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Altered Genitourinary Function


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What is the function of the Renal System?
1. Formation & Excretion of urine
2. Fluid/Electrolyte balance
3. Acid/base balance
4. Blood pressure regulation
5. Stimulation of RBC production in bone marrow
6. Regulates Calcium metabolism

Growth & Development of Genitourinary System:
- FLUID is CRUCIAL to body chemistry
- Kidneys are still developing in children (less efficient at regulating electrolytes and acid-base balance)
- smaller bladder capacity
- No innvervation (supply of nerves) of stretch receptors (to let them know when they have to go to the bathroom)
- SHORTER urethra
- kidneys have less padding (more susceptible to trauma)

Nursing responsibilties related to the genitourinary system:
1. Assessment - assess EARS by looking for malformations (odd shape, pin holes, skin tags) - may indicate renal issues because ears develop the same time as the renal system); assess UMBILICAL CORD (if only one vessel, could indicate problem with renal system); assess the stream when they urinate (is it normal?)
2. I & O
3. Weight - weigh diaper then subtract the weight after urination (measure in grams)
4. Blood Pressure
5. Specimen collection - using cotton balls, urinary bag, catheterization (know whether or not it needs to be sterile)
6. Diagnostic tests

What are the normal characteristics of urine?
- Color (yellow to amber)
- Clear
- Newborn: 1-2 ml/kg/hr
- Child: 1 ml/kg/hr

What are the normal characteristics of urinalysis?
1. pH: 5-9
2. Specific gravity: 1.001 - 1.035
3. Protein: LESS than 20 mg/dL
4. Urobilinogen: UP to 1 mg/dL
5. None of the following:
- glucose
- ketones
- Hgb
- WBCs
- RBCs
- Casts
- Nitrates

What are 2 types of genitourinary tract disorders?
1. Urinary Tract Infection
2. Vesicoureteral Reflux
What are the PATHOGENIC causes of urinary tract infections (UTIs)?
1. E. Coli (most common - 85%)
2. Streptococci
3. Staphylococcus saprophyticus
4. occasionally fungal and parasitic pathogens (immunocompromised or if on antibiotics)

What are the NORMAL physiologic and mechanical DEFENCE mechanisms of the genitourinary system?
- emptying bladder
- normal antibacterial properties of urine & tract
- competent ureterovesical junction
- peristalic activity

What are the causes and pathophysiology of urinary tract infections (UTIs)?
1. Alterations of defence mechanisms (increased risk)
2. Organisms are usually introduced via ascending route from URETHRA
3. more common in GIRLS (shorter urethra and hygeine issues)
4. Urologic instruments (ex. catheters)
5. Sexual intercourse can cause bacteria to ascend from perineum and vagina
6. RARELY result from hematogenous route (bloodstream) - unless prior injury to urinary tract

What are the classifications of urinary tract infections (UTIs)?
1. Upper (more serious symptoms and can become systemic):
- Renal parenchyma (kidney tissue)
- pelvis
- ureters
ex. pylonephritis
2. Lower (more of an irritation and does not cause long-term damage)
- ex. cystitis (inflammation of bladder) and urethritis

What are common indications of urinary tract infections (UTIs) in neonates?
- poor feeding
- vomiting
- FTT (failure to thrive) - current weight and rate of weight gain is significantly lower than other children the same age and gender
- frequent urination
- jaundice

What are common indications of urinary tract infections (UTIs) in infants?
- Fever
- Foul-smelling urine
- vomiting

What are common indications of urinary tract infections (UTIs) in older children?
Older Children:
- urinary frequency
- pain with micturition (hurt when they urinate)
- abdominal pain
- unusual bedwetting (may be toilet trained but start to wet the bed again)

How are urinary tract infections (UTIs) diagnosed?
1. Microscopic analysis (WBCs / bacteria)
2. Urine Culture (clean catch specimen preferred, U-bag for collection from a child, catheterization or suprapubic aspiration)
3. Imaging studies (IVP - intravenous pyelogram [inserting dye and xray] or abdominal CT)

What nursing care is required for urinary tract infections (UTIs)?
1. Monitor I&O
2. Encourage frequent voiding
3. Encourage increased fluid intake
4. Acidify the urine
5. Medications (need to take full course of antibiotics)
6. Proper cleaning (front to back)
7. More frequent diaper changes
8. Cranberry juice (decreases speed of bacterial multiplication and decreases bacterial adhesion
9. Avoid bubble baths and perfume soaps (irritating)
10. Wear cotton underwear (more breathable)

What is Vesicoureteral Reflux (VUR)?
- retrograde flow of bladder urine into the ureters (backflow)
- Graded I-V for degree of reflux (1-5)
- Primary reflux is congenital (familial pattern)
- Secondary reflux - acquired (ex. from stones, scarring or damage to valves [ureters have one way valves but some children can have problems with that] ****sometimes associated with spina bifida)

What are the S&S of Vesicoureteral Reflux (VUR)?
- Fever (infection)
- Vomiting
- Urgency
- Dribbling
- Poor weight gain
- Abdominal mass

How to manage Vesicoureteral Reflux (VUR)?
- Grade I-II: Continuous LOW dose antibiotics
- Grade III-V: usually requires SURGICAL re-implantation of ureters (in another area of the bladder and use muscles to strengthen valves)
- Follow up renal ULTRASOUNDS

What are congenital disorders of the genitourinary system?
1. Hypospadias / Epispadias
2. Cryptorchidism
3. Hydronephrosis

What is the cause & pathophysiology of HYPOSPADIAS and EPISPADIAS?
****Associated with SPINA BIFIDA
- hypospadias (more common than epispadias) 1:500 newborns
- location of opening may be anywhere on under or upper side of penis
- does not interfere with voiding
- may interfere with reproduction if not repaired
- newborn assessment is important

How is Hypospadias and Epispadias managed?
- early identification
- Surgery BEFORE 18 MONTHS
- release of chordee (downward curvature of penis) before hypospadias repair
- circumcision is DELAYED

Postoperative care for hypospadias and epidspadias care:
1. Urethral stent
2. Restraints (need to be restrained)
3. Increased fluid intake / monitor I&O
4. Medications (pain medication / antispasmotic)
5. Discharge teaching
6. Monitor S&S for complications
7. Urinary Catheter (clamp and unclamp catheter until they establish normal urinary flow)
8. Usually bloody urine the 1st day postop

What is Cryptorchidism?
- Failure of one or both testes to descend from inguinal canal into the scrotum
- exposes the testes to body heat (lowering sperm count)
- Greater risk for:
1. Torsion (spermatic cord twists and cuts of blood supply causing ischemia)
2. Trauma
3. Cancer

How to manage Crytorchidism?
1. Human chorionic gonadotropin hormone (HCG) - stimulates testosterone
2. Orchiopexy (surgical procedure) - not complex; usually day surgery - may stay a few hours or overnight
3. Home instructions for early discharge

What is Hydronephrosis?
- Enlargement of renal pelvis and calyces (swelling of kidney and urine can\'t exit because of obstruction)
- usually CONGENITAL obstruction
- obstruction may lead to infection or abdominal mass [can be felt]
- can be caused by renal colic: obstruction by renal calculi - kidney stones
- various types of obstructions

How is Hydronephrosis managed?
1. Surgery (depends on severity and location of obstruction)
2. Pyelotomy: incision of the renal pelvis
3. Ablation: surgical removal of body tissue
4. Lithotripsy: non-invasive alternative to surgery for the treatment of kidney stones; uses high-energy shock waves to disintegrate the kidney stones
5. Post-op catheter or stent
6. May need permanent urinary diversion (if repair is not possible)

What is Enuresis?
- Repeated and involuntary voiding (by a child beyond the age that bladder control is expected)
- 50% at night
- 10% day
- 40% both
- primary, intermittent or secondary
- boys take longer to achieve bladder maturity

What causes Enuresis?
- neurological
- congenital structural disorders
- illness or stress (secondary)
- genetics (parental history of bedwetting)
- bladder has smaller functional capacity and neuromuscular maturation of inhibitory fibers is delayed (primary)

How is Enuresis managed?

- Multi-treatment approach
- fluid restrictions at night
- bladder training schedule
- enuresis alarms
- medication - antidepressant
- psychosocial support (positive reinforcement, is there any stress)
- involve child in treatment plan

What are 2 acquired renal health problems?
1. Acute Glomerulonephritis
2. Nephrotic Syndrome
What is Acute Glomerulonephritis?
- Inflammation / infection of the glomerulus of the kidney
- Acute post streptococcal glomerulonephritis (APSG) (most common form)
- preceded by a streptococcal infection (usually of skin or respiratory tract)

What are the S&S of Acute Glomerulonephritis?
1. Generalized edema (due to decreased filtration)
- periorbital (around the eyes)
- lower extremities
- ascites (accumulation of fluid in the abdominal cavity)
2. Hypertension (high BP)
3. Hematuria and Proteinuria (blood and protein in urine) - coke coloured
5. Oliguria (low amount of urine)
6. Lethargy (tired and not feeling well)
7. Anorexia (lack or loss of appetite for food)

What is Acute Post Streptococcal Glomerulonephritis (APSG)?
- Noninfectious renal disease (autoimmune)
- Onset: 5-12 days after other type of infection
- often Group A beta-hemolytic streptococci
- 6-7 YEAR OLDS (most common)
- Uncommon in really young children (especially under 2 years)

What is the prognosis of Acute Glomerulonephritis?
- VERY GOOD prognosis
- 95% - rapid improvement to complete recovery
- 5-15% - chronic glomerulonephritis
- 1% - irreversible damage

How is Acute Glomerulonephritis managed?
- Manage edema
- Nutrition - low to moderate protein intake
- monitor v/s (check BP, could be a rise) and mental status
- bed rest only during acute period
- medications - antihypertensives (require close monitoring), diuretics
- monitor electrolytes
- respiratory assessment (could be fluid on lungs)
- Check weight, abdominal girths

What is Nephrotic Syndrome?
- Most common glomerular injury in children
- Idiopathic (unknown cause)
What are the S&S of Nephrotic Syndrome?
- Proteinuria (protein in urine) - massive urinary protein loss
- Hypoalbuminemia (low protein [albumin] in blood
- Hyperlipidemia (high fat levels in blood)
- Edema (**No problem with hypertension)
- More common in boys

What is the pathophysiology of Nephrotic Syndrome?
- increased permeability of glomerular membrane allows albumin to pass into the urine
- kidneys reabsorb Na (sodium) and H2O (water)
- Protein deficiency leads to massive edema
- High risk for infection due to decreased immunoglobulins (visiting restrictions)
- Hyperlipidemia (high lipid content in blood) occurs secondary to liver stimulation by decreased volume of albumin
- pallor
- edema (***but NO hypertension)
- relapses often occur
(***see diagram of nephrotic syndrome in slides)

How is Nephrotic Syndrome managed?
- monitor weight, I&O and abdominal girth
- Diet
- Prevent infection
- regular turning schedule
- IV albumin
- Corticosteroids
- Diuretics

Compare Acute Glomerulonephritis to Nephrotic Syndrome
Acute Glomerulonephritis:
- 6-7 YEAR OLDS (school age)
- mild edema
- hypertension
- coke coloured urine

Nephrotic Syndrome:
- Preschoolers
- more severe edema (but NO hypertension)
- increased permeability
- protein in urine
- high risk for infection (restrict visitors)
- corticosteroids (reduce swelling)

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