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Genitourinary Alterations
NUR 264 – PediatricsAngela Jackson, RN, MSN
Developmental Differences
Kidney development begins in the first weeks of embryo development
Primary function of the kidney prior to birth is to maintain adequate amniotic fluid levels
The newborn is unable to dispose of excess water & solutes rapidly or efficiently, which makes them prone to fluid volume excess
Loop of Henle is short in newborns, reducing their ability to reabsorb sodium & water resulting in very dilute urine
Urea synthesis and excretion are slower in newborn, which decreases concentration ability
Developmental Differences
Newborns retain large quantities of nitrogen and essential electrolytes to meet growth needs in first few weeks which decrease concentration ability
Hydrogen ion excretion, acid secretion and sodium bicarbonate levels are decrease during the first year of life. Severe metabolic acidosis develops more rapidly
Sodium excretion is decreased and kidneys are less able to adapt to sodium deficiency or excess. Inadequate sodium reabsorption from tubules result in increased sodium losses in diarrhea and vomiting
Developmental Differences
Newborn’s bladder lies in the abdomen. The bladder is in the pelvis by puberty
Control of detrusor & urethral sphincter function to control process of urination by 4 years old
Shorter urethra in children contributes to urinary infections
The kidneys are less protected in the child compared with the adult because of unossified ribs, less fat padding, and the larger size of the kidney proportional to the abdomen.
Bladder capacity increases with age from 20-50 ml at birth to 700 ml by adulthood
Reproductive system is functionally immature until puberty
Vesicoureteral Reflux (VUR) Backflow of urine from the bladder up the ureter
to the kidney Occurs when the site where the ureter enters
the bladder fails to maintain a unidirectional flow Most common anatomic disorder affecting the
genitourinary tract Familial reflux is common
Reflux is present in one-third of siblings who have an affected brother or sister
Also a high incidence of transmission from parent to child
VUR: Pathophysiology In normal anatomy the ureter extends
from the kidney to the bladder. It then passes through the bladder wall for a distance that enables the ureter to act as a sphincter. The ureter at this point functions as a one-way valve to prevent the backflow of urine
With VUR, the ureter is not long enough to perform these functions and reflux occurs
VUR: Clinical Manifestations
May be asymptomatic Persistent and repeated urinary
tract infections Enuresis Flank pain Abdominal pain
VUR: Diagnosis
Cystogram Voiding cystourethrogram (VCUG) Reflux is graded on a scale of I to
V, with I being the least severe and V the most severe
VUR: Treatment The goals of medical management
are : Prevention of UTIs Prevention of kidney damage
Treatment includes: Surveillance Antibiotics
Surgical management may be necessary if medical management fails
VUR: Nursing Management
Education Importance of strict adherence to
medical regimen Proper hygiene Preparation for diagnostic studies
Nephrotic Syndrome (NS) Disorder of the kidney characterized by
altered glomeruli permeability, resulting in massive loss of protein in the urine
Primary, or idiopathic, is the most common type of nephrotic syndrome in children
NS affects boys more often than girls (2:1) NS usually occurs between ages 2 and 6,
peaking at age 2-3 years
NS: Pathophysiology Primary NS is thought to be an autoimmune
response resulting from an antigen-antibody reaction
Glomeruli become increasingly permeable to plasma protein, allowing massive urinary protein loss
Fluids shift from the intravascular to the interstitial space, resulting in edema
Hypoalbuminemia results from urinary loss of protein
Lipoprotein production increases, resulting in a rise in cholesterol and triglyceride levels
NS: Clinical Manifestations Proteinuria Weight gain Shifting edema
(morning Periorbital edema shifting to generalized edema throughout the day)
Oliguria
Dark, frothy urine Pallor Irritability Fatigue Normal B/P Anorexia Abdominal pain
NS: Diagnosis
Urinalysis reveals massive proteinuria (3+ to 4+)
Hypoalbuminemia (serum albumin <2.5gm / dl)
Hyperlipidemia
NS: Treatment
Corticosteroids Diuretics when severe edema is
present Albumin Dietary restrictions Immunosuppressant medications
are used when steroid therapy fails
NS: Nursing Management Strict I & O, closely monitor VS, daily weight Reposition frequently Measure abdominal girth Monitor serum and urine electrolytes and
protein as ordered Assess for edema and dehydration Monitor skin integrity Monitor for signs and symptoms of infection Administration of medication as ordered Teach parents to test urine for protein with
dipstick
Acute Glomerulonephritis (AGN)
Acute inflammation of the glomeruli within the kidney
Results in acute renal failure Incidence peaks at seven years of
age, is unusual in children younger than three
Occurs more often in males
AGN: Pathophysiology Usually caused by a bacterial infection of
the throat or skin. The most common organism is streptococcus (group A beta)
Immune system responds to the bacteria by producing antibodies. The antibody/antigen reaction within the glomeruli forms immune complexes and inflammation occurs, damaging the glomeruli
AGN: Clinical Manifestations Gross hematuria Proteinuria Oliguria Periorbital edema Edema of face,
abdomen Pallor, lethargy,
irritability, headache
Abdominal pain, anorexia, vomiting
Dysuria Cloudy, brown
colored urine Fatigue Elevated blood
pressure ranging from mild to moderate
AGN: Diagnosis Urinalysis shows hematuria, proteinuria
and increased specific gravity Elevated blood urea nitrogen and
creatinine may be present Electrolytes are normal unless renal
failure is present Anemia is present as a result of
hemodilution Streptozyme test is positive Urine cultures are negative
AGN: Treatment
Goals of treatment are: Identification and treatment of the
source of the inflammation Maintenance of fluid and electrolyte
balance Maintenance of blood pressure within
the normal range
AGN: Treatment (cont.)
If child has normal B/P and urine output, may be managed at home
Children with generalized edema, oliguria, hypertension, and gross hematuria need to be admitted to the hospital
AGN: Treatment (cont.)
Treatment of the hospitalized child includes: Diuretics Antihypertensives Dietary restrictions Antibiotic therapy for treatment of
streptococcal infection
AGN: Nursing Management
Close monitoring of B/P Strict Intake and Output Daily weights Administration of medications as
ordered
Questions??