Renal Urinary Tract & Reproductive Conditions

Kidney Outer Cortex

Composed of the glomeruli and convoluted tubules of the nephron and blood vessels

Kidney Inner Medulla

Composed of the renal pyramid

Role of the Kidneys in Acid Base Balance

remove excess acid and base through the urine.

Role of Lungs in Acid Base Balance Lungs

regulate the amount of carbon dioxide in the blood (PCO2) acid

Differences in Pediatrics Kidney

large in relation to stomach; prone to injury. Kidneys are immature and less efficient. The renal system does not reach maturity until 2 years of age. Glomerular filtration rate is slower. Increased risk for dehydration. (Diluent)

Differences in Pediatrics GU

Urethra is shorter; Increased risk for UTI. Reproductive organs are immature until adolescence.

Bladder capacity in newborn

30 ml

Infectious and Inflammatory Disorders

UTI, Acute Glomerulonephritis, Nephrotic Syndrome, Hemolytic Uremic Syndrome, Acute kidney injury

Urinary Tract Infections

A microbial invasion of the urinary tract.

Lower urinary tract Infection

(cystitis)

UTI spreads to infect the upper urinary tract

(Pyelonephritis), causing a kidney infection.

UTI Risks bladder doesn’t completely empty

Urinary Stasis (learning to relax sphincter), Constipation

UTI Risks

Hot Tubs, Sexual Abuse (recurrent) , Bubble Baths

UTI Risks anatomical

Age <12 months, Girls, uncircumcised infant boys

UTI Signs and Symptoms

Dysuria, Urgency, Frequency (might be more difficult to recognize in toddlers), flank pain, abdominal pain, Fever, Concentrated urine, strong-smelling urine, personality changes, hematuria

Infants (Birth to 12 months) UTI

Nonspecific, fever (which may be only manifestation – do a UA), irritability, abdominal fullness, foul-smelling urine, poor growth, poor feeding, vomiting, diarrhea, weight loss

UTI Toddlers (1 year to 2 years)

Fever, chills, poor appetite, vomiting, urinary hesitancy, incontinence after toilet training, rubs back (flank pain)

Children and adolescents (3 years to 18 years)

Dysuria, urge to urinate, frequent urination, abdominal or flank pain, urinary burning, fever, constipation, incontinence in a previously continent child, chills

UTI URINE specimen

Clean-catch (Urinalysis) (potty trained) , U-bag for collection from infant/Toddler (Urinalysis), Specimen obtained by catheterization has more accurate results (Urine culture) (if sepsis), Stimulate void with wet gauze on supra pubic area

UTI Drug Therapy

Trimethoprim-sulfamethoxazole (TMP-SMX-Bactrim), Nitrofurantoin (Macrodantin), Amoxicillin, Augmentin (amoxicillin-clavulanate), Cefalexin (Keflex), Pyridium (analgesic effect on the urinary tract), Tylenol

UTI Drug Therapy ABX

Risk for C Diff, watch for diarrhea

Nitrofurantoin (Macrodantin)

Abx, urine turns bight orange to brown

Pyridium

(analgesic effect on the urinary tract), not for long term (mask symptoms, don’t know if progression to upper infection) , not for reduced kidney function, Urine turns bright orange or brown

Normal Urinalysis

pH 4.6 to 8, Sp gr 1.001 to 1.030, There should be almost no WBC, RBC, no proteins. No albumin, glucose, ketones, or nitrates.

UTI treatment

Increase fluids, wipe front to back, frequent diaper change, no bubble baths

Acute Kidney Injury

The inability of the kidneys to excrete waste material, concentrate urine, and conserve electrolytes. This is REVERSIBLE

Acute Kidney Injury S/S

Urine output changes, Edema, CNS changes, Cardiac arrythmias, Tachypnea (fluid overload and Acidosis) , Seizures

Prerenal

Any condition that causes decreased kidney perfusion (dehydration, blood loss, HF)

Intrinsic Renal

Damage to the kidney structure (toxins, meds like abx or NSAIDS, inflammation)

Post Renal

Obstruction of the urinary system (scar tissue or malformation)

Acute Kidney Injury Electrolyte imbalances

High K, High Phosphatase, Low Calcium, Low sodium (watch neuro)

Acute Kidney Injury Labs

BUN & Creatinine - High in Blood versus Low in urine, GFR (infant – 40-60)

Acute Kidney Injury keep in mind

Metabolic Acidosis, ECG – for cardiac arrhythmias, Intravenous Pyelogram, 24 hour urine test

Acute Kidney Injury Azotemia

urea and creatinine build up in the blood

Acute Kidney Injury Anemia

reduced production of erythropoietin

Acute Poststreptococcal Glomerulonephritis (APSG)

Occurs 1-2 weeks after a streptococcal infection like strep throat, impetigo, or scarlet fever (antibodies created to fight strep, clog up kidneys)

Glomerulonephritis

Inflammation of the glomeruli in the kidneys)

APSG S/S

Gross hematuria(tea/brown/cola), Periorbital edema & facial edema, Hypertension, Proteinuria, increased BUN & Creatinine, oliguria, headache, loss of appiete

Nursing Management of APSG

The Goal is to manage edema, protect the heart and kidneys, (immunocompromised too)

APSG Manage edema

Daily weights, Monitor Blood pressure. Accurate I&O, Assess neuro status/behavior changes

APSG Nutrition

Low-sodium, Low protein, Restrict fluids, Restrict high potassium foods

APSG Electrolyte imbalances

Low Ca, High Phos, High K, Na

APSG Medications

Calcium Carbonate (Ca + Phos), Sodium Polystyrene Sulfonate (K), Antibiotics(prophylaxis’s immunocompromised) , Diuretics, Insulin (K)

Nephrotic Syndrome

Damage to the glomerular membrane, Massive amounts of protein (albumin) leak out of the blood vessels and pass into the urine.

Nephrotic Syndrome Signs & Symptoms

Edema that begins in the face, Tachycardia, Pale skin, fissure, Hyperlipidemia , Vomiting, Proteinuria, frothy urine, Fatigue, Low of immunoglobulins, Acistisis

Nephrotic Syndrome Nursing Management

decrease the excretion of protein! , Provide rest (consider cluster care), Strict I & O, Prevent infection, Encourage nutritional intake with fluid restrictions. Elevate lower extremities

Nephrotic Syndrome Daily

Daily weights, Daily abdominal girth measurements

Nephrotic Syndrome

Monitor urine protein, Monitor vital signs (low BP) , Monitor skin for breakdown (weak skin, frequent diaper changes

Nephrotic Syndrome medications

Corticosteroid (Prednisone). Diuretic (Furosemide/Lasix), Plasma Expander (Albumin). Immunosuppressant (Cyclophosphamide) (for reoccurring)

Hemolytic Uremic Syndrome (HUS) An acute kidney injury

damages blood vessels , Hemolytic anemia, blood clots form in the kidney arterioles. Thrombocytopenia, Shiga Toxin producing E. Coli, Usually develops after a GI illness. (food poising – under 5)

Hemolytic Uremic Syndrome Signs & Symptoms

Loss of appetite, Irritable, Lethargic/Stupor, Hallucinations, Edema, Pallor, Bruising, Purpura, Petechiae or rectal bleeding. Anuric, Severe Hypertension, Fever

Hemolytic Uremic Syndrome Goal Management

supportive care…managing the symptoms until the kidneys can heal. Don’t give Anti coags

Hemolytic Uremic Syndrome Management

Monitor I & O, Daily Weights, Administer fluid replacement, Treat Hypertension (Lasix) , Correct acidosis and electrolyte imbalances, Seizure precautions,

Hemolytic Uremic Syndrome Intervention

Blood transfusion for severe anemia, Dialysis for child anuric >24 hours

Functional Alterations of the GU Tract

Vesicoureteral Reflux, Cryptorchidism, Epispadias/Hypospadias, Hydrocele, Phimosis, Bladder exstrophy

Hydrocele

increased Fluid in the testicle

Phimosis

foreskin too tight to retract

Vesicoureteral Reflux (VUR)

The valve between the ureters and the bladder is not working properly (ureterovesical junction). should operate as a one-way valve but operates as a two-way valve. Allows urine in the bladder to flow backward (reflux) into one or both ureters and kidneys.

Signs & Symptoms of VUR

Recurrent UTI, flank pain, abdominal pain, Enuresis (incontinence)

The best way to diagnose VUR is

with a voiding cystourethrogram (VCUG).

VUR Nursing care

Surgery (reimplanting the ureter), Medical management (antibiotics and anticholinergic agents), The goal is to prevent pyelonephritis and scarring.

VUR anticholinergic agents

Oxybutynin (Ditropan) relax bladder reduce pressure

Cryptorchidism

One or both testicles has not descended into the scrotum.

Cryptorchidism DX

Physical exam, Ultrasound, MRI

Cryptorchidism Treatment

Surgical repair(w/in 3-6m), orchiopexy done between ages 1 and 2. (can cause infertile or testicular caner)

Cryptorchidism Post op education

Pain management, infection, frequent diaper changes, Abx and Vaseline ointment, don’t straddle legs, no tub baths, void within 6 hr if home

Epispadias

The urethral meatus is located on the dorsal (top) aspect of the penis. Discovered on a newborn assessment. Seen in conjunction with bladder exstrophy.

Hypospadias

The urethral meatus is located on the ventral (bottom) aspect of the penis. The meatus may occur anywhere along the ventral shaft, ranging from minimal displacement on the glans to a perineal location.

Epispadias and Hypospadias Treatment & Nursing Management

Surgery performed before 18 months and before toilet training. Delay circumcision until after surgery. (need foreskin) , Foley catheter placed

Epispadias and Hypospadias Post Operative

provide analgesics, antibiotics, and anticholinergic medications (oxybutynin) to decrease bladder spasms.

Bladder Exstrophy

Birth defect in which the bladder develops outside the abdominal cavity. Other organs of the GU and GI tract that are at home in the pelvis can also be affected. Bladder unable to store urine Diagnosed during pregnancy on routine fetal ultrasound.

Treatment of Bladder Exstrophy

Surgery within the first 48 hours of life. Multiple surgeries are required. Spinal, abdominal, rectal defects, and epispadias are common co-morbidities.

Goals of Bladder Exstrophy surgery

closure of bladder and abdominal wall, approximation of pelvic rami. (opening of pelvic bones during surgery)

Bladder Exstrophy Preoperative

psychological and medical preparation.

Bladder Exstrophy Postoperative care

Immobilization to promote healing in the pelvic area (spica cast or traction (pins) for 4-6 weeks)., potential continence issues later in life