DISORDERS OF THE GENITO
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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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