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NURSING MANAGEMENTNURSING MANAGEMENTOF GENITOURINARYOF GENITOURINARYDYSFUNCTION:DYSFUNCTION:
Theoretical Skills and Knowledge,Scientific Principles, Critical
Thinking, Healthcare Promotion,
Wellness and Illness, and StressAdaptation
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Lecture Objectives:Lecture Objectives:
1.1. Describe common renal and urinaryDescribe common renal and urinarydisorders that occur in children.disorders that occur in children.
2.2. Assess a child for a renal or urinary tractAssess a child for a renal or urinary tract
disorder.disorder.3.3. Formulate nursing diagnoses related toFormulate nursing diagnoses related to
renal or urinary tract disorders.renal or urinary tract disorders.
4.4. Establish outcomes related to the care ofEstablish outcomes related to the care of
a child with renal or urinary disorder.a child with renal or urinary disorder.5.5. Plan nursing care related to urinary orPlan nursing care related to urinary or
renal disorders.renal disorders.
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Lecture Objectives (cont.)Lecture Objectives (cont.)
6.6. Implement nursing care for the child with aImplement nursing care for the child with arenal or urinary disorder.renal or urinary disorder.
7.7. Evaluate outcomes for achievment andEvaluate outcomes for achievment andeffectiveness of care.effectiveness of care.
8.8. Analyze methods for making nursing care of theAnalyze methods for making nursing care of thechild with a renal or urinary disorder morechild with a renal or urinary disorder morefamily centered.family centered.
9.9. Compare and contrast acute and chronic renalCompare and contrast acute and chronic renal
failure.failure.10.10. Discuss the types of renal dialysis.Discuss the types of renal dialysis.
11.11. Assess for signs of kidney transplant rejection.Assess for signs of kidney transplant rejection.
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Reading Assignment:Reading Assignment:
Wong, Perry & Hockenberry
Ch. 50; p 1643-1669
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Renal System AssessmentRenal System Assessment Physical assessmentPhysical assessment
Palpation, percussionPalpation, percussion
Health historyHealth history
Previous UTIs, calculi, stasis,Previous UTIs, calculi, stasis,
retention, pregnancy, STDs, bladderretention, pregnancy, STDs, bladdercancercancer
Meds: antibiotics, anticholinergics,Meds: antibiotics, anticholinergics,antispasmodicsantispasmodics
Urologic instrumentationUrologic instrumentation
Urinary hygieneUrinary hygiene
Patterns of eliminationPatterns of elimination
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Nursing AssessmentNursing Assessment
of Urinary Tract Infectionof Urinary Tract Infection(UTI)(UTI)
Nausea, vomiting, anorexia,Nausea, vomiting, anorexia,
chills, nocturia, frequency,chills, nocturia, frequency,urgencyurgency
Suprapubic or lower back pain,Suprapubic or lower back pain,
bladder spasms, dysuria,bladder spasms, dysuria,burning on urinationburning on urination
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Nursing AssessmentNursing Assessmentof Urinary Tract Infectionof Urinary Tract Infection
(UTI)(UTI) Objective dataObjective data
FeverFever Hematuria, foulHematuria, foul--smelling urine; tender,smelling urine; tender,
enlarged kidneyenlarged kidney
Leukocytosis, positive findings forLeukocytosis, positive findings for
bacteria, WBCs, RBCs, pyuria,bacteria, WBCs, RBCs, pyuria,ultrasound, CT scan, IVPultrasound, CT scan, IVP
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Diagnostic StudiesDiagnostic Studies
Renal scanRenal scan
CystogramCystogram
RetrogradeRetrogradepyelogrampyelogram
UltrasoundUltrasound
CTCT
MRIMRI
Renal arteriogramRenal arteriogram
UAUA
Urine C&SUrine C&S
BUNBUN CreatinineCreatinine
KUBKUB
IVPIVPVCG/VCUGVCG/VCUG
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Normal UrinalysisNormal Urinalysis
pH: 5 to 9pH: 5 to 9 Sp gr: 1.001 to 1.035Sp gr: 1.001 to 1.035 Protein:
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Normal Characteristics of UrineNormal Characteristics of Urine
Color rangeColor range
ClearClear
Newborn productionNewborn productionapprox 1approx 1--22ml/kg/hrml/kg/hr
Child productionChild productionapprox 1 ml/kg/hrapprox 1 ml/kg/hr
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Urinary Tract Infection (UTI)Urinary Tract Infection (UTI)
Is itIs it reallyreally thatthatserious?serious?
Concept ofConcept ofasymptomaticasymptomaticbacteria in urinarybacteria in urinarytracttract
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Urinary Tract Infection (UTI)Urinary Tract Infection (UTI)
CausesCauses
Escherichia coliEscherichia coli mostmost
common pathogencommon pathogen StreptococciStreptococci
StaphylococcusStaphylococcus
saprophyticussaprophyticus Occasionally fungal andOccasionally fungal and
parasitic pathogensparasitic pathogens
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Classification of UTIClassification of UTI
Upper tract:Upper tract: involves renalinvolves renalparenchyma, pelvis, and uretersparenchyma, pelvis, and ureters
Typically causes fever, chills, flankTypically causes fever, chills, flankpainpain
Lower tract:Lower tract: involves lower urinaryinvolves lower urinarytracttract
Usually no systemic manifestationsUsually no systemic manifestations
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Classification of UTIClassification of UTI
Lower tractLower tract
CystitisCystitis
UrethritisUrethritis GlomeruloGlomerulo--
nephritisnephritis
Upper tractUpper tract
PyelonephritisPyelonephritis
VURVUR
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Classification of UTIClassification of UTI
Uncomplicated infectionUncomplicated infection
Complicated infectionsComplicated infections
StonesStones
ObstructionObstruction
CathetersCatheters
Diabetes or neurologicDiabetes or neurologicdiseasedisease
Recurrent infectionsRecurrent infections
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Types of UTIsTypes of UTIs
RecurrentRecurrentrepeated episodesrepeated episodes
PersistentPersistentbacteriuria despitebacteriuria despite
antibioticsantibiotics FebrileFebriletypically indicatestypically indicates
pyelonephritispyelonephritis
UrosepsisUrosepsisbacterial illness; urinarybacterial illness; urinarypathogens in bloodpathogens in blood
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Etiology andEtiology and
Pathophysiology of UTIPathophysiology of UTI Physiologic and mechanicalPhysiologic and mechanical
defense mechanisms maintaindefense mechanisms maintain
sterilitysterility Emptying bladderEmptying bladder
Normal antibacterial properties ofNormal antibacterial properties ofurine and tracturine and tract
Ureterovesical junctionUreterovesical junctioncompetencecompetence
Peristaltic activityPeristaltic activity
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Etiology and Pathophysiology ofEtiology and Pathophysiology of
UTIUTIAlteration of defenseAlteration of defense
mechanisms increases riskmechanisms increases risk
of UTIof UTI Organisms usuallyOrganisms usually
introduced via ascendingintroduced via ascendingroute from urethraroute from urethra
Less common routesLess common routes BloodstreamBloodstream
Lymphatic systemLymphatic system
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Etiology and Pathophysiology ofEtiology and Pathophysiology of
UTIUTI Contributing factor: urologicContributing factor: urologic
instrumentationinstrumentation
Allows bacteria present in opening ofAllows bacteria present in opening ofurethra to enter urethra or bladderurethra to enter urethra or bladder
Sexual intercourse promotesSexual intercourse promotesmilkingmilking
of bacteria from perineum andof bacteria from perineum andvaginavagina May cause minor urethral traumaMay cause minor urethral trauma
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Etiology and Pathophysiology ofEtiology and Pathophysiology of
UTIUTI UTIs rarely result fromUTIs rarely result from
hematogenous routehematogenous route
For kidney infection to occurFor kidney infection to occurfrom hematogenousfrom hematogenoustransmission, must have priortransmission, must have priorinjury to urinary tractinjury to urinary tract
Obstruction of ureterObstruction of ureter
Damage from stonesDamage from stones
Renal scarsRenal scars
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Etiology and Pathophysiology ofEtiology and Pathophysiology of
UTIUTI UTI is a common nosocomialUTI is a common nosocomial
infectioninfection
OftenOften E. coliE. coli
SeldomSeldom PseudomonasPseudomonas
Urologic instrumentationUrologic instrumentation
common predisposing factorcommon predisposing factor
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Clinical Manifestations of UTIClinical Manifestations of UTI
SymptomsSymptoms
DysuriaDysuria
Frequent urination (>q2h)Frequent urination (>q2h) UrgencyUrgency
Suprapubic discomfort orSuprapubic discomfort orpressurepressure
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Clinical Manifestations of UTIClinical Manifestations of UTI
Urine may contain visible blood orUrine may contain visible blood orsediment (cloudy appearance)sediment (cloudy appearance)
Flank pain, chills, and feverFlank pain, chills, and feverindicate infection of upper tractindicate infection of upper tract(pyelonephritis)(pyelonephritis)
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Pediatric ManifestationsPediatric Manifestations
FrequencyFrequency
Fever in some casesFever in some cases
Odiferous urineOdiferous urine Blood or bloodBlood or blood--tinged urinetinged urine
Sometimes NO symptomsSometimes NO symptoms
except generalized sepsisexcept generalized sepsis
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Pediatric ManifestationsPediatric Manifestations
Pediatric patients withPediatric patients withsignificant bacteriuria may havesignificant bacteriuria may haveno symptoms or nonspecificno symptoms or nonspecificsymptoms like fatigue orsymptoms like fatigue oranorexiaanorexia
So how do you find out?So how do you find out?
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Diagnostic Studies of UTIDiagnostic Studies of UTI
DipstickDipstick
MicroscopicMicroscopicurinalysisurinalysis
CultureCulture
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Diagnostic Studies of UTIDiagnostic Studies of UTI
CleanClean--catch is preferredcatch is preferred
UU--bag for collection from childbag for collection from child
Specimen obtained bySpecimen obtained bycatheterization or suprapubiccatheterization or suprapubicneedle aspiration has moreneedle aspiration has moreaccurate resultsaccurate results
May be necessary when cleanMay be necessary when clean--catchcatchcannot be obtainedcannot be obtained
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Diagnostic Studies of UTIDiagnostic Studies of UTI
Sensitivity testing determinesSensitivity testing determinessusceptibility to antibioticssusceptibility to antibiotics
Imaging studies for suspectedImaging studies for suspectedobstructionobstruction
IVP or Abd CTIVP or Abd CT
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Collaborative Care for UTICollaborative Care for UTI
Drug Therapy: AntibioticsDrug Therapy: Antibiotics Uncomplicated cystitis: shortUncomplicated cystitis: short--
term course of antibioticsterm course of antibiotics
Complicated UTIs: longComplicated UTIs: long--termtermtreatmenttreatment
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Collaborative Care for UTICollaborative Care for UTI
Drug Therapy: AntibioticsDrug Therapy: Antibiotics TrimethoprimTrimethoprim--sulfamethoxazole (TMPsulfamethoxazole (TMP--
SMX) or nitrofurantoinSMX) or nitrofurantoin
AmoxicillinAmoxicillin
CephalexinCephalexin OthersOthers
Gentamycin, carbenicillinGentamycin, carbenicillin ++++
Pyridium (OTC)Pyridium (OTC)
Combination agents (e.g., Urised) used toCombination agents (e.g., Urised) used torelieve painrelieve pain
Preparations with methylene blue tintPreparations with methylene blue tint
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Collaborative Care for UTICollaborative Care for UTI
Drug TherapyDrug Therapy For repeated UTIsFor repeated UTIs
Prophylactic or suppressiveProphylactic or suppressive
antibioticsantibiotics TMPTMP--SMX administered daily toSMX administered daily to
prevent recurrence or singleprevent recurrence or singledose before events likely todose before events likely to
cause UTIcause UTI
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Etiology and PathophysiologyEtiology and Pathophysiology
of Acute Pyelonephritisof Acute Pyelonephritis Inflammation caused byInflammation caused by
bacteria, fungi, protozoa, orbacteria, fungi, protozoa, or
viruses infecting kidneysviruses infecting kidneys Urosepsis: systemic infectionUrosepsis: systemic infection
from urologic sourcefrom urologic source
Can lead to septic shock and deathCan lead to septic shock and deathin 15% of casesin 15% of cases
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Etiology and PathophysiologyEtiology and Pathophysiology
of Acute Pyelonephritisof Acute Pyelonephritis Usually infection isUsually infection is
via ascendingvia ascending
urethral routeurethral route Frequent causesFrequent causes
E. coliE. coli
Proteus
Proteus
KlebsiellaKlebsiella
EnterobacterEnterobacter
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Etiology and PathophysiologyEtiology and Pathophysiology
of Acute Pyelonephritisof Acute Pyelonephritis Commonly starts in renalCommonly starts in renal
medulla and spreads tomedulla and spreads to
adjacent cortexadjacent cortex Recurring episodes lead toRecurring episodes lead to
scarred, poorly functioningscarred, poorly functioningkidney and chronickidney and chronicpyelonephritispyelonephritis
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Clinical ManifestationsClinical Manifestations
of Acute Pyelonephritisof Acute Pyelonephritis Vary from mild to classic and very severeVary from mild to classic and very severe
Presenting symptomsPresenting symptoms
N/V, anorexia, chills, nocturia, frequency,N/V, anorexia, chills, nocturia, frequency,urgencyurgency
Suprapubic or low back pain, dysuriaSuprapubic or low back pain, dysuria
Fever, hematuria, foulFever, hematuria, foul--smelling urinesmelling urine
Costovertebral tendernessCostovertebral tenderness
Symptoms often subside in a few days, evenSymptoms often subside in a few days, evenwithout therapywithout therapy
Bacteriuria and pyuria still persistBacteriuria and pyuria still persist
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Diagnostic StudiesDiagnostic Studies
of Acute Pyelonephritisof Acute Pyelonephritis UrinalysisUrinalysis
WBC castsWBC casts
CBCCBC Imaging studies (IVPImaging studies (IVP
or CT)or CT)
UltrasoundUltrasound
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Collaborative CareCollaborative Care
of Acute Pyelonephritisof Acute Pyelonephritis HospitalizationHospitalization
ParenteralParenteral
antibioticsantibiotics
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Collaborative CareCollaborative Care
of Acute Pyelonephritisof Acute Pyelonephritis Relapses treated with 6Relapses treated with 6--weekweek
course of antibioticscourse of antibiotics
Reinfections treated asReinfections treated asindividual episodes orindividual episodes ormanaged with longmanaged with long--termtermtherapytherapy
Prophylaxis may be used forProphylaxis may be used forrecurrent infectionsrecurrent infections
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Types of GlomerulonephritisTypes of Glomerulonephritis
Most are postinfectiousMost are postinfectious Pneumococcal, streptococcal,Pneumococcal, streptococcal,
or viralor viral
May be distinct entityMay be distinct entity oror May be a manifestation ofMay be a manifestation of
systemic disordersystemic disorder SLESLE
Sickle cell diseaseSickle cell disease OthersOthers
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GlomerulonephritisGlomerulonephritis
SymptomsSymptoms Generalized edema due toGeneralized edema due to
decreased glomerular filtrationdecreased glomerular filtration
Begins with periorbitalBegins with periorbital
Progresses to lower extremitiesProgresses to lower extremitiesand then to ascitesand then to ascites
HTN due to increased ECFHTN due to increased ECF
OliguriaOliguria
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Glomerulonephritis SymptomsGlomerulonephritis Symptoms
HematuriaHematuria
Bleeding in upper urinaryBleeding in upper urinary
tracttract
smoky urinesmoky urine ProteinuriaProteinuria
Increased amount of protein =Increased amount of protein =increased severity of renal diseaseincreased severity of renal disease
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Acute PostAcute Post--StreptococcalStreptococcal
GlomerulonephritisGlomerulonephritis Is a noninfectious renal diseaseIs a noninfectious renal disease
AutoimmuneAutoimmune
Onset 5 to 12 days afterOnset 5 to 12 days after otherother type oftype ofinfectioninfection
Often group A Often group A --hemolytic streptococcihemolytic streptococci
Most common in 6 to 7 years oldMost common in 6 to 7 years old
Uncommon in
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Diagnosing APSGDiagnosing APSG
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PrognosisPrognosis
95%95%rapid improvement torapid improvement tocomplete recoverycomplete recovery
5% to 15%5% to 15%chronicchronicglomerulonephritisglomerulonephritis
1%1%irreversible damageirreversible damage
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Nursing Management ofNursing Management of
APSGAPSG Manage edemaManage edema Daily weightsDaily weights
Accurate I&OAccurate I&O
Daily abdominal girthDaily abdominal girth
NutritionNutrition Low sodium, low toLow sodium, low to
moderate proteinmoderate protein
Susceptibility to infectionsSusceptibility to infections
Bed rest is not necessaryBed rest is not necessary
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Nephrotic SyndromeNephrotic Syndrome
Most common presentation ofMost common presentation ofglomerular injury in childrenglomerular injury in children
CharacteristicsCharacteristics ProteinuriaProteinuria
HypoalbuminemiaHypoalbuminemia
HyperlipidemiaHyperlipidemia
EdemaEdema
Massive urinary protein lossMassive urinary protein loss
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Types of NephroticTypes of Nephrotic
SyndromeSyndrome Minimal change nephrotic syndromeMinimal change nephrotic syndrome(MCNS)(MCNS)AKAAKA
Idiopathic nephrosisIdiopathic nephrosis Nil diseaseNil disease Uncomplicated nephrosisUncomplicated nephrosis Childhood nephrosisChildhood nephrosis Minimal lesion nephrosisMinimal lesion nephrosis
Congenital nephrotic syndromeCongenital nephrotic syndrome Secondary nephrotic syndromeSecondary nephrotic syndrome
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Changes in NephroticChanges in Nephrotic
SyndromeSyndrome Glomerular membraneGlomerular membrane Normally impermeable to large proteinsNormally impermeable to large proteins
Becomes permeable to proteins,Becomes permeable to proteins,especially albuminespecially albumin
Albumin lost in urineAlbumin lost in urine(hyperalbuminuria)(hyperalbuminuria)
Serum albumin decreasedSerum albumin decreased(hypoalbuminemia)(hypoalbuminemia)
Fluid shifts from plasma to interstitialFluid shifts from plasma to interstitialspacesspaces
HypovolemiaHypovolemia
AscitesAscites
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Nephrotic SyndromeNephrotic Syndrome
ManagementManagement Supportive careSupportive care DietDiet
Low to moderate proteinLow to moderate protein Sodium restrictions when largeSodium restrictions when large
amount edema presentamount edema present SteroidsSteroids
2 mg/kg divided into BID doses2 mg/kg divided into BID doses Prednisone drug of choice ($$ andPrednisone drug of choice ($$ and
safest)safest) Immunosuppressant therapyImmunosuppressant therapy(Cytoxan)(Cytoxan)
DiureticsDiuretics
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Family IssuesFamily Issues
Chronic condition with relapsesChronic condition with relapses Developmental milestonesDevelopmental milestones Social isolationSocial isolation
Lack of energyLack of energy
Immunosuppression/protectionImmunosuppression/protection Change in appearance due toChange in appearance due to
edemaedema
SelfSelf--imageimage
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Nursing InterventionsNursing Interventions
Aseptic technique duringAseptic technique duringcatheterizationscatheterizations
Avoid unnecessary catheterizationAvoid unnecessary catheterizationand early removal of indwellingand early removal of indwellingcatheterscatheters
Prevents nosocomial infectionsPrevents nosocomial infections
Wash hands before and after contactWash hands before and after contact
Wear gloves for care of urinary systemWear gloves for care of urinary system
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Nursing InterventionsNursing Interventions
Routine and thorough perineal careRoutine and thorough perineal carefor all hospitalized patientsfor all hospitalized patients
Avoid incontinent episodes byAvoid incontinent episodes byanswering call light and offeringanswering call light and offeringbedpan at frequent intervalsbedpan at frequent intervals
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Nursing InterventionsNursing Interventions
Ensure adequate fluid intakeEnsure adequate fluid intake(patient with urinary problems may(patient with urinary problems maythink will be more uncomfortable)think will be more uncomfortable)
Dilutes urine, making bladder lessDilutes urine, making bladder lessirritableirritable
Flushes out bacteria before they canFlushes out bacteria before they can
colonizecolonizeAvoid caffeine, alcohol, citrus juices,Avoid caffeine, alcohol, citrus juices,
chocolate, and highly spiced foodschocolate, and highly spiced foods
Potential bladder irritantsPotential bladder irritants
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Nursing InterventionsNursing Interventions
Discharge to home instructionsDischarge to home instructions
FollowFollow--up urine cultureup urine culture Recurrent symptoms typically occur in 1 to 2Recurrent symptoms typically occur in 1 to 2
weeks after therapyweeks after therapy
Encourage adequate fluids even afterEncourage adequate fluids even afterinfectioninfection
LowLow--dose, longdose, long--term antibiotics toterm antibiotics toprevent relapses or reinfectionsprevent relapses or reinfections
Explain rationale to enhance complianceExplain rationale to enhance compliance
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HemolyticHemolytic--UremicUremicSyndromeSyndrome
PathophysiologyPathophysiology
Diagnostic evaluationDiagnostic evaluation
TherapeuticTherapeuticmanagementmanagement
PrognosisPrognosis
Nursing considerationNursing consideration
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Wilms TumorWilms Tumor
EtiologyEtiology
Diagnostic evaluationDiagnostic evaluation
Therapeutic managementTherapeutic management Surgical removalSurgical removal
Chemotherapy and/orChemotherapy and/orradiationradiation
Nursing considerationsNursing considerations
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Renal FailureRenal Failure
Acute renal failure (ARF)Acute renal failure (ARF)
Chronic renal failureChronic renal failure
(CRF)(CRF)
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Acute Renal Failure (ARF)Acute Renal Failure (ARF)
Definition: kidneys suddenly unableDefinition: kidneys suddenly unableto regulate volume and compositionto regulate volume and compositionof urineof urine
Not common in childrenNot common in children
Principal feature is oliguriaPrincipal feature is oliguria
Associated with azotemia, metabolicAssociated with azotemia, metabolicacidosis, and electrolyte disturbancesacidosis, and electrolyte disturbances
Most common pathologic cause:Most common pathologic cause:transient renal failure resulting fromtransient renal failure resulting from
severe dehydrationsevere dehydration
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Acute Renal Failure (ARF)Acute Renal Failure (ARF)
PathophysiologyPathophysiologyusuallyusuallyreversiblereversible
Diagnostic evaluationDiagnostic evaluation Therapeutic managementTherapeutic management
Nursing considerationsNursing considerations
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Complications of ARFComplications of ARF
HyperkalemiaHyperkalemia
HypertensionHypertension
AnemiaAnemia SeizuresSeizures
HypervolemiaHypervolemia
Cardiac failure with pulmonaryCardiac failure with pulmonaryedemaedema
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Chronic Renal Failure (CRF)Chronic Renal Failure (CRF)
Begins when diseased kidneysBegins when diseased kidneyscannot maintain normal chemicalcannot maintain normal chemicalstructure of body fluidsstructure of body fluids
Clinical syndrome calledClinical syndrome called uremiauremia
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Potential Causes of CRFPotential Causes of CRF
Congenital renal and urinaryCongenital renal and urinarytract malformationstract malformations
VUR associated with recurrentVUR associated with recurrentUTIsUTIs
Chronic pyelonephritisChronic pyelonephritis
Chronic glomerulonephritisChronic glomerulonephritis
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CRF (contd)CRF (contd)
PathophysiologyPathophysiology
Diagnostic evaluationDiagnostic evaluation
Therapeutic managementTherapeutic management Manage diet, hypertension,Manage diet, hypertension,
recurrent infections, seizuresrecurrent infections, seizures
Nursing considerationsNursing considerations
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DialysisDialysis
PeritonealPeritonealdialysisdialysis
HemodialysisHemodialysis
HemofiltrationHemofiltration
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Peritoneal DialysisPeritoneal Dialysis
The preferred method of dialysis forThe preferred method of dialysis forchildrenchildren
Abdominal cavity acts asAbdominal cavity acts as
semipermeable membrane forsemipermeable membrane forfiltrationfiltration
Can be managed at home in someCan be managed at home in somecasescases
Warmed solution enters peritonealWarmed solution enters peritonealcavity by gravity, remains for period ofcavity by gravity, remains for period oftime before removaltime before removal
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HemodialysisHemodialysis
Requires creation of a vascularRequires creation of a vascularaccess and special dialysisaccess and special dialysisequipmentequipment
Best suited for children who can beBest suited for children who can bebrought to facility 3 times/weekbrought to facility 3 times/weekfor 4 to 6 hoursfor 4 to 6 hours
Achieves rapid correction of fluidAchieves rapid correction of fluidand electrolyte abnormalitiesand electrolyte abnormalities
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TransplantationTransplantation
From living related donorFrom living related donor
From cadaver donorFrom cadaver donor
Primary goal is LT survival ofPrimary goal is LT survival of
grafted tissuegrafted tissue
Role of immunosuppressant therapyRole of immunosuppressant therapy