Caring for the Child with a Renal, Urinary Tract, or Reproductive Condition - PowerPoint PPT Presentation

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Caring for the Child with a Renal, Urinary Tract, or Reproductive Condition


Chapter 32 Caring for the Child with a Renal, Urinary Tract, or Reproductive Condition – PowerPoint PPT presentation

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Title: Caring for the Child with a Renal, Urinary Tract, or Reproductive Condition

Chapter 32
  • Caring for the Child with a Renal, Urinary Tract,
    or Reproductive Condition

A P Review
  • Outer cortex
  • Composed of the glomeruli and convoluted tubules
    of the nephron and blood vessels
  • Inner medulla
  • Composed of the renal pyramid

Fluid and Electrolyte Balance
  • Compared to adults, children are at a greater
    risk for fluid and electrolyte imbalance.
    Children have
  • A proportionately greater amount of body water
  • Require more fluid intake and subsequently
    excrete more fluid
  • A greater body surface area and a higher
    percentage of total body water
  • A greater potential for fluid loss via the
    gastrointestinal tract and skin
  • An increased incidence of fever, upper
    respiratory infections, and gastroenteritis
  • A greater metabolic rate
  • Immature kidneys that are inefficient at
    excreting waste products
  • Kidneys that have a decreased ability to
    concentrate urine
  • Increased risk for developing hypernatremia based
    on their inability to verbalize thirst

Calculation of Daily Maintenance Fluid
  • There are two methods of fluid maintenance.
  • The surface area method is the most common and is
    used for
  • children gt22 lb (10 kg) 15002000 mL/m2 per day
  • Childs Weight Daily
    Maintenance Fluid Requirement
  • 010 kg (022 lbs) 100 mL/kg of
    body weight
  • 1120 kg (24.244lbs) 1000 mL 50
    mL/kg for each kg gt10
  • gt20 kg (gt44 lbs) 1500 mL
    20 mL/kg for each kg gt20
  • Note The method used to measure normal urinary
    output is 12 mL/kg per hour.

Types of Dehydration
  • Isotonic
  • Dehydration occurs when electrolyte and water
    deficits are present in balanced proportions
    (sodium and water are lost in equal amounts).
  • Serum sodium remains in normal limits of 130150
  • This is the most common type of dehydration.
    Hypovolemic shock is the greatest concern.
  • Hypotonic
  • Dehydration occurs when the electrolyte deficit
    exceeds the water deficit.
  • The serum sodium concentration is lt130 mEq/L.
  • Physical signs are more severe with smaller fluid
  • Hypertonic
  • Dehydration is the most dangerous type and occurs
    when water loss is in excess of electrolyte loss.
  • The sodium serum concentration is gt150 mEq/L.
  • Seizures are likely to occur.

Nursing Care
  • Obtain daily weights
  • Measure intake and output
  • Assess hydration status
  • Laboratory tests include specific gravity,
    hematocrit, blood urea nitrogen (BUN),
    creatinine, Na, K and CA
  • Assess type of acid-base disturbance
  • Administer oral clear liquids as ordered (12 oz
    every hour)
  • Start an IV for fluid and electrolyte replacement
    as ordered
  • Ensure that the child has voided prior to
    administering intravenous Potassium (K)
  • Cleanse perineal area and apply protective
    topical ointment
  • Encourage parents to be involved in the care of
  • Educate parents about signs and symptoms of
    dehydration, re-hydration, and when to call the
  • Encourage parents to be compliant with follow-up

Disorders of the Renal and Urinary Systems
Urinary Tract Infections
  • Signs and symptoms
  • School-age new enuresis, strong-smelling urine,
    urgency, flank pain, and changes of personality
  • Nursing care
  • Collaborate with patient, family, and health care
  • Explain treatment process to family
  • Obtain history
  • Administer IV fluids
  • Administer oral or IV antibiotics
  • Keep track of intake and output and odors

Vesicoureteral Reflux (VUR)
  • Signs and symptoms
  • Recurrent UTI, flank pain, abdominal pain, and
  • Nursing care
  • Surgery (reimplanting the ureter)
  • Medical management (antibiotics and
    anticholinergic agents)
  • Educate the parents about signs and symptoms of
    UTI and the importance of medication
  • Postsurgicalmanage intake and output, pain
    control and infection

Unexplained Proteinuria
  • Signs and symptoms
  • Positive proteinuria by dipstick
  • Nursing care
  • Outpatient settinginstruct parent how to obtain
    a first-morning voided specimen
  • Educate parents about other urological tests
  • Reinforce proper follow-up care

  • Signs and symptoms
  • Blood in the urine
  • Nursing care
  • Educate parents and child about laboratory and
    procedural tests
  • Explain cause of hematuria
  • Educate parents and child about proper techniques
    of collecting a urine specimen
  • Test urine with a dipstick

Post-Streptococcal Glomerulonephritis
  • Signs and symptoms
  • Gross hematuria, either tea- or coffee-colored
    urine, periorbital edema
  • Nursing care
  • Give antibiotic therapy
  • Monitor fluid intake and output
  • Administer diuretic medications and
    antihypertension drugs
  • Teach family that severe glomerulonephritis may
    require peritoneal dialysis or hemodialysis
  • Support family
  • Assess child pharynx and upper respiratory tract
    for signs of acute infection
  • Obtain a streptococcal culture (rapid or full
    streptococcal culture)
  • Monitor for hypertension and urinary output
  • Asses for risk of renal failure
  • Educate parents about dietary restrictions
    (sodium, potassium, and fluid intake)

Hemolytic Uremic Syndrome
  • Signs and symptoms
  • Gastroenteritis (diarrhea and vomiting), as well
    as upper respiratory tract infection
  • Triadthrombocytopenia, anemia, and acute renal
    failure (pallor, lethargy, anorexia, anemia, and
  • Nursing care
  • Tell family that child may be in the intensive
    care unit
  • Monitor intake and output, LOC, signs of ICP,
    CHF, bleeding, and hypertension
  • Monitor daily weights, electrolyte imbalances,
    and arterial blood gas
  • Assess BUN and creatinine (renal status
  • Assess lungs for CHF
  • Assess peripheral and periorbital edema
  • Monitor vital signs
  • Tell family that electrocardiographic monitoring
    is recommended
  • Understand that antibiotics are contraindicated

Henoch-Schonlein Purpura (HSP)
  • Signs and symptoms
  • Hematuria and hypertension, bloody diarrhea,
    crampy abdominal pain, purpural rash
  • Joint pain and swelling, scrotal swelling
  • Nursing care
  • Administer corticosteroids
  • Discuss immunosuppressant medications and
    possibility of renal transplant
  • Monitor for signs of bleeding, pallor, vital sign
    alterations, abdominal pain, oliguria, and urine

Chronic Glomerulonephritis
  • Signs and symptoms
  • Decreased urine output, high blood pressure,
    headaches, and other signs of fluid overload
  • Nursing care
  • Manage diet (restrict salt and fluid with
    low-potassium foods)
  • Plasma exchange may be instituted in severe cases
  • If hypertension is present, give diuretics
  • Carefully monitor urine output, weight, and
    abdominal girth
  • Monitor for complications
  • Develop trusting, supportive, developmentally
    appropriate relationships
  • Educate family that long-term follow-up includes
  • Note that care is similar to that of acute and
    chronic renal failure
  • If renal failure occurs, prepare for dialysis and
    renal transplant

Structural Defects of the Urinary System
Renal Trauma
  • Signs and symptoms
  • Flank tenderness, hematoma, a palpable mass, and
    other symptoms related to abdominal injury
  • Nursing care
  • Follow advanced trauma life-support guidelines
  • If bruising without any urinary extravasationis
    found, ensure bedrest, analgesia, and
    prophylactic grades IV and V require referral to
    an urologist
  • Gather detailed history of problem
  • Perform nursing assessment, physical examination,
    and gather crucial information
  • Surgery may be required (prepare child and
  • After surgery, monitor vital signs, urinary,
    respiratory, cardiac, GI status, and surgical
  • Monitor intake and output, weight, abdominal
    girth, administer IV fluids, and manage pain
  • Report signs of renal perfusion
  • Address psychosocial care

Acute Renal Failure (ARF)
  • Signs and symptoms
  • Fever, rash, bloody diarrhea, pallor, vomiting,
    diarrhea, abdominal pain, hemorrhage, shock,
    anuria, or polyuria
  • Nursing care
  • Support parents
  • Administer medications
  • Monitor nutritional intake and fluid intake and
  • Collaborate with health care team to prevent

Chronic Renal Failure
  • Signs and symptoms
  • Similar to those of acute renal failurefever,
    rash, bloody diarrhea, pallor, vomiting,
    abdominal pain, hemorrhage, shock, anuria or
  • Nursing care
  • Obtain history
  • Obtain laboratory results
  • Give medications
  • Goals are mutually established with the patient
    and family
  • Collaborate with health care team
  • Facilitate care with nutritionists who will
    assist with meals
  • Facilitate pastoral care
  • Understand that nursing care is based on
    multisystem organ failure
  • Provide patient teaching and referral to support

Dialysis in Pediatric Nursing
Peritoneal Dialysis
  • Peritoneal dialysis (the process of dialysis uses
    the peritoneal membrane to filter blood and
    purify it)
  • Nursing care
  • Assist parents in learning peritoneal dialysis
  • Monitor for peritonitis (antibiotics,
    hospitalization, and follow-up)
  • Monitor abdominal catheter site for signs of
    infection or malfunctioning equipment
  • Make certain that the returning dialysate
    solution remains clear

  • Hemodialysis is dialysis through the blood, using
    a special machine. Children must be hemodialyzed
    three times a week at a dialysis center
  • Signs and symptoms
  • At the onset, a child may experience several side
    effects hypotension, dizziness, nausea, or
    muscle cramps.
  • Nursing care
  • Educate parents on how to keep the AV fistula
    site clean and safe
  • No jewelry near access site
  • No blood pressure on that arm
  • Avoid carrying heavy objects, sleeping with arm
    under head or body
  • Check pulse at the site daily
  • Promote lifelong coping skills

Renal Transplantation
  • Renal transplants are received from donors
  • Children are maintained on dialysis until a
    kidney is available
  • Children who receive a transplant are usually in
    end-stage renal disease
  • Children receiving transplant must not be
  • Nursing care
  • Instruct family about long-term medications that
    prevent rejectioncyclosporine and steroids
  • Give antihypertensive and diuretic medication as
  • Ensure a protein-restricted diet
  • Facilitate care by accessing other members of the
    health care team

Functional Disorders of the Urinary Tract
Dysfunctional Elimination Syndrome/Voiding
  • Signs and symptoms
  • Frequency, urinary incontinence, and urgency
  • Nursing care
  • Ask child about voiding
  • Monitor stool elimination (maintain a normal
    bowel routine)
  • Assess for emotional or social problems
  • Teach girls with an inflamed perineum that they
    can take baking soda sitz baths and use barrier
  • Promote adequate water intake
  • Administer antibiotics (treatment and prophylaxis)

  • Signs and symptoms
  • Primary nocturnal enuresis (PNE)
  • Do not awaken in response to a full bladder
  • Secondary nocturnal enuresis (SNE)
  • UTIs, constipation, diabetes mellitus,
    obstructive sleep apnea, psychological stress,
    and urge syndrome with dysfunctional voiding
  • Nursing care
  • Administer medications
  • Desmopressin (DDAVP)
  • Imipramine (Tofranil)
  • Educate parents about developmental stage and
    child who is a deep sleeper
  • Teach parents about avoidance of fluids close to
  • Teach parents to use reward charts
  • Teach parents that commercial items are available
  • Teach parents about behavioral treatment
    (battery-operated bed-wetting alarm)

Exostrophy of the Bladder
  • Signs and symptoms
  • Visualization that the bladder is open on the
    abdominal wall
  • Nursing care
  • Surgery necessary within the first 48 hours of
  • Presurgical psychological and medical preparation
  • Postsurgical care
  • Keep area clean
  • Teach caregiver that diaper should be loose
    fitted and changed frequently

Reproductive Disorders Affecting Girls
  • Signs and symptoms
  • Vulvar itching
  • Vaginal candidiasis has thick curdy white
    discharge and is pruritic and foul-smelling
    (brown or green)
  • Nursing care
  • Teach young girls to avoid predisposing factors
  • Teach young girls about over-the-counter
    antifungal remedies applied topically
  • Instruct young girls to wipe from the front to
    the back after voiding
  • Educate patients about complementary treatments

Labial Adhesions
  • Signs and symptoms
  • Thin film develops over the labia
  • Nursing care
  • Communicate that spontaneous resolution may occur
    over time
  • Teach family about lysis of adhesions
  • Treat with hormone cream
  • Inform family that complications may include UTI

  • Signs and symptoms
  • Primary amenorrheadelayed puberty
  • Secondary amenorrheas/s of pregnancy
  • Hypothyroidismdry skin, dry hair, fatigue,
    hoarseness, constipation, and enlarged thyroid
  • Hyperthyroidismoily skin and hair, diaphoresis,
    tachycardia, diarrhea, and a goiter
  • Polycystic ovarian syndromeexcessive hair and
  • Corpus luteum cystspain in lower quadrants
  • Nursing care
  • Educate about pregnancy
  • Assist with constructing a calendar depicting
    abnormal menstrual pattern
  • Assess eating disorders and excessive exercise
  • Assess family members who experienced amenorrhea

Reproductive Disorders Affecting Boys
  • Signs and symptoms
  • Feel like a bag of worms
  • Distended veins in the scrotum on standing
  • Accentuation of the veins with the Valsalva
  • Decrease in visibility of the varicocele when
    in the supine position
  • Small testes
  • Nursing care
  • Surgical ligation
  • Postsurgical nursing care

  • Signs and symptoms
  • A retractile testis has descended but retracts
    with exam and physical stimulation
  • An ectopic testes is outside of the normal
  • Nursing care
  • Surgical repair orchiopexy done between ages 1
    and 2
  • Instruct caregiver to have the child wear loose
    clothing and use analgesics as ordered
  • Instruct caregiver to observe for erythema,
    purulent discharge, fever, and increased pain at
    the incision site (indicative of infection)
  • Instruct caregiver to change diapers more
    frequently and avoid having the older child
    engage in sports or straddle riding toys that
    might injure the surgical site

Hypospadias and Epispadias
  • Signs and symptoms
  • Hypospadiasopening of urethra below the tip on
    the bottom side of the penis
  • Epispadiasopening of the urethra above the tip
    of the penis
  • Nursing care
  • Surgery performed before 18 months and before
    toilet training (urethral stent, Foley catheter
    in place, and compression dressing applied)
  • Instruct parents to have the child soak in warm
    water for 20 minutes before the surgical
    follow-up appointment (loosen the dressing)
  • Assess for postsurgical complications
  • Monitor for signs of infection
  • Watch for evidence of UTI
  • Assess pain (oxybutynin chloride relieves bladder
  • Assess parents knowledge deficit and feelings

Testicular Torsion
  • Signs and symptoms
  • Neonatescrotum appears dusky colored, a solid
    mass is palpated, scrotal edema, and minimal pain
  • Older malessevere and persistent pain
  • Nursing care
  • Surgery within 48 hours
  • Postoperative care

Reproductive Disorders Affecting Both Girls Boys
Ambiguous Genitalia
  • Signs and symptoms
  • External reproductive organs not easily
    identified as male or female
  • Nursing care
  • Discuss endocrinology and genetic referrals
  • Surgery
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