GU

Question 1

urinary system

Answer 1

maintains balance
hormonal fxns:
stimulation of production of erythropoietin
production of renin (BP regulation)
metabolism of vitamin D to its active form (calcium metabolism)
excretes waste
functionally immature until puberty

Question 2

pediatric differences in GU sx

Answer 2

kidney- larger in relation to stomach- prone to injury
urethra- shorter- risk for bacteria into bladder (UTI)
GFR- slower in infant; risk for dehydration
bladder capacity- 30ml in newborn; increases to adult size by 1 yr
reproductive organs- immature at birth until adolescence

Question 3

review of urinary A&P

Answer 3

glomerular filtration- process of filtering blood as it flows through kidneys
tubular resorption- necessary fluids, electrolytes, proteins & blood cells are retained
tubular secretion- waste products & fluids filtered out

Question 4

urinary system

Answer 4

for kidneys to function effectively, following conditions need to be present:
unimpaired renal blood flow
adequate GFR
normal tubular function
unobstructed urine flow

Question 5

significant data when assessing PMHX for GU disorders

Answer 5

PMHX- maternal polyhydramnios, oligohydramnios, diabetes, HTN, alcohol/ cocaine ingestion
neonatal hx- presence of single umbilical artery, abdominal mass, chromosome abnormality, congenital malformation
family hx- renal disease/ uropathology, chronic UTIs, renal calculi, hx of parental enuresis

Question 6

structural defects- misc disorders/ anomalies of GU tract

Answer 6

bladder extrophy- extrusion of bladder outside of body
hydrocele- painless swelling of scrotum d/t collection of fluid
phimosis- inability to retract prepuce @ an age when it should retract (3 yo)
testicular torsion- rotation of testicle that interrupts its blood supply
at risk of losing testicle

Question 7

bladder extrophy

Answer 7

rare congenital defect
etiology- failure of abdominal wall to close during fetal development- leads to eversion of bladder
treatment- surgical reconstruction in several stages
nursing care- cover w/ wet sterile gauze post-delivery, prepare for surgery

Question 8

urinary/ renal disorders

Answer 8

structural disorders:
hypospadias/ epispadias
bladder extrophy
obstructive uropathy
hydronephrosis
vesicoureteral reflux
enuresis- continued incontinence of urine past age of toilet training

Question 9

hypospadias/ epispadias

Answer 9

congenital anomalies involving abnormal location of urethral meatus
result from failure of urethra folds to fuse completely over urethral groove
familial tendency but exact mechanism unknown
hypospadias often in conjunction w/ congenital inguinal hernias, undescended testes, chordee (more common than epispadias)
epispadias often occurs w/ bladder extrophy

Question 10

hypospadias vs epispadias

Answer 10

hypospadias- urethral meatus may be located anywhere along course of ventral surface of penile shaft
epispadias- meatal opening is located on dorsal surface of penile shaft, & may be at level of bladder neck

Question 11

hydronephrosis

Answer 11

obstruction of ureteropelvic junction/ other parts of ureter causes dilation of kidney
pelvis & calyces of kidney are dilated
can occur as congenital defect, result of obstructive uropathy/ secondary to VUR

Question 12

hydronephrosis

Answer 12

accumulation of urine in renal pelvis as result of obstructed outflow, & compromises kidney function
most children w/ hydronephrosis are born w/ condition, but can develop during childhood. it is most common urinary tract anomaly & ranges in severity
in mild hydronephrosis, pelvic dilation is barely noticeable, whereas in severe hydronephrosis swelling occupies much of abdomen

Question 13

hydronephrosis

Answer 13

mild-moderate cases- may be no s/sx & condition can resolve w/in 1st yr of life
abdominal mass
s/sx similar to UTIs
can be assoc w/ VUR
in more severe cases, when kidney fxn is affected, infant/ child can experience pain, bleeding, & infections
tx= surgery to correct blockage

Question 14

vesicoureteral reflux

Answer 14

VUR results in backflow or urine from bladder into kidneys
valvelike mechanism @ junction of ureter & bladder prevents urine reflux into ureters; when there is defect of vesicoureteral junction= VUR results
prevents complete emptying & creates reservoir for bacterial growth

Question 15

VUR

Answer 15

most children w/ symptomatic UTIs have VUR
diagnosis:
renal US
VCUG- voiding cystourethorogram- x-ray exam of bladder & lower urinary tract that uses fluoroscopy & contrast material
complications- reflux of infected urine can cause pylonephritis
*similar to GER

Question 16

disorders affecting urinary elimination

Answer 16

UTIs- most common GU disorder of children

enuresis- inability to control urination

Question 17

UTI

Answer 17

microbial invasion of kidneys, ureters, bladder, urethra
neonatal period- UTIs occur most commonly in males, possibly bc of higher incidence of congenital abnormalities
by age 4 mos- UTIs are more common in females bc of placement & size of urethra
causes:
incomplete bladder emptying
irritation by bubble baths
poor hygiene
VUR
urinary tract obstruction
pathophysiology:
bacteria enter urethra & ascend urinary tract
e. coli causes 75-90% of UTIs in females

Question 18

UTI

Answer 18

other s/sx:
V/D
irritability
poor PO intake
malodorous urine
oliguria
constipation
*most common clinical presentation in child <2= FEVER
complications:
risk of renal failure
UTI <1
delay in diagnosis
anatomic/ neurologic obstruction
recurrent episodes of upper UTI
clinical findings:
abdominal pain
enuresis
frequency/ urgency
pain/ burning w/ urination (dysuria)
hematuria
lethargy/ irritability
poor feeding patterns
cloudy, foul-smelling urine
\+/- blood, positive nitrites, positive leukocyte esterase

Question 19

enuresis

Answer 19

repeated involuntary voiding by child who has reached age where bladder control is expected (5-6yo)
nocturnal= more common in boys
diurnal= more common in girls
primary, intermittent, secondary

Question 20

enuresis

Answer 20

primary- child has never had dry night; attributed to maturational delay & small functional bladder
intermittent- child has occasional nights/ periods of dryness
secondary- child begins bedwetting who has been reliably dry for 6-12 mos; assoc w/ stress, infections, sleep disorders
clinical manifestations for diurnal:
frequency
urgency
constant dribbling
involuntary loss of control after voiding
nocturnal:
bedwetting

Question 21

enuresis

Answer 21

thorough hx is obtained
clinical therapy:
multitreatment approach
limit drinks before bedtime, void just before bed
1/3 of nocturnal treated w/ meds:
imipramine hydrochloride (tricyclic antidepressant)
desmopressin acetate (DDAVP)- antidiuretic effect
meds not recc for <6 yo
behavioral interventions (more common than meds)- fluid intake programs, bladder alarms, bladder training

Question 22

enuresis

Answer 22

nursing management:
thorough hx:
what interventions have already been tried, describe voiding/ bowel elimination patterns, whether enuresis is primary/ secondary, whether child is concerned/ any evidence of sexual abuse
evaluated if parent/ child are equally motivated to resolve problem
teaching

Question 23

urinary/ renal disorders

Answer 23

acquired disorders that result in altered renal fxn:
nephrotic syndrome
acute glomerulonephritis
hemolytic-uremic syndrome

Question 24

nephrotic syndrome

Answer 24

kidneys lose significant amount of protein in urine, resulting in low blood levels of protein
not specific disease, but clinical state characterized by:
proteinuria
hypoalbuminemia
hyperlipidemia (compensatory mechanism for liver to secrete fats)
edema

Question 25

nephrotic syndrome

Answer 25

classified as primary/ secondary MCNS results from disorder w/in glomerulus if nephrons allow increased protein to escape from blood, leads to edema/ hypoalbuminemia glomerular injury--> protein leakage into urinary space--> plasma volume down, CO down--> stimulation of RAAS--> sodium & H2O rentention--> expansion of sodium space--> edema

Question 26

nephrotic syndrome

Answer 26

``` primary occurs predominantly in preschool children incidence peaks btwn 2-3 yrs syndrom rare after age 8 more common in boys some forms may progress to ESRD characteristic s/sx include: edema/ weight gain excessive clotting factors hyperlipidemia low serum sodium ```

Question 27

nephrotic syndrome

Answer 27

clinical manifestations by body system: renal- oliguria; dark, frothy urine CV- normotensive; HTN later vascular- thrombosis GI- anorexia, abd pain, N/V/D skin- pallor, shiny w/ prominent veins, brittle hair, edema, skin breakdown pulmonary- resp distress & pulmonary congestion diagnostic tests: UA- severe proteinuria (primary indicator), hematuria & casts; elevated spec gray bc of proteinuria renal biopsy- identifies type of nephrotic syndrome child has, & can be used to monitor response to medical management blood studies show serum creatanine, BUN, cholesterol

Question 28

nephrotic syndrome

Answer 28

treatment depends on cause of disease, may include: corticosteroids (PREDNISONE)- reduce swelling/ excretion of protein in urine; take RX x 6 wks, then taper diuretics- help w/ swelling ace inhibitors antithromboltiics- hyperlipidemia NSAIDs

Question 29

nephrotic syndrome discharge planning

Answer 29

parents need to monitor protein in urine daily using dipsticks understand that relapses do occur no added salt diet monitor daily weight no s/sx of disease for 2 yrs= disease free

Question 30

APSGN (acute poststrep glomerulonephritis)

Answer 30

most often response to GABHS infection of skin/ pharynx other organisms- staph, pneumococcus, coxsackievirus abx are for strep infection, not APSGN body responds to strep bacteria by forming antibodies, which combine w/ bacterial antigens to form antigen-antibody complexes--> these get trapped in glomerulus & cause inflammatory response

Question 31

APSGN

Answer 31

``` highest in ages 2-12 more common during winter/ spring months child typically has recent respiratory infection (w/in 1-2 wks)/ strep/ impetigo; recovers, then develops after 8-14 days clinical manifestations: abrupt onset of abdominal pain irritability microscopic hematuria (most all cases) acute HTN nonspecific s/sx: include general malaise, weakness, anorexia ```

Question 32

APSGN

Answer 32

clinical manifestations: dark urine (brown, tea, cola colored)- OFTEN 1ST CLINICAL S/SX dark urine caused by hemolysis of RBC that have penetrated glomerular basement membrane & passed into tubular system periorbital edema/ dependent edema- onset of puffiness of face/ eyelids is sudden; usually prominent upon awakening in some cases- generalized edema & other features of circulatory congestion, such as dyspnea, may be present edema is result of defect in renal excretion of salt & water, can result in acute HTN- HIGH STROKE RISK

Question 33

APSGN lab findings

Answer 33

``` hematuria proteinuria leukocytes decreased serum protein anemia ESR increased serum IgG antibodies against strep + circulatory overload causing EKG changes ```

Question 34

APSGN nursing care

Answer 34

VS, especially BP F&E's w/ strict I&O's, specific gravity daily weights urine dipstick for +hematuria, + proteinuria assess edema (periorbital, dependent) measure abdominal girth auscultate heart/ lung sounds, not respiratory effort monitor neurologic signs secondary to HTN (LOC, HA, sz activity, vomiting)

Question 35

glomerulonephritis vs/ nephrotic syndrome

Answer 35

APSGN: manifestations- hematuria, edema, school age, HTN management- supportive, antihypertensives, low Na+ diet NS: manifestations- proteinuria, edema (insidious onset, large amount), hypovolemia, normotensive (until later stages), pallor, fatigue, toddler management- prednisone to initiate remission diuretics, possible abx, possible albumin, no salt diet

Question 36

hemolytic uremic syndrome (HUS)

Answer 36

``` 3 features: hemolytic anemia thrombocytopenia ARF features an antecedent diarrheal illness e. coli--> majority of cases 6 mos- 4 yrs ```

Question 37

causes of HUS

Answer 37

``` antecedent diarrheal illness idiopathic inherited drug related assoc w/ malignancies transplantation malignant HTN tx: maintaining acid/ base balance, controlling HTN, & maintaining fluid balance supportive therapy ```

Question 38

dialysis

Answer 38

peritoneal dialysis- preferred method 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 time before removal

Question 39

hemodialysis

Answer 39

requires creation of vascular access & special dialysis equipment best suited for children who can be brought to facility 3x/ week for 4-6 hrs achieves rapid correction of fluid & electrolyte abnormalities