Caring for patients with alterations in the genitourinary system

Kidney is large in relations to stomach making the kidney more prone to injury, Urethra is shorter increasing the risk for UTIs, *Shorter urethra in boys ⬆️risk for UTIs, *Females are at increase risk for UTI due to their shorter urethra and proximity of the urethral opening to the rectum, *Urine sample with any trauma!

Glomerular filtration rate is slower in infants (increasing their risk for dehydration), Bladder capacity is 30mL in newborn, Is at adult size 1-2 yrs old, Urine out should be 0.5-2mL/kg/hr (Sarah said to just think of it as 1mL/kg/hr) (adult urine output frequency is 3-8 times/day)

Puberty hormonal changes, Adolescence reproductive organs mature

F: Pubic hair begins to curl and spread over mons pubis, genitalia pigmentation increases, F: Breast bud and areola continue to enlarge; no seperation of breasts, F: First menstrual period (average 12 yrs, normal range 9-16 yrs), M: Pubic hair spreads literally, begins to curl; pigmementation increases, M: Growth enlargement of testes in scrotum (scrotum reddish in color) and continued lengthening of penis, M: Leggy look due to extremities growing faster than the trunk

F: Pubic hair becomes coarse in texture and continues to curl: amount of hair increases, F: Areola and papilla separate from the contour of the breast to form a secondary mound, M: Pubic hair becomes coarser in texture and takes on adult distribution, M: Testes and scrotum continue to grow; scrotal skin darkens, penis grows in width, and glans penis develops, M: May experience breast enlargement, M: Voice changes more masculine due to rapid enlargement of larynx and pharynx as well as lung changes

F: Mature pubic hair distribution and coarseness, M: Mature pubic hair distribution and coarseness, M: Breast enlargement disappears, M: Adult size and shape of testes, scrotum, and penis; scrotal skin darkening

CBC, BUN, electrolytes, Cr, total protein, albumin, UA (clean catchm, suprapubic, catheterized) C&S, Greatinine clearance, Timed urine collections (24 hrs) for Cr, total protien

Cystoscopy, urodynamic studies, Voiding cystourethrogram (VCUG, looks for reflux of urine using contrast), Renal ultrasound, IV pyelogram (IVP), Renal biopsy

Family history, Birth history, Past medical history, Chief complaint or HPI, *Hx: of allergies kids with geneti urologic malformations at higher risk for late allergy, *Hx: of renal disorders, DM type 1, gestational DM, fequency of UTIs

Voiding patterns or changes, Cramping or pain (Suprapubic, abdomen, or flank pain), Fever-infeciton, Toilet training (when potty trained, were they potty trained and now experience ping incontinence or never potty trained), *Prior spinal disturbance can affect urination (spina bifida), *Voiding changes to color or smell, visible blood, frothy or sentiment?

Observation (overall appearance of abd, genital are open diaper for infant, diaper rash, females/males use discretion and privacy (cluster care with doctors), Ascultation- HR, BP, affected by kidneys and overall fluid status, Percussion (full bladder=dullness, a well as over spleen and kidneys if flank pain), Palpation (if known tumor do not palpate

Age of the child and developmental considerations will affect the collection technique -Specific gravity ONLY-can use cotton ball method -If potty trained and developmentally appropriate, can get clean catch urine sample, Urine collection bags are mose appropriate or infants and toddlers who are not toilet trained -Bags are not appropriate for diagnosing UTIs, UA sent to the lab vs urine dipstick -lab takes longer but its more accurate -dipstick factors may affect it, user error, sample contain stool, is quick and convenient, Urine C&S -***should be obtained using a sterile straight catheter*** -***Obtain culture before starting any abx***, (note in ppt)-Newly potty-trained toddlers may be elcutant to go in a place “unapproved” by parents -Toddlers and preschoolers are usually unable to void on request -Schoolaged children usually more cooperative but may have questions -Adolescents may be embarrassed to carry container, ensure privacy *make not of menses with the specimen so presence of blood is explained*

Discontinue non-indicated foleys, Foley indications include: accurate I/Os for critically ill pts, urinary retention or obstruction, periop used for selected procedures, neurogenic bladder, urinary incontinence in patients with open perineal or sacral wounds, or comfort for end of life

Insert foleys with sterile technique, Secure the catheter to patient, Maintain free flow of urine by eliminating kinks in tubing, Pericare should be performed and documented every shift and PRN (e.g. loose stool); clean perineum front to back, Empty catheter bag every shift or when drainage babe is 2/3 full, whichever occurs first, Do not rest collection bag on floor, Maintain a closed and sealed system when possible

Utilize nurse driven protocol when possible, Foleys should be removes when pt no loner meets criteria for use (no longer indicated)

Congenital midline closure defect leaving bladder exposed through surface of the abdomen, can vary in severity, Causes unknown but may be genetic and environmentally components, Risks- family hx, Caucasian race, male, IVF, pregnancy, *Infection prevention, skin integrity are key* (lots of incontinence), Surgery is required can be extensive involving urologist, orthopedic surgeon, plastic surgeon, Extensice post op care -pain management -external fixation for pelvis -drain and catheter management

Hypospadias- urethral opening is on the ventral side of the penis, Epispadias-urethral opening is on the dorsal surface of the penis, *Can occur anywhere along the length of the penis, *Can affect voiding, fertility with sperm path and erections, *Surgically corrected between 6mos-1yr, *Can occur with other GU disorders such inguinal hernia, hydrocele and cryptorchidsim, *Can occur in females very rare, mostly males

Pain management (analgesics), Antispasmodics (oxybutinin) (decreases bladder spasms), Monitor stent or catheter (in place 1 week), Strict I&O, Pressure dressing on penis to reduce swelling and bruising, Double diaper method where hole is cut in first and catheter tube fed through with an additional diaper on top (no drainiage bag) keeps urine and stool separate

No bathing (Sponge bath only), No straddling (holding or on toys, on hip) for 1 month, How to keep catheter/stent clean, Monitor output, Double diaper method, When to follow up, Good hand hygiene

Condition where urine back flows (retrograde flow) up the ureters during bladder contractions with voiding -Primary reflux- congenital abnormality -Secondary reflux-due to and acquired condition, Can be one sided or bilateral, Graded based on severity (usually stage 1&2 will resolve on own, more severe require suregery to fix) :1-4 (I-V) :Higher grades at risk for renal damage, Treatment goal-prevention of pyelonephritis and renal scaring (scarring can lead to HTN later in life and renal insufficiency or failure) -continuous abx prophylaxis -surgical corrections, Educate family on s/s of UTI (need to monitor closely!), How do you assess infants or developmentally delayed children that can’t express dysuria?, Voiding cystourethrogram (VCUG), *Is usually diagnosed after frequent UTIs, **This condition does not in itself ⬆️risk fo UTIs but if there is a UTI present this ⬆️ risk of pyelonephritis**

Lower UTI (urethra or bladder), Cystitis -dysuria frequency, hesitancy to void, urine incontinence, dribbling, Upper UTI (ureters, renal pelvis, calyces, of renal parenchyma) -Pyelonephritis -Fever flank pain nause and vomitting, Diagnosis -UA -Urine C&S (remember from a straight cath!), Managment -Abx -Encourage fluids -Fever, *-Empty bladder completely -could be helped by relaxed toilet posture for girls with feet supports on a stool and knees bent, *Some children benefit from “double voiding” (void, wait a few mins and void again), *Voiding after intercourse flushes bacteria introduce intro the urethra, *Recurrent UTIs or neurogenic bladder may be started on prophylactic abx (daily low dose)

Incontinence past the age of toilet training, Primary enuresis -Enuresis in the child who has never achieved bladder control, Secondary enuresis -Urinary incontinence in the child who previously demonstrated bladder control over a period of at least 3-6 consecutive months, Diurnal enuresis -Daytime loss of urinary control, Nocturnal enuresis -Nightime bed wetting

Rule out pathological reason (DM, diabetes insipidus, UTI, constipation) -Dysfuntional voiding (holding of urine) most common daytime causes -Nocturnal causes: drinking lots of water, OSA, sexual abuse, Limit fluid and bladder irritants in the evening, Voiding schedule during the day, Wake up during the night to void, Bed alarms or underwear alarms, Use patience, avoid punishment, Can be shameful or embarrassing for child, *Behavioral training: -Restriction or elimination of fluid after the evening meal -Avoidance of caffeinated and sugar containing beverages after 4 pm -Voiding schedule set throughout the day -Purposeful interruption of sleep to void -Enuresis alarms Reward system for children by parents

Increase in glomerular permeability resulting in abnormal protien (albumin) loss in the urine (decreased amount in the blood), Protienuria & hypoalbuminemia, Edema: The onset is insidious, first appears surrounding the eyes (periorbital) then slowly progresses to become generalized, Ascites (can cause ⬆️ work of breathing), Weight gain, Pitting edema in extremities, Severe muscle wasting, Anoxia & and fatigue, irritability, Normal or decreased BP (unless in renal failure than ⬆️ BP), Decreased urine output frothy urine

Urine exams: Heavy proteinuria -3+ to 4+, Serum albumin: this will be low, and value with remain <1g/dL, Hypercholesterolemia: This may show milky appearance to the plasma, Serum triglycerides: Elevated, BUN and Cr: remains in normal range but may be elevated in some cases

1: Congenital: inherited, 1: Idiopathic (most common in kids) called MCNS; minimal change nephrotic syndrom; onset by 6 yrs, 2: Infections (HIV, CMV, hep B, syphallis), 2: Systemic lupus erythamatous, 2: Diabetes, 2: Cancers

Daily weights, Strict I&O, urine dipsticks, Monitor for fever (high risk of infection), Follow fluid restriction if ordered, Pneumococcal vaccine, Encourage adequate nutrition: -Protien rich snacks -Sodium & fluid restriction, Education: -Infection prevention -Urine dipstick -Medication administration, Emotional support, Complications: anemia, infections poor growth, peritonitis, thrombosis, and renal failure

Corticosteroids -Take with food -Decreases protien wasting in urine -immunosuppressed now -Avoid live vaccines until 2 weeks after steroids, Diuretics such as furosemide -be aware of K+ levels, Albumin, Prophylactic abx, *Emotional support: chronic contion with remissions and relapses, freq. hospitalizations, social isolation, body image issues r/t steroid use and edema

OK great thanks!

Tx focuses on managing fluid volume and HTN management, Abx may be perscribed with evidence of current streptococcal infection, Vital signs with freq. BP monitoring -antihypertensive administration, Dietary and fluid restriction (low sodium or no added salt) management, Daily weight, Strict I&O, Urine dipsticks, Avoid NSAIDs (can decrease GFR), Focused assessment included cardiac, pulmonary, and neuro, Seizure precautions (⬆️BP can causes encephalopathy), Frequent rest periods

Injury to the glomerular blood vessels from bacterial toxins, chemicals and viruses, Commonly from toxin producing strain of E. coli, Vomitting, Pallor, Lethargy, Hemorrhagic signs (bruising, petechiae, bloody stool), Oliguria or Andria, CNS involvement (seizure coma)

Urine: proteinuria, hematuria, BUN and Cr. ⬆️, Secondary to anemia: low hgb and HCT, high reticulocyte count (immature RBCs), Typically preceded by diarrheal unless including hemorrhagic colitis, 1st upper resp or GI infection then sudden hemolysis and renal failure, GI infection from food contamination, swimming pools, animals, Primarily in infants and children 6mo-5yrs, Damage is due to micro thrombin events in kidneys, **3 KEY characteristics!** 1. Hemolytic anemia 2. Thrombocytopenia 3. Acute renal failure

Can be fromn viruses (adenovirus coxsakievirus), Toxins from bacteria such as e.coli, shigellae, and salmonellae, Hemolytic anemia- is the premature dectruction of RBCs, the condition may occur in association with some infections diseases, with certain inherited RBC disordered, or as a response to drugs or other toxic agents

Fluid restrictions, DW, strict I&O, Nutritional support with ⬆️calorie & carb: ⬇️ protein, sodium, potassium, and phosphorus diet ( avoid chips, soups, instant pudding, salt substitutes oranges prunes), Monitoring VS (⬆️BP) neuro signs, and lab values (including electrolytes and blood counts, Monitor: -Progressive renal impairement (oliguria, ⬆️Cr & serum potassium -Bleeding -Neuro impairment, Packed RBC transfusion and dialysis may be necessary, Educate family on safe food prep!

SUDDEN decline: in kidney fix resulting in a build up toxins, met waste, fluid & electrolytes, Usually reversible but can lead to chronic renal failure, Causes in pediatric renal failure: ⬇️Renal perfusion from shock, hemolytic anemia, nephrotoxic meds, Complications: CHF HTN Electrolyte imbalances Neuro complications Pulmonary edema

Azotemia is the accumulation of nitrogenous waste within the blood, Uremia is the production of toxic symptoms due to the retention of nitrogenous products, Labs: ⬆️BUN and Cr Protienuria or hematuria hyperkalemia hypercalcemia, Manage HTN (paremters needed for these meds!) -labetolol or procardia -recheck BP for effectiveness, Strict I&O, specific gravity, Monitor for fluid overload; diuretics, Dialyis if complications arise

Neuro complications from uremia, Nephrotoxic meds: cephalosporins, abx like vanco (check BUN creat and drug levels, Signs of hyperkalemia (muscle cramps, irregular pulse, or weakness), Hypocalcemia (muscle twitching or stiffness), Signs of fluid overload

Usually begins when the diseases kidneys can no longer maintain the normal chemical structure of body fluids under normal conditions. Progressive deterioration over months or years, Causes for chronic renal failure in peds: congenital structural defects, inherited conditions, or acquired conditons, Complitcations: Severe anemia HTN and HF Renal rickets (brittle bones) Growth retardation and delayed sexual maturation Depresison, anxiety, impaired social interaction, poor self esteem

Therapeutic management -Peritoneal dyalsis or hemodialysis -Kidney transplant -Medicatitons to treat complications: hypocalcemis & hyperphosphatemia, anemia, metabolic acidosis, growth retardation, nurtritional deficiency, Promoting growth: -Nutritional support within imposed dietary restrictions, Encourage psychosocial well-being -Involve social work or psychology for those exhibiting depression or anxiety -Ensure that family is aware of the financial and support resources with the community, Suggest involvement in American kidney foundation, *dialysis

UTI may result from urinary stasis behind the labia, The vaginal orifice may become inaccessible if left untreated, Younger children under 5 higher risk, Tx: Topical estrogen cream (daily twice daily), Tx: Petroleum jelly applied to labia daily for 1 month following labial seperation to prevent recurrence of adhesions

Inflammation of upper femal genital tract, Can include the fallopian tubes, ovaries, or peritoneum, Caused by bacteria traveling through the cervix or vagina to upper tract, Most common bacterial culprits from chlamydia and gonorrhea, Treat with a abx, fluids, and pain meds (usually outpatient), Education of prevention: -Use of condoms or abstinence -STI screening -Avoid vaginal douche as it can cause overgrowth of bacteria -Treat all sexual partners

Fever, Abdominal pain, Pain with intercourse, Dysmenorrhea (painful menstrual cycles), Abnormal uterine bleeding, Chronic pelvic pain, Ectopic pregnancy, Infertility related to scarring

Known as undescended testicle (s), Failure of one or both testes to descend into scrotum, Causes- mechanical, hormonal, chromosomal, Retractile testes can be pushed back into scrotum where undescended testes cannot, Tx: Surgical correction if not resolved by 6 mo, Tx: Higher risk of sterility and testicular cancer if not correct by school-age years, Tx: Surgical procedure- called an orchiopexy repositions testicles, Nursing management: -pain control -skin glue -no rough play or straddle toys 2-4 weeks after surgery -no submerging in water for 2-4 weeks!

Hydrocele- fluid in the scrotal sac and is seen in infant s and usually resolves by 1 yr, Varicocele- venous varicose try also the spermatic cord and swelling in scrotum can be associated with infertility, Usually resolves spontaneously, If not resolved, outpatient surgery is needed