Transcript Slide 1
NURSING MANAGEMENT OF GENITOURINARY DYSFUNCTION:
Theoretical Skills and Knowledge, Scientific Principles, Critical Thinking, Healthcare Promotion, Wellness and Illness, and Stress Adaptation
Lecture Objectives: 1.
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Describe common renal and urinary disorders that occur in children.
Assess a child for a renal or urinary tract disorder.
Formulate nursing diagnoses related to renal or urinary tract disorders.
Establish outcomes related to the care of a child with renal or urinary disorder.
Plan nursing care related to urinary or renal disorders.
Lecture Objectives (cont.) 6.
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Implement nursing care for the child with a renal or urinary disorder.
Evaluate outcomes for achievment and effectiveness of care.
Analyze methods for making nursing care of the child with a renal or urinary disorder more family centered.
Compare and contrast acute and chronic renal failure.
Discuss the types of renal dialysis.
Assess for signs of kidney transplant rejection.
Reading Assignment:
Wong, Perry & Hockenberry Ch. 50; p 1643-1669
Renal System Assessment
Physical assessment
– Palpation, percussion
Health history
– Previous UTIs, calculi, stasis,
retention, pregnancy, STDs, bladder cancer
– Meds: antibiotics, anticholinergics,
antispasmodics
– Urologic instrumentation – Urinary hygiene – Patterns of elimination
Nursing Assessment of Urinary Tract Infection (UTI)
Nausea, vomiting, anorexia, chills, nocturia, frequency, urgency
Suprapubic or lower back pain, bladder spasms, dysuria, burning on urination
Nursing Assessment of Urinary Tract Infection (UTI)
Objective data
– Fever – Hematuria, foul-smelling urine; tender,
enlarged kidney
– Leukocytosis, positive findings for
bacteria, WBCs, RBCs, pyuria, ultrasound, CT scan, IVP
Diagnostic Studies
Renal scan Cystogram Retrograde pyelogram Ultrasound CT MRI Renal arteriogram
UA Urine C&S BUN Creatinine KUB IVP VCG/VCUG
Normal Urinalysis
pH: 5 to 9 Sp gr: 1.001 to 1.035
Protein: <20 mg/dl Urobilinogen: up to 1 mg/dl None of the following:
– Glucose – Ketones – Hgb – WBCs – RBCs – Casts – Nitrite
Normal Characteristics of Urine
Color range
Clear
Newborn production—approx 1-2 ml/kg/hr
Child production—approx 1 ml/kg/hr
Urinary Tract Infection (UTI)
Is it really serious?
that Concept of “asymptomatic bacteria” in urinary tract
Urinary Tract Infection (UTI)
Causes Escherichia coli most common pathogen
Streptococci Staphylococcus saprophyticus
Occasionally fungal and parasitic pathogens
Classification of UTI
Upper tract: involves renal parenchyma, pelvis, and ureters
– Typically causes fever, chills, flank
pain Lower tract: tract involves lower urinary
– Usually no systemic manifestations
Classification of UTI
Lower tract
Cystitis
Urethritis
Glomerulo nephritis
Upper tract
Pyelonephritis
VUR
Classification of UTI
Uncomplicated infection
Complicated infections
– Stones – Obstruction – Catheters – Diabetes or neurologic
disease
– Recurrent infections
Types of UTIs
Recurrent—repeated episodes
Persistent—bacteriuria despite antibiotics
Febrile—typically indicates pyelonephritis
Urosepsis—bacterial illness; urinary pathogens in blood
Etiology and Pathophysiology of UTI
Physiologic and mechanical defense mechanisms maintain sterility
– Emptying bladder – Normal antibacterial properties of
urine and tract
– Ureterovesical junction
competence
– Peristaltic activity
Etiology and Pathophysiology of UTI
Alteration of defense mechanisms increases risk of UTI Organisms usually introduced via ascending route from urethra Less common routes
– Bloodstream – Lymphatic system
Etiology and Pathophysiology of UTI
Contributing factor: urologic instrumentation
– Allows bacteria present in opening of
urethra to enter urethra or bladder Sexual intercourse promotes “milking” of bacteria from perineum and vagina
– May cause minor urethral trauma
Etiology and Pathophysiology of UTI
UTIs rarely result from hematogenous route For kidney infection to occur from hematogenous transmission, must have prior injury to urinary tract
– Obstruction of ureter – Damage from stones – Renal scars
Etiology and Pathophysiology of UTI
UTI is a common nosocomial infection
– Often
E. coli
– Seldom
Pseudomonas Urologic instrumentation common predisposing factor
Clinical Manifestations of UTI
Symptoms
– Dysuria – Frequent urination (>q2h) – Urgency – Suprapubic discomfort or
pressure
Clinical Manifestations of UTI
Urine may contain visible blood or sediment (cloudy appearance)
Flank pain, chills, and fever indicate infection of upper tract (pyelonephritis)
Pediatric Manifestations
Frequency
Fever in some cases Odiferous urine Blood or blood-tinged urine Sometimes NO symptoms except generalized sepsis
Pediatric Manifestations
Pediatric patients with significant bacteriuria may have no symptoms or nonspecific symptoms like fatigue or anorexia So how do you find out?
Diagnostic Studies of UTI
Dipstick Microscopic urinalysis Culture
Diagnostic Studies of UTI
Clean-catch is preferred
U-bag for collection from child Specimen obtained by catheterization or suprapubic needle aspiration has more accurate results
– May be necessary when clean-catch
cannot be obtained
Diagnostic Studies of UTI
Sensitivity testing determines susceptibility to antibiotics
Imaging studies for suspected obstruction
– IVP or Abd CT
Collaborative Care for UTI Drug Therapy: Antibiotics
Uncomplicated cystitis: short term course of antibiotics
Complicated UTIs: long-term treatment
Collaborative Care for UTI Drug Therapy: Antibiotics
Trimethoprim-sulfamethoxazole (TMP SMX) or nitrofurantoin
Amoxicillin
Cephalexin Others
– Gentamycin, carbenicillin
++ Pyridium (OTC) Combination agents (e.g., Urised) used to relieve pain
– Preparations with methylene blue tint
Collaborative Care for UTI Drug Therapy
For repeated UTIs
– Prophylactic or suppressive
antibiotics
– TMP-SMX administered daily to
prevent recurrence or single dose before events likely to cause UTI
Etiology and Pathophysiology of Acute Pyelonephritis
Inflammation caused by bacteria, fungi, protozoa, or viruses infecting kidneys
Urosepsis: systemic infection from urologic source
– Can lead to septic shock and death
in 15% of cases
Etiology and Pathophysiology of Acute Pyelonephritis
Usually infection is via ascending urethral route
Frequent causes
–
E. coli
– –
Proteus Klebsiella
–
Enterobacter
Etiology and Pathophysiology of Acute Pyelonephritis
Commonly starts in renal medulla and spreads to adjacent cortex
Recurring episodes lead to scarred, poorly functioning kidney and chronic pyelonephritis
Clinical Manifestations of Acute Pyelonephritis Vary from mild to “classic” and very severe Presenting symptoms
– N/V, anorexia, chills, nocturia, frequency,
urgency
– Suprapubic or low back pain, dysuria – Fever, hematuria, foul-smelling urine
Costovertebral tenderness
Symptoms often subside in a few days, even without therapy
– Bacteriuria and pyuria still persist
Diagnostic Studies of Acute Pyelonephritis
Urinalysis
WBC casts
CBC
Imaging studies (IVP or CT)
Ultrasound
Collaborative Care of Acute Pyelonephritis
Hospitalization
Parenteral antibiotics
Collaborative Care of Acute Pyelonephritis Relapses treated with 6-week course of antibiotics
Reinfections treated as individual episodes or managed with long-term therapy
– Prophylaxis may be used for
recurrent infections
Types of Glomerulonephritis
Most are postinfectious
– Pneumococcal, streptococcal,
or viral May be distinct entity or May be a manifestation of systemic disorder
– SLE – Sickle cell disease – Others
Glomerulonephritis Symptoms
Generalized edema due to decreased glomerular filtration
– Begins with periorbital – Progresses to lower extremities
and then to ascites HTN due to increased ECF
Oliguria
Glomerulonephritis Symptoms
Hematuria
– Bleeding in upper urinary
tract→smoky urine Proteinuria
– Increased amount of protein =
increased severity of renal disease
Acute Post-Streptococcal Glomerulonephritis Is a noninfectious renal disease
– Autoimmune
Onset 5 to 12 days after infection other type of Often group A ß-hemolytic streptococci Most common in 6 to 7 years old Uncommon in <2 years old Can occur at any age
Diagnosing APSG
Prognosis
95%—rapid improvement to complete recovery 5% to 15%—chronic glomerulonephritis 1%—irreversible damage
Nursing Management of APSG
Manage edema
– Daily weights – Accurate I&O – Daily abdominal girth
Nutrition
– Low sodium, low to
moderate protein Susceptibility to infections Bed rest is not necessary
Nephrotic Syndrome
Most common presentation of glomerular injury in children
Characteristics
– Proteinuria – Hypoalbuminemia – Hyperlipidemia – Edema – Massive urinary protein loss
Types of Nephrotic Syndrome Minimal change nephrotic syndrome (MCNS)
– AKA
Idiopathic nephrosis
Nil disease Uncomplicated nephrosis Childhood nephrosis
Minimal lesion nephrosis Congenital nephrotic syndrome Secondary nephrotic syndrome
Changes in Nephrotic Syndrome Glomerular membrane
– Normally impermeable to large proteins – Becomes permeable to proteins,
especially albumin
– Albumin lost in urine
(hyperalbuminuria)
– Serum albumin decreased
(hypoalbuminemia)
– Fluid shifts from plasma to interstitial
spaces
Hypovolemia Ascites
Nephrotic Syndrome Management Supportive care Diet
– Low to moderate protein – Sodium restrictions when large
amount edema present Steroids
– 2 mg/kg divided into BID doses – Prednisone drug of choice ($$ and
safest) Immunosuppressant therapy (Cytoxan) Diuretics
Family Issues
Chronic condition with relapses Developmental milestones Social isolation
– Lack of energy – Immunosuppression/protection – Change in appearance due to
edema
– Self-image
Nursing Interventions
Aseptic technique during catheterizations
Avoid unnecessary catheterization and early removal of indwelling catheters
Prevents nosocomial infections
– Wash hands before and after contact – Wear gloves for care of urinary system
Nursing Interventions
Routine and thorough perineal care for all hospitalized patients Avoid incontinent episodes by answering call light and offering bedpan at frequent intervals
Nursing Interventions
Ensure adequate fluid intake (patient with urinary problems may think will be more uncomfortable)
– Dilutes urine, making bladder less
irritable
– Flushes out bacteria before they can
colonize
– Avoid caffeine, alcohol, citrus juices,
chocolate, and highly spiced foods
Potential bladder irritants
Nursing Interventions
Discharge to home instructions
Follow-up urine culture
Recurrent symptoms typically occur in 1 to 2 weeks after therapy
– Encourage adequate fluids even after
infection
– Low-dose, long-term antibiotics to
prevent relapses or reinfections
– Explain rationale to enhance compliance
Hemolytic-Uremic Syndrome
Pathophysiology
Diagnostic evaluation Therapeutic management Prognosis Nursing consideration
Wilms’ Tumor
Etiology
Diagnostic evaluation
Therapeutic management
– Surgical removal – Chemotherapy and/or
radiation
Nursing considerations
Renal Failure
Acute renal failure (ARF)
Chronic renal failure (CRF)
Acute Renal Failure (ARF)
Definition: kidneys suddenly unable to regulate volume and composition of urine
Not common in children
Principal feature is oliguria
– Associated with azotemia, metabolic
acidosis, and electrolyte disturbances
Most common pathologic cause: transient renal failure resulting from severe dehydration
Acute Renal Failure (ARF)
Pathophysiology—usually reversible Diagnostic evaluation Therapeutic management Nursing considerations
Complications of ARF
Hyperkalemia
Hypertension Anemia Seizures Hypervolemia Cardiac failure with pulmonary edema
Chronic Renal Failure (CRF)
Begins when diseased kidneys cannot maintain normal chemical structure of body fluids Clinical syndrome called uremia
Potential Causes of CRF
Congenital renal and urinary tract malformations
VUR associated with recurrent UTIs
Chronic pyelonephritis
Chronic glomerulonephritis
CRF (cont’d)
Pathophysiology
Diagnostic evaluation
Therapeutic management
– Manage diet, hypertension,
recurrent infections, seizures
Nursing considerations
Dialysis
Peritoneal dialysis
Hemodialysis
Hemofiltration
Peritoneal Dialysis
The preferred method of dialysis for children Abdominal cavity acts as semipermeable membrane for filtration Can be managed at home in some cases Warmed solution enters peritoneal cavity by gravity, remains for period of time before removal
Hemodialysis
Requires creation of a vascular access and special dialysis equipment Best suited for children who can be brought to facility 3 times/week for 4 to 6 hours Achieves rapid correction of fluid and electrolyte abnormalities
Transplantation
From living related donor
From cadaver donor
Primary goal is LT survival of grafted tissue
Role of immunosuppressant therapy