chapter 46 renal/urinary tract disorders review a&p review normal urinalysis & child’s...
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Chapter 46 Renal/Urinary Tract Disorders Review A&P Review normal urinalysis & child’s output-
pg 1347 Review diagnostic studies Dialysis covered in critical care-procedure
same for children
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Exstrophy of the Bladder Midline closure defect during first 8 weeks
of embryonic life Bladder lies open & exposed on abdomen Pic 1354
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Assessment-revealed by fetal sonogram Bladder appears bright red & continually
drains urine from open surface Epispadius may also be present-males Mgt-surgical repair
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Preop-keep exposed bladder covered by a sterile plastic bowel bag
Prevent skin from excoriation Infants legs may be flexed & brought
together & wrapped to prevent further separation of the symphysis
Position on back
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Postop- one or two step procedure Position infant on back or in infant seat,
prevent contamination from feces, indwelling or suprapubic catheter inserted to allow new bladder to rest. Immediately postop-urine may be blood tinged but should clear after couple of hours.
Antispasmodics, antibiotics & analgesics, bracing of pubic bones(4-6 weeks)
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Hypospadius Urethral opening not at end of penis but
on lower aspect Pics 1355 Assess for other defects Mgt-don’t circumcise-foreskin may be
needed for surgical repair Postop-urinary urethral catheter-may
notice painful bladder spasms as long as the catheter is in place (3-7 days)
Analgesics, antispasmodics
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UTI Assessment-dysuria, frequency, burning &
hematuria Low grade fever, abdominal pain &
enuresis Pyelonephritis-high fever, abdominal or
flank pain, vomiting & malaise Mgt-antibiotics, analgesics, increased
fluids. Teaching-1356
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Reflux Retrograde flow of urine from bladder to ureters
r/t defective valve Assess-history of repeated UTI’s, voiding
cystogram Mgt-double voiding techniques, prophylactic
antibiotics, corrected by cystoscopy Postop-suprapubic catheter & 2 ureteral stents-
observe closely every hour for first 24 hrs & then every 4. Note color & amount of drainage-initially bloody but will clear in 24-48h.Analgesics & antispasmodics, sterile drsg to absorb leaking urine-no tub baths until suprapubic site closed completely
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Hydronephrosis Enlargement of the pelvis of the kidney
with urine as a result of back pressure in the ureter generally caused by obstruction
Children usually asymptomatic, may have repeated UTI’s, elevated BP, flank & abdominal discomfort
Tx-surgical correction of obstruction
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Enuresis Usually nocturnal Children older than 5 need evaluated for
an organic cause Assess for-stress, abdominal pain, UTI Mgt-Limit stress, limit fluids after dinner
(not if sickle cell ). May be prescribed DDAVP. May need bladder stretching exercises
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Kidney Agenesis Absence of a kidney often has Potter’s
syndrome( misshapen low set ears & stiff, inflexible lungs from the lack of amniotic fluid in utero).
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Polycystic kidney-”Potter facies”-wide spaced eyes, epicanthal folds, flattened nose & small jaw. May be associated with a cerebral aneurysm. Tx-surgical removal of kidney or transplantation
Renal hypoplasia-small, underdeveloped kidneys-transplantation
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Prune Belly Syndrome
Pic 1361 Severe urinary tract dilation mainly in
boys Three symptoms: deficiency of usual
abdominal muscle tone; bilateral undescended testes; dilated faulty development of the bladder & upper urinary tract
Kidney transplantation
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Acute Glomerulonephritis Assessment-usually 5-10 yrs of age post
strept infection All children who had impetigo, strept
infections should have a urinalysis 2 weeks post infection to evaluate for glomerulonephritis
Sudden onset of hematuria & proteinuria-urine appears tea colored, reddish-brown or smokey
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Abdominal pain, low grade fever, edema, N&V or headache
Elevated protein, elevated ESR rate, Bun & creatinine increase, mild anemia due to increased blood volume
Mgt-course 1-2 weeks-quiet play-return to school after kidney function is normal. Daily wts, I&O
Diet, antibiotics & diuretics usually not ordered unless heart failure occurs=Lasix, digoxin, semi-fowlers, & oxygen
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Chronic glomerulonephritis May follow acute glomerulonephritis or nephrotic
syndrome Alport’s syndrome-progressive chronic
glomerulonephritis inherited as an autosomal dominant disorder
Acute symptoms of edema, hematuria, hypertension or oliguria.
TX-symptomatic-antihypertensives, bedrest, diuretics, corticosteroids
Prognosis poor. May need dialysis or transplantation
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Nephrotic Syndrome ( Nephrosis) Altered glomeruli permeability d/t fusion of
the glomeruli membrane surfaces causing abnormal loss of protein in urine
Three forms: congenital: secondary (sickle cell, SLE; or primary
Four characteristic symptoms: proteinuria; edema; low serum albumin; hyperlipidemia
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Assess-periorbital edema usually most prominent when they wake up, ascites-clothes don’t fit, skin becomes pale, stretched & taut
Table-pg1364
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Mgt-corticosteroids such as prednisone-give every other day. Cytoxin for immunosupprssion if don’t respond to corticosteroids
Foods high in potassium-1365 Foods high in potassium especially if
receiving diuretics, fluid & sodium may be restricted during acute phase.
Keep child in semi fowlers-more comfortable & reduces periorbital edema
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Hemolytic-Uremic Syndrome Occurs during summer in children 6mon-
4yrs of age following recent Ecoli infection Transient diarrhea, fever, hematuria,
oliguria, edema, petechiae Supportive tx to maintain heart & kidney
function ie peritoneal dialysis Most recover completely but some have
chronic renal impairment or may die
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Renal Failure Oliguria-output <1ml/kg/wt/hr Azotemia, uremia, hyperkalemia Tx-IVF’s, diuretics, daily wts, I&O, diet-low
pro, K,& Na & high in CHO Peritoneal or Hemodialysis Kidney transplantation