Week 10 GU Alterations By Teresa Hunt RN,BSN - PowerPoint Presentation

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Week 10GU Alterations

By Teresa Hunt RN,BSN

University of Central Florida

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Infants can’t concentrate urine.They achieve complete bladder control by 4-5

yrs

old.Most children with acute renal failure will recover kidney function.Shorter urethras lead to increase incidence of UTI’s.Kidneys function is proportional to body size. Function reduced with stress.Bladder capacity is 10mL/kg

Difference In Pediatrics

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Urinary System

Kidney produces:

Renin – regulate blood pressure by decreasing levels.Erythropoietin – stimulates red blood cell production by the bone marrow.Metabolize Vitamin D to its active form. Necessary for calcium metabolism

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Enuresis (Diurnal/Daytime)

Holding

Distance to bathroomInterruption in playIncomplete emptyingPeersOveractive bladderUrgency

FrequencyPicture Citation:

Wikihow. (

n.d.

) How to manage urinary incontinence in

children. Retrieved 11/15/14

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Enuresis (Nocturnal/Night-time)

Affects 15-20% of children at 5

yrs old and spontaneously resolve.Occurs more often in families with hx of bedwetting.

DDAVPWetting alarmFluid RestrictionsAvoid extra sugar and caffeine intake after 4pm

Picture reference:

Lifestyle Theme on Genesis Framework. (2014). Bedwetting. Retrieved Nov 12, 2014.

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Urinary Tract Infection (UTI)In the USA prevalence is 3%-5% in girls and 1% in boys

Signs and Symptoms

Burning with urination

Frequency and urgency

Fever Abdominal discomfortUrine Analysis

Nitrates, Bacteria, Blood and WBC’s

Urine Culture

>100,000 colonies

<100,000 colonization

Causes

Obstruction

Voiding dysfunction resulting in urinary stasis

Anatomic difference

Individual susceptibility to infection

Reflux

Sexual activity

Behavioral

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UTI Treatment

Antibiotics 7-14 days

Sulfamethoxazole – TrimethoprimNitrofurantoinCephalosporins

IM CeftriaxoneIVGentamicin (aminoglycoside)

CephalosporinAmpicillin

Girls – wipe front to back

Cranberry juice

Prophylactic antibiotics

Same as upper left

Possible circumcision

Adhesions removal (penile/vaginal)

Behavior Modification

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Specimen Collection

Clean- Catch

Used in children that are toilet-trained.Patient cleans with 3 castile soaps then pees a little into the toilet and then pee into the cup.

Sterile Catheterization

Used in children (<2yrs)

5Fr or 8Fr

Sterile Technique

Need holding help!

Issues:

Girls are “fluffy” and Urethra and vagina are closely placed.

Boys uncircumcised

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Vesicoureteral Reflux

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VUR Classification

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VUR Treatment

Most with grade 1 –

3 will spontaneously correct without interventions.No resolution, insertion of Deflux into submucosa.Grade 4 & 5, ureter re-implantation surgery.

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Hydronephrosis

Caused by an obstruction of the

ureteropelvic junction.Fluid backs up into the kidney. Can be reversed if obstruction is corrected or incomplete.

Increased dilation is associated with increased damage

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Hypospadias/Epispadias

Hypospadias occurs in 1:250 males.

Epispadias is very rare.May have Chordee.

May have altered urinary stream direction.Correction not always needed.Picture Reference

Kraft, K.H., Shukla, A.R., and Canning, D.A. [2010] Hypospadias. Urol. Clin. North Am. 37(2), 167–181.

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Hypospadias Repair

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Cryptorchidism (Undescended testicles)

Occurs in 4.5% of normal, healthy boys.

It can be unilateral or bilateral.Usually spontaneously corrects by 6 months of life.Found by physical exam.

Ultrasound 1st radiological test for UDT

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UDT: Orchiopexy

The surgical process of moving the testicles down the vaginal process and then closing the track.

Testicles are tacked to the scrotal area. At times it can have an external button to assist healing and prevent migration of testicles

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Testicular Torsion

When the testicle rotates and obstructs blood flow.

Presents with:Severe & progressive pain, erythema and edema.Medical Emergency: Surgical correction

Can result in loss of testicle.Determined by ultrasound

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Bladder Exstrophy

The infant is born with the bladder outside of the body.

Usually diagnosed in utero. Patient maintains kidney function and may be able to empty bladder without catheterizing.Surgical correction to be done at 6-8 weeks of life.

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Hydrocele

Collection of fluid that is isolated to the scrotum.

Has a bluish hue and “twinkles” with trans-illumination.Monitor, can self resolve. Do not aspirate, surgical intervention if it does not resolve.

(Yu, 2014)

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Phymosis

Tight foreskin, unable to retract.

Increase change for UTI’s

Can have ballooning with urination from trapped urine (see left)

Usually caused by adhesions to the glands.

Balanoposthitis

(recurrent infections)

Poor Hygiene

Very difficult to catheterize

Can treat with:

Betamethasone Cream

Steroid used for 6-8weeks BID/TID with foreskin retractions.

Circumcision

(

Cendron

, 2014)

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Meatal Stenosis

Very small ureteral opening.

Occurs with recurrent meatitis from moist environment, prior hypospadias repair, trauma, and prolonged urethral cath.Frequently experience erratic stream, difficult to initiate stream, UTI’s.

Surgical correction necessary to open up meatal opening (Meatotomy

). Do not dilate the urethra.(Cendron, 2014)

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Kidney Stones

Nephrolithiasis is the process of stone formation

Are the accumulation of crystals from dietary minerals in urine.Can take up to 4 weeks to pass. For large stones, may need surgical intervention.

Identified by Ultrasound, CT (1st choice), Stone analysis (after passed or removed, Gold standard)(Baggett, 2014)

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Kidney Stones, Cont.

Symptoms:

Dysurina, urinary frequency, Hematuria, Pain (flank, Lower abdomen & groin (renal Colic)), N/V, fever, UTIRenal colic comes in waves and lasts 20-60 min.

Uncontrolled pain must go to the ED(Baggett, 2014)

Treatment

INCREASED FLUID INTAKE

.

Decreased Salt and eggs.

Medications

Sodium citrate (increase urinary pH, HCTZ (decrease calcium excretion), Antibiotics, Bladder relaxers (

ditropan

, Detrol)

Surgery:

Extracorporeal Shock Wave Lithotripsy (ESWL)

Ureteroscopy

Percutaneous

Nephrolithotomy

Open Stone Surgery

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Pain Scale

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Poststreptococcal Glomerulonephritis

Sudden, self-limiting, and fully resolves

Manifestations:Hematuria (cola-colored urine), Edema (abrupt onset, mild

periorbital or lower extremity), HTN, Proteinuria, usually young school aged children.Labs:

RBCs, cast, Small Proteinurea (0 – 3+), Altered electrolytes, elevated blood urea nitrogen or creatinine levels, Elevated ASO titer or

Streptozyme

, decreased complement.

Management:

Supportive, Anti-

hypertensives

and diuretics, antibiotic treatment for active streptococcal infection, Low-Salt diet, Possible fluid restrictions.

Nephrotic

Syndrome

Manifestations:

Severe Proteinuria (Frothy Urine), Edema (insidious onset, massive from shift of fluid into interstitial spaces), Hypovolemia, Normotensive, Pallor, Fatigue, Usually toddler or preschool-age child.

Labs:

Protein in urine 3-4+,

Hypoalbuminemia

, elevated cholesterol and triglyceride, H/H, and PLT levels.

Management:

Prednisone, diuretics, possible albumin administration, prevent infections and skin breakdown, no-added-salt diet

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Poststreptococcal

Glomerulonephritis

Nephrotic

Syndrome

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Acute Renal Failure

Defined as sudden, severe loss of kidney function.

Can be improved once the underlying condition can be corrected.Manifestations:Electrolyte abnormalities, fluid volume shifts, increased BUN and serum creatinine levels, acid-based imbalances, and nonspecific symptoms such as poor feeding, decreased appetite, vomiting, lethargy, SZ and pallor

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End Stage Renal Disease (ESRD)

Defined as an irreversible loss of kidney function that usually occurs over months to years.

Usually caused by congenital anomalies such as obstruction, VUR, and Renal Dysplasia.Dialysis or kidney transplantation when kidney function is between 5-10%.

Manifestations:

Electrolyte abnormalities, fluid volume shifts (dehydration or fluid overload), acid-base imbalance, renal

osteodystrophy

(rickets), anemia, poor growth, HTN, fatigue, decreased appetite, poor feeding, N/V and neurologic symptoms from waste accumulation in the blood.

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Reference

Boston

Childrens Hospital (2014). Treatment forbladder exstrophy

and epispadias in children. KidsMD

Health Topics. Retrieved from

http

://

www.childrenshospital.org/health- topics/conditions/b/bladder-

exstrophy

-and-

epispadias

/treatments

Cendron

, M. (2014). Circumcision and circumcision revision

. Essential Pediatric Urology

for the

Pediatric Care

Clinician.

Boston

Children’s

Hospital Urology Convention.

Chowdhury

, P.,

Nayak

, P.,

Mallick

, S.,

Gurumurthy

, S., Deepak, D.

&

Mossadeq

, A. (January-March 2014).

Single stage

ventral onlay

buccal mucosal graft

urethroplasty

for navicular fossa

stricures

.

Indian Journal of Urology

. 30 (1). 17-22

Yu, R. (2014). Module III: Pediatric

andrology

: Swollen scrotum

(Hydrocele). Essential Pediatric Urology for the Pediatric

Care Clinician.

Boston Children’s Hospital Urology

Convention.

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Reference Cont.

Baggett, A. (2014). What are kidney stones?. Boston

Children’s Urology Department.