DISORDERS OF THE GENITO

January 29, 2018 | Author: Anonymous | Category: Science, Health Science, Urology
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Aim

To show an in-depth understanding of the genito-urinary disorders in children and the process of care in the nursing management

By the end of this session, the student should be able to:  Understand the anatomy and physiology of the renal system and structure and function  Identify the differences between adult and children GU system  Describe the most common diagnostic investigations and procedures for GU disorders

 Understand the general assessment of children with

genitourinary disorders  Understand the common genitourinary disorders in children  Plan the nursing management for children with GU disorders

 Begins during 1st week of gestation  Completed by end of 1st year after birth  Excretion less than adult  By the age of 6 to 12 months, filtration and

absorption is nearly like adults  For healthy infant, the kidneys operate at a functional level appropriate for the size of the body.

Nephron  



Glomeruli – filter water and solutes from blood Tubules – reabsorb needed substances (water, protein, electrolytes, glucose, amino acids) from filtrate and allow unneeded substances to leave the body in urine Urine formed in the nephron, passes into renal pelvis, through ureter into bladder and out of body through urethra

Urine formed in the nephron, passes into renal pelvis, through ureter into bladder and out of body through urethra

Glomeruli : filter water and solutes from blood

Tubules : reabsorb needed substances (water, protein, electrolytes, glucose, amino acids) from filtrate and allow unneeded substances to leave the body in urine

 Maintaining body fluid volume and

composition

 Secretes hormones: Renin

– helps with the regulation of blood pressure  Erythropoietin – stimulates red blood cell production by the bone marrow  Metabolised Vitamin D – responsible for calcium metabolism

 Urinalysis  CT Scan- an x-ray procedure that combines many

x-ray images with the aid of a computer to generate cross-sectional views and, if needed, three-dimensional images of the internal organs and structures of the body.



gross indicator of renal function



(BUN) test measures the amount of nitrogen in blood that comes from the waste product urea.



Urea is made when protein is broken down in body.



Blood urea nitrogen (BUN) and creatinine tests can be used together to find the BUN-tocreatinine ratio (BUN:creatinine). body in the urine.



A blood urea nitrogen (BUN) test is done to determine : 

kidneys are working normally.



kidney disease is getting worse.



See if treatment of kidney disease is working.



See if severe dehydration is present. Dehydration generally causes BUN levels to rise more than creatinine levels. This causes a high BUN-to-creatinine ratio. Kidney disease or blockage of the flow of urine from kidney causes both BUN and creatinine levels to go up.

 KUB (Kidney, Ureter, Bladder) x-ray  Renal Biopsy

Renal Ultrasound

An injection of x-ray contrast media via a needle or cannula into the vein, typically in the arm. The contrast is excreted or removed from the bloodstream via the kidneys, and the contrast media becomes visible on x-rays almost immediately after injection

 a urologic procedure where the physician

injects contrast into the ureter in order to visualize the ureter and kidney.

 Micturating Cystourethrography (MCUG) – serial

x-ray of the bladder and urethra after IV infusion of iodine-bound contrast medium ( to detect blockage)

 Urinary tract infection (UTI)  Nephrotic syndrome  Acute Post-Streptococcal

Glomerulonephritis (APSGN)  Vesicoureteral reflux  Hypospadias

Definition  UTI is the presence of bacteria in the urine  Infection usually occur at the upper urinary tract or at the lower urinary tract Incidence  Common age of onset for UTI is 2-6 years  Girl>Boy - Female has shorter urethra  Uncircumcised male prone to develop UTI

 Causative organisms – E. Coli

 Route of entry -bacteria ascending from the 

 



area outside of the urethra. Vesico-ureteral reflux Infections – URTI, GE Poor perineal hygiene - fecal organisms are the most common infecting organisms due to the proximity of the rectum to the urethra. Short female urethra

 Urethritis – infection of the urethra  Cystitis – an infection in the bladder

that has moved up from the urethra

 Pyelonephritis – a urinary infection

of the kidney as a result of an infection in the urinary tract

Unexplained fever (febrile fits)

Abdominal pain

Poor growth

Foul-smelling urine

Irritability

Poor feeding Vomiting

Weight loss (failure to weight gain)

 Urinary  

  

frequency/urgency Dysuria Foul-smelling urine Cloudy urine Incontinence during day and/or night Increased irritability

 Nausea and vomiting  Low abdominal or

flank pain  Fever and chills  Fatigue  Small amount of urine while micturating despite feeling of urgency

 Central pyrexia but peripherally cold  Poor colour  Pale, grey mottled skin  Quiet and lethargic child

 Poor tone  Tachycardic and hypertensive



Obtaining a urine specimen:- Urine bag - Clean catch urine - Mid-stream urine - Catheterisation

- Supra-pubic aspiration-draining the bladder by inserting a sterile needle through the skin above the pubic arch and into the bladder.

  

Ultrasound Plain x-ray Micturating Cystourethrogram (MCUG)

 Obtain urine specimen before antibiotics

     



started, sent for ME/CS Blood tests Strict I/O chart Monitor vital signs esp. body temperature Administer antibiotics as prescribed (5 days course) Administer anti-pyretic drugs to reduce fever and pain Advised to take plenty of fluids to prevent dehydration and to flush the urinary tract If the child is unable (vomiting) or refuse to take fluids, administer IV fluids as prescribed

Fever due to increased body temperature related to urinary tract infection. 2. Alteration in urination (frequency, pain, burning, dribbling and enuresis) related to infection. 3. Pain related to inflammatory changes in the urinary tract. 4. Lack of knowledge about UTI and health prevention 1.

Goal: to reduce fever and maintain normal body temperature Nursing interventions

Rationales

• monitor body temperature every 4º • encourage plenty of fluid intake • administer anti-pyrexial medications as prescribed • maintain bed rest • wear thin loose clothing

• baseline obs. • to maintain hydration • to maintain an optimum body temp.

• to reduce the body heat • give tepid-sponging with luke-warm • to reduce body heat water

Problem 2: Alteration in urination (frequency, pain, burning, dribbling and enuresis) related to infection Goal: to ensure that the child is comfortable during urination Nursing interventions Rationales • assess the urinary frequency, pain or • as baseline obs. burning sensation during micturation • assess the colour & odour of urine • as baseline obs. • strict I/O chart • to observe urinary frequency • administer antibiotics as prescribed • to prevent spread of infection • to prevent • observe for signs & symptoms of complications serious infection

 Ensure the child to pass urine regularly

(every 2-3 hours) and take the time to completely empty the bladder  Avoid holding urine for prolonged period of time  Perineal hygiene - wipe from front to back  Avoid tight fitting clothing or diapers; wear cotton panties  Avoid constipation  Encourage fluid intake  Avoid bubble baths

You are required to do the nursing care plan for problem no. 3 & 4, including nursing interventions and rationales

 Alteration of glomerular

membrane permeability with massive proteinuria, hypoalbuminaemia, hyperlipidaemia and oedema

 It occurs when the filters in the kidney leak an

excessive amount of protein. The level of protein in the blood ↓ and this allows fluid to leak across the blood vessels into the tissues – causing oedema  Nephrotic syndrome are caused by changes in the immune system

 For unknown reason, the glomerular

membrane, usually impermeable to large proteins becomes permeable.  Protein, especially albumin, leaks through the membrane and is lost in the urine.  Plasma proteins decrease as proteinuria increase.

 The colloidal osmotic pressure which holds water in

the vascular compartments is reduced owing to decrease amount of serum albumin. This allows fluid to flow from the capillaries into the extracellular space, producing oedema.  Accumulation of fluid in the interstitial spaces and peritoneal cavity is also increased by an overproduction of aldosterone, which causes retention of sodium.  There is increased susceptibility to infection due to decreased gamma-globulin.  Causing generalised oedema

 1 : 50 000 children  Males > females  Common age of onset is between 2 to 6 years,

but can occur at any age

 Oedema

 ↓ urine output

- initially noted in the periorbital area - ascites - intense scrotal oedema - striae may appear due to skin overstretching - pitting oedema  ↑ weight

 Proteinuria (foamy urine 

   

indicates proteinuria) Fatigue Irritable and depression Severe recurrent infections Anorexia Wasting of skeletal muscles

 Urinalysis

- protein 3+ - 4+ on dipstick - haematuria may be absent or microscopic

 Blood test

- total serum protein – low - serum albumin – low - cholesterol and lipoproteins – high  Renal function test – often normal  Blood pressure – often normal but 25% hypertension  Renal biopsy

1. 2. 3. 4.

Generalised oedema due to fluid volume excess related to glomerular dysfunction Impaired skin integrity related to oedema Altered urinary pattern related to glomerular dysfunction Increased susceptibility to infection related to disease process and steroid therapy

5. 6. 7. 8.

Altered body image (round face) due to sideeffects of medication Inadequate nutritional intake related to large loss of protein from the urine Knowledge deficit of the disease process and treatment Anxiety and depression due to the up and down of the course of disease

Goal : to relieve oedema Nursing interventions  Administer steroids – prednisolone 2-4mg/kg to control oedema  Observe for side-effects of steroids – Cushing’s syndrome (moon face, abdominal distension, striae, ↑ appetite, ↑ weight, aggravation of adolescent acne)

 Administer diuretic – frusemide. Diuretics

can cause loss of electrolytes esp. potassium, encourage ↑ potassium food e.g. citrus fruits, date, apricot, banana  Keep the child CRIB during periods of severe oedema  Strict I/O chart – restrict intake of fluid – offer small amount of measured fluid during severe oedema, for infant measure the diaper’s wt.  Measure daily weight and abdominal girth – to check any weight gain due to water retention

Goal : to protect the child from skin breakdown Nursing intervention  Position the child comfortably in bed so that oedematous skin is well-support with a pillow  Elevate the child’s head to reduce periorbital oedema  Provide good skin care – give bath and maintain hygiene esp. genitals and moist area  Change bedding daily and free from creases

 For problems 3 – 9, you are required to look for

the nursing interventions yourself.

 Admission to ward  Explain to parents nature of illness  Blood for FBC/DC, U +E, Creat., Serum lipid,   



C&S, LFT, serum albumin For CXR and Echo Daily urine dipstick for protein, ME and C&S – every morning Daily BP, weight and abdominal girth Start on IV infusion

 Administration of IV albumin

 Start on steroid therapy – prednisolone given at

a dose of 2mg/kg/day divided into 2-3 doses. This regimen is continued until remission is achieved  Remission is achieved when the urine is 0 or trace for protein for 5 to 7 consecutive days  Administer prophylactic antibiotics to reduce infections

 Start on diuretic therapy – frusemide (lasix)  Dietary restriction – provide ↑ protein, high 

  

carbohydrate, ↑ potassium diet & no salt diet Strict I/O chart Provide careful skin care Good hygiene CRIB

Question and Answer

DEFINITION  The backflow or reflux of urine from the

bladder into the ureters and possibly the kidneys. The urine returns to the bladder after passing urine.

 Fever >39ºC  Irritability  Poor feeding  Vomiting

 Dysuria as evidenced by crying when passing

urine  Change in urine colour or odor

 Abdominal or suprapubic pain  Frequency in passing urine  Urgency in passing urine

 Dysuria  New or increased incidence of

enuresis

 In normal functioning urinary tract, there is

a valve-like mechanism at the junction of the ureter and bladder that prevents urine from refluxing in the ureters  As urine fills the bladder or the bladder contracts during micturating, pressure in the bladder occludes the opening to the ureter  When a defect occur at the vesioco-ureteral junction, VUR occur

 MCUG – to visualise the urethra, evaluate

degree of reflux and define any abnormalities  Renal scan – to assess renal scarring and function  Urodynamic studies – this is done when there is micturating dysfunction (frequency, urgency, or incontinence) is present  Cystograms  Urine culture  Blood test – serum creatinine

 GRADE I: reflux into ureter only – no

dilatation  GRADE II: reflux into ureter, pelvis and calyces with no dilaltation and normal calyceal fornices  GRADE III: mild dilatation of ureter and renal pelvis  GRADE IV: moderate dilatation of ureter, pelvis and calyces  GRADE V: gross dilatation of ureter, pelvis and calyces

GRADE IV: moderate dilatation of ureter, pelvis and calyces

GRADE V: gross dilatation of ureter, pelvis and calyces

Reflux can be divided into 2 categories :1.

PRIMARY REFLUX - caused by abnormal position of the ureteral bud on the wolffian duct during development of the urinary tract, resulting in smaller, tunneled segment of the ureter

2.

SECONDARY REFLUX - occurs as a result of acquired bladder dysfunction

 Daily low dose of prophylactic antibiotic to

prevent UTI  Urinalysis and urine ME/CS – every 3 to 4 months to evaluate for UTI  Monitor ↑BP

 Surgery – reimplantation of the ureter into the

bladder  Indicated due to recurrent UTI despite antibiotics, Grade 5 reflux or progressive renal injury

Definition 

Hypospadias is a congenital anomaly in which the actual opening of the urethral meatus is “below” the normal placement on the glans of penis

 Occurs from incomplete development of the

urethra in utero  Exact causes unknown – may be genetic, environmental or hormonal factor

 Stenosis of the opening could occur – may lead

to UTI or hydronephrosis  May interfere with fertility if left uncorrected  The location of the meatus may make it difficult for the child to urinate standing up

 The choice of surgical correction is affected

primarily by the severity of the defect  Surgery is done when the child’s age is less than 18 months  Reconstruction of the meatal opening is done – Meatal advancement granuloplasty (MAGPI)

The goal for surgical correction: To enhance the child’s ability to pass urine in the standing position with a straight stream  To improve the physical appearance of the genitalia for psychological reasons  To preserve a sexually adequate organ

1.

Ashwill, J.W. and Droske, S. C. 1997. Nursing Care of Children. Principles and Practice. USA: W.B. Saunders.

2.

Brunner, L.S. and Suddarth, D.S. 1986. The Lippincott Manual of Peadiatric Nursing. (3rd ed.) UK: Chapman & Hall.

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