hypospadias
  • Might interfere with fertility in the mature male
    if not corrected.

11
Assessment
Usually discovered during Newborn
Physical Assessment
12
Ask Yourself?
  • Why would the nurse question an order to prepare
    the infant for a circumcision?

13
Answer
  • The nurse would question the order for a
    circumcision because the foreskin is used in
    reconstruction and repair of the defect.

14
  • What is the relation of epispadius or hypospadius
    to infertility?

15
Answer
  • If the urethral opening is not at the end of the
    penis, then the male will not be able to deposit
    his sperm at the opening of the os of the cervix.

16
Interventions
  • Medical Treatment
  • Surgery
  • Reconstructive repositions uretheral opening at
    tip of penis
  • Stent placed in urethra to maintain patency
  • Chordee released and urethra lengthened.

17
  • The reason for surgery at about 1 year of age is
    because
  • a. children will experience less pain
  • b. chordee may be reabsorbed
  • c. the child has not developed body image
  • and castration anxiety
  • d. the repair is easier before toilet training
  • C answer

18
Post op Nursing Care
  • 1. Assess bleeding - Bleeding is controlled
    post-operatively by the use of pressure
    dressings. However, a small amount of bleeding
    for the first several days post-operatively is
    normal. A few drops of blood or a spot no larger
    than a quarter on the diaper is acceptable.
  • 2. Maintain urinary drainage care for
    catheter foley / suprapubic, or urethral
    stent. Use double diapering see Teaching
    Highlights on p. 1632.
  • (see following slide)

19
A double diapering technique protects the urinary
stent after surgery. The inner diaper collects
stool and the outer diaper collects urine.
20
  • 3. Control Bladder Spasms - usually due to the
    presence of the in-dwelling catheters are common
    post-operatively and are controlled by
    medications that relax the bladder (ie.
    Antispasmotics- Pro-Banthine and Ditropan)
  • 4. Control Pain may be given Tylenol
  • 5. Increase fluids intake assists in
  • maintaining hydration and free flow of
    urine.
  • 6. Do not allow to play on any straddle toys.
  • 7. Prevent infection no bathing or swimming
    until
  • stents removed.
  • 8. Call Dr if
  • temp is over 101
  • loss of appetite
  • pus or increased bleeding from stent
  • cloudy or foul smelling urine

21
Obstructive Uropathy
22
Common Sites for Obstruction
  • Stenosis of ureteropelvic valve
  • Stenosis of ureterovescicular junction
  • Stenosis of the posterior urethral valve
  • (See page 1633)

23
Vesicoureteral Reflux
24
Pathophysiology
  • Reflux occurs because the valve that guards the
    entrance from the bladder to the ureter is
    defective from
  • Primary reflux congenital abnormal insertion of
    ureters into the bladder
  • Secondary reflux repeated UTIs cause scarring
    of valve
  • Bladder pressure that is stronger than usual,
    neurogenic bladder
  • Backflow happens at voiding when bladder
    contracts, urine is swept up the ureters
  • Results in stasis of urine in ureters or kidneys
    which in turn leads to infection or
    hydronephrosis.

25
Clinical Manifestations
  • Fever
  • Vomiting
  • Chills
  • Straining or crying on urination, poor urine
    stream,
  • Enuresis (bedwetting), incontinence in a toilet
    trained child, frequent urination.
  • Strong smelling urine
  • Abdominal or back/flank pain

26
Diagnostic Tests
  • Urine culture
  • done every 2-3 months
  • cystourethrogram
  • renal ultrasound - a non-invasive test in which a
    transducer is passed over the kidney producing
    sound waves which bounce off the kidney,
    transmitting a picture of the organ on a video
    screen. The test is used to determine the size
    and shape of the kidney, and to detect a mass,
    kidney stone, cyst, or other obstruction or
    abnormalities.

27
Therapeutic Interventions
  • Drug Therapy
  • Antibiotics
  • Penicillin
  • Cephalosporins
  • Urinary Antiseptics
  • Nitrofurantoin
  • Surgery
  • Repair of significant anatomical anomalies,
    uretheral implantation

28
Nursing Care
  • Keep accurate record of intake and output. Keep
    records from stents and catheter separate.
    Decreased output from stent could indicate
    obstruction.
  • Secure stents and catheter to prevent
    displacement.
  • Assess vital signs for signs of infection.
  • Assess pain. Handle child gently Administer
    pain medications
  • Patient Teaching
  • - regarding prevention of UTI,
  • - importance of taking all antibiotics,
    continue
  • taking antiseptics even when have no
    symptoms.

29
Evaluation
  • Follow-up
  • Go in for a VCUG (voiding cystourethrogram) after
    a few months

30
Urinary Tract Infection
31
Test Yourself
  • Which of the following organisms is the most
    common cause of UTI in children?
  • a. staphylococcus
  • b. klebsiella
  • c. pseudomonas
  • escherichia coli
  • All are causative agents, Escherichia coli is the
    more common cause of first time UTIs. (page
    1635.

32
Urinary Tract Infections
  • Etiology and Pathophysiology
  • Tend to occur more in girls than in boys because
    the urethra is shorter in girls and is located
    close to the vagina and anus.
  • Pathogens enter as an ascending infection
  • Most common causative organism is Escherichia coli

33
Assessment
  • Typical symptoms of older children and adults
    dysuria, frequency, urgency, burning,hematuria
    may not be present.
  • Symptoms not always clear
  • Fever
  • Mild abdominal pain
  • Bedwetting (enuresis)
  • If gets worse high fever, flank pain, vomiting,
    malaise

34
Diagnostic Tests
  • Urine for culture and sensitivity
  • Clean catch
  • Suprapubic aspiration
  • Catheterization
  • A Positive Test
  • Bacteria colony count is more than 100.000/ml.
  • Proteinuria may also be present indicating
    presence of bacteria.

35
Therapeutic Interventions
  • Drug Therapy
  • Antibiotics specific to causative organism
  • Analgesics Tylenol
  • Nursing Care
  • Force fluids childs choice
  • Dysuria sit in warm water in bathtub and void
    into the water

36
Therapeutic Interventions
  • Parent Teaching
  • Change diaper frequently
  • Teach girls to wipe front to back
  • Discourage bubble baths
  • Encourage children to drink periodically during
    the day
  • Bathe daily
  • Adolescent start menstruating encourage change
    of pad every 4 hours
  • When girls become sexually active teach to
    urinate immediately after intercourse

37
Evaluation
  • Follow up
  • Return for repeat urinalysis usually after 72
    hours of treatment to be sure treatment is
    working
  • Girls who have more than three UTIs, and boys
    with first UTI should be referred to urologist
    for further evaluation.

38
Enuresis
Repeated involuntary voiding by a child old
enough That bladder control is expected about
5-6 years of age
39
EnuresisMultitreatment Approach
  • Fluid Restriction
  • Bladder exercises
  • Timed voiding
  • Enuresis alarms
  • Reward system
  • Medications

40
Nephrotic Syndrome
41
Nephrotic Syndrome
  • chronic renal disorder in which the basement
    membrane
  • surfaces of the glomeruli are affected, causing
    loss of protein in the urine. The glomeruli
    membrane has increased permeability permitting
    albumin and protein to pass through the membrane
    and excreted in the urine.

42
Note the contrast between the normal glomerular
anatomy and the changes that exist in nephrotic
syndrome permitting protein to be excreted in the
urine.
43
Clinical Manifestations
  • Four most common characteristics
  • 1. Edema - May have periorbital edema
  • upon rising in morning and shifts
  • during the day.
  • 2. Massive proteinuria and hypoproteinemia
  • 3. Hypoalbuminemia
  • 4. Hyperlipidemia

44
Other signs and symptoms
  • Fatigue
  • Anorexia
  • weight gain
  • Abdominal pain from large amount of fluid in
    abdominal

45
Ask Yourself?
  • Which of the following signs and symptoms are
    characteristic of minimal change nephrotic
    syndrome?
  • a. gross hematuria, proteinuria, fever
  • b. hypertension, edema, fatigue
  • c. poor appetitie, proteinuria, edema
  • d. body image change, hypotension
  • Answer C

46
Diagnostic Tests
  • 1. Urinalysis protein-to-creatitine (PR/CR)
    ratio of
  • first morning void to assess for
    proteinuria. Urine
  • appears dark and frothy.
  • 2. Blood tests hypoalbuminemia, elevated
  • cholesterol and triglycerides,
    elevated hgb, hct,
  • platelets

47
Try this
  • Prednisone is the primary drug used in treating
    NS. What are the side effects and nursing
    implications?
  • What teaching should the nurse include with
    respect to this medication?

48
Answers
  • Nursing Implications related to Prednisone
    therapy
  • see drug guide on p. 1641.

49
Complications
  • Children with Nephrotic Syndrome are prone to
    infection related to
  • Loss of immunoglobins in the urine
  • Corticosteroid Therapy

50
Therapeutic Interventions
  • 1. Administer medications assess for side
    effects
  • Prednisone, Albumin,
  • 2. Prevention of infection avoid people with
    infections.
  • May be placed on protective isolation.
  • 3. Keep accurate record of IO. Measure
    abdominal girth, weigh daily.
  • 4.  Test urine for protein and specific gravity
    to see if treatment is effective
  • 5.  Diet
  • Normal diet for childs age
  • A no added salt diet is recommended during
    steroid treatment.
  • 6. Promote rest
  • 7. Discharge teaching

51
Acute Postinfectious Glomerulonephritis
52
Acute PostinfectiousGlomerulonephritis
  • Immune-complex disease which causes inflammation
    of the glomeruli of the kidney as a result of an
    infection elsewhere in the body.

53
Etiology and Pathophysiology
  • Usual organism is Group A beta-hemolytic
    streptococcus
  • Organism not found in kidney, but the
    antigen-antibody complexes become trapped in the
    membrane of the glomeruli causing inflammation,
    obstruction and edema in kidney
  • The glomeruli become inflamed
  • and scarred, and slowly lose their
  • ability to remove wastes and excess
  • water from the blood to make urine.

54
Acute Glomerulonephritis
55
  • Decreased glomerular filtration leads to
    accumulation of sodium and water in bloodstream
    causing increased intravascular and interstitial
    fluid volume, or edema
  • Protein molecules filter through the damaged
    glomeruli proteinuria
  • Damage to glomeruli leads to hematuria.
  • High B/P, Heart failure may result
  • Common in boy 5-10 years old. Occurs 1-2 weeks
    after a respiratory infection or after impetigo.
  • Has 2 phases
  • Edematous phase 4-10 days
  • Diuresis phase

56
Assessment
  • 1. Renal
  • a. Moderate Proteinuria
  • b. Sudden onset of hematuria (tea-colored,
    reddish-brown, or smoky) and next develops
    oliguria
  • c. Excessive foaming of urine
  • 2. Cardiovascular
  • a.  Edema-usually eyes, hands, feet, not
    generalized
  • b.  Hypertension from hypervolemia which can lead
    to
  • c.  Cardiac involvement CHF- orthopnea / dyspnea,
  • cardiac enlargement, pulmonary edema
  • 3.Neuro
  • a. Encephalopathy (headache, irritability,
  • convulsions, coma-from cerebral
    edema)

57
Test Yourself
  • A 6 year old is admitted with R/O AGN which of
    the following symptoms is the child most likely
    have?
  • a. normal blood pressure, diarrhea
  • b. periorbital edema, grossly bloody urine
  • c. severe, generalized edema, ascites
  • d. severe flank pain, vomiting

58
Diagnostic Tests
  • Urinalysis- protein (moderate), RBC's, WBC's,
    Specific Gravity elevated.
  • All children should have a urinalysis 2 wks
    after strep infection.
  • Blood-
  • 1)     ASO titer (antistreptolysin O) (antibody
    formation against Streptococcus) is elevated,
    indicating a recent hemolytic streptococcal
    infection Normal titer is 170-330 Todd units IgG
    antibodies against Streptococcus may be found
  • 2)     ESR (erythrocyte sedimentation rate)
    elevated showing inflammatory process
  • 3)     BUN(urea nitrogen) creatinine elevated
    indicating glomeruli damage

59
Therapeutic Interventions
  • 1. Depends on the severity of the disease.
    No
  • specific treatment. Bedrest encouraged.
    Disease
  • is self-limiting!
  • 2. Treat at home if normal BP adequate
    output.
  • 3. Must be hospitalized if
  • BP increases
  • gross hematuria
  • oliguria present.
  • This way the child can be monitored closely
    and prevent complications. Rarely develops into
    acute renal failure

60
Main Goals Relieve Hypertension
Reestablish fluid and electrolyte balance by
  • Keep accurate record of IO. Be sure that child
  • does not exceed maximum intake ordered.
  • Record characteristics of urine output including
  • presence of proteinuria and hematuria.
  • Check and record specific gravity with each
    voiding
  • Monitor vital signs and neuro vital signs
  • Monitor and record amount of edema at least once
  • a shift.

61
  • Daily weights
  • Bedrest for 4-10 days during acute phase.
    Semi-fowlers position to assist with breathing.
    Quiet play.
  • Oxygen therpay
  • Diet therapy
  • Limit salt intake with hypertension or edema
  • Limit protein if BUN elevated
  • Decrease intake of Potassium if output decreased
  • Drug therapy
  • Antibiotics
  • Digiiiitalization
  • Antihypertensives- vasodilators

62
Critical Thinking
  • With a diagnosis of AGN, which of these nursing
    diagnoses should receive priority?
  • a. fluid volume excess
  • b. risk for impaired skin integrity
  • c. risk for injury
  • d. activity intolerance

63
Critical Thinking
  • When teaching parents about known
  • antecedent infections in acute
  • glomerulonephritis, which of the following
  • should the nurse cover?
  • A. Herpes simplex
  • B. Scabies
  • C. Varicella
  • D. Impetigo

64
Cryptorchidism
  • Failure of one or both of the testes to descend
    from abdominal cavity to the scrotum

65
Etiology and Pathophysiology
  • Testes usually descend into the scrotal sac
    during the 7-9 month gestation
  • They may descend anytime up to 6 weeks after
    birth. Rarely descend after that time.
  • Cause unknown
  • Theories
  • Inadequate length of spermatic vessels
  • Lowered testosterone levels

66
Why is it important that the testes are in the
scrotal sac?
67
Answer
  • The higher temperatures in the abdomen than in
    the scrotum results in morphologic changes to the
    testis mainly concerned with lower sperm counts
    at sexual maturity.

68
Assessment
Diagnosed on Newborn Physical Exam
Palpate the testes separately between thumb and
forefinger, with thumb and forefinger of other
hand over the inguinal canal.
69
Therapeutic Interventions
  • Surgery
  • Orchiopexy done via laproscopy
  • Done around 1 year of age
  • Nursing Care Post-op
  • Minimal activity for few day to ensure that the
    internal sutures remain intact
  • Allow opportunity to express fears about
    mutilation or castration by playing with puppets
    or dolls.

70
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