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Disorders of the Genitourinary Tract

Disorders of the Genitourinary Tract

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Published by: atilano_patrick on Apr 05, 2010
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Disorders of the GenitoUrinary TractUrinary Tract Infection (UTI)1. General information1. Bacterial invasion of the kidneys or bladder 2. More common in girls, preschool, and school-age children3. Usually caused by E. coli; predisposing factors include poor hygiene, irritation from bubble baths, urinary reflux4. The invading organism ascends the urinary tract, irritating the mucosa and causing characteristic symptoms.2. Assessment findings1. Low-grade fever 2. Abdominal pain3. Enuresis, pain/burning on urination, frequency, hematuria3. Nursing interventions1. Administer antibiotics as ordered; prevention of kidney infection/glomerulonephritis important. (Note: obtain cultures before starting antibiotics.)2. Provide warm baths and allow child to void in water to alleviate painful voiding.3. Force fluids.4. Encourage measures to acidify urine (cranberry juice, acid-ash diet).5. Provide client teaching and discharge planning concerning1. Avoidance of tub baths (contamination from dirty water may allow microorganisms to travel up urethra)2. Avoidance of bubble baths that might irritate urethra3. Importance for girls to wipe perineum from front to back 4. Increase in foods/fluids that acidify urine.Vesicoureteral Reflux1. General information1. Regurgitation of urine from the bladder into the ureters due to faulty valve mechanism at the vesicoureteral junction2. Predisposes child to1. UTIs from urine stasis2. Pyelonephritis from chronic UTIs3. Hydronephrosis from increased pressure on renal pelvis2. Assessment findings: same as for urinary tract infections3. Nursing interventions for surgical reimplantation of ureters1. Assist with preoperative studies as needed (IVP, voiding cystourethrogram, cystoscopy).2. Provide postoperative care.1. Monitor drains; may have one from bladder and one from each ureter (ureteral stents).2. Check output from all drains (expect bloody drainage initially) and record carefully.3. Observe drainage from abdominal dressing; note color, amount, frequency.4.Administer medication for bladder spasms as ordered.Exstrophy of the Bladder 1. General information1. Congenital malformation in which nonfusion of abdominal and anterior walls of the bladder during embryologicdevelopment causes anterior surface of bladder to lie open on abdominal wall2. Varying degrees of defect2. Assessment findings1. Associated structural changes1. Prolapsed rectum2. Inguinal hernia3. Widely split symphysis4. Rotated hips2. Associated anomalies1. Epispadias2. Cleft scrotum or clitoris3. Undescended testicles4. Chordee (downward deflection of the penis)3. Medical management: two-stage reconstructive surgery, possibly with urinary diversion; usually delayed until age 3-6 months4. Nursing interventions: preoperative1. Provide bladder care; prevent infection.1. Keep area as clean as possible; urine on skin will cause irritation and ulceration.2. Change diaper frequently; keep diaper loose fitting.3. Wash with mild soap and water.4. Cover exposed bladder with Vaseline gauze.5. Nursing interventions: postoperative1. Design play activities to foster toddler's need for autonomy (e.g., Play- Doh, talking toys, books); child will be immobilizedfor extended period of time.2. Prevent trauma; as child gets older and more mobile, trauma more likely; teach parents to avoid areas such as sandboxes.Undescended Testicles (Cryptorchidism)1. General information1. Unilateral or bilateral absence of testes in scrotal sac2. Testes normally descend at 8 months of gestation, will therefore be absent in premature infants3. Incidence increased in children having genetically transmitted diseases
4. Unilateral cryptorchidism most common5. 75% will descend spontaneously by age 1 year 2. Medical management1. Whether or not to treat is still controversial; if testes remain in abdomen, damage to the testes (sterility) is possible becauseof increased body temperature.2. If not descended by age 8 or 9, chorionic gonadotropin can be given.3. Orchipexy: surgical procedure to retrieve and secure testes placement; performed between ages 1-3 years.3. Assessment findings: unable to palpate testes in scrotal sac (when palpating testes be careful not to elicit cremasteric reflex, which pulls testes higher in pelvic cavity)4. Nursing interventions1. Advise parents of absence of testes and provide information about treatment options.2. Support parents if surgery is to be performed.3. Post-op, avoid disturbing the tension mechanism (will be in place for about 1 week).4. Avoid contamination of incision.Hypospadias1. General information1. Urethral opening located anywhere along the ventral surface of penis2. Chordee (ventral curvature of the penis) often associated, causing constriction3. In extreme cases, child's sex may be uncertain2. Medical management1. Minimal defects need no intervention2. Neonatal circumcision delayed, tissue may be needed for corrective repair 3. Surgery performed at age 3-9 months; 2 years of age for complex repairs.3. Assessment findings1. Urinary meatus misplaced2. Inability to make straight stream of urine4. Nursing interventions1. Diaper normally.2. Provide support for parents.3. Provide support for child at time of surgery.4. Post-operatively check pressure dressing, monitor catheter drainage, assess pain.Enuresis1. General information1. Involuntary passage of urine after the age of control is expected (about 4 years)2. Types1. Primary: in children who have never achieved control2. Secondary: in children who have developed complete control and lose it3. May occur at any time of day but is most frequent at night4. More common in boys5. No organic cause can be identified; familial tendency6. Etiologic possibilities1. Sleep disturbances2. Delayed neurologic development3. Immature development of bladder leading to decreased capacity4. Psychologic problems2. Medical management1. Bladder retention exercises2. Behavior modification, e.g., bed alarm devices3. Drug therapy: results are temporary; side effects may be unpleasant or even dangerous1. Tricyclic antidepressants: imipramine HCI (Tofranil)2. Anticholinergics3. Assessment findings1. Physical exam normal2. History of repeated involuntary urination4. Nursing interventions1. Provide information/counseling to family as needed.1. Confirm that this is not conscious behavior and that child is not purposely misbehaving.2. Assure parents that they are not responsible and that this is a relatively common problem.2. Involve child in care; give praise and support with small accomplishments.1. Age 5-6 years; can strip bed of wet sheets.2. Age 10-12 years: can do laundry and change bed.3. Avoid scolding and belittling child. Nephrosis (Nephrotic Syndrome)1. General information1. Autoimmune process leading to structural alteration of glomerular membrane that results in increased permeability to plasma proteins, particularly albumin2. Course of the disease consists of exacerbations and remissions over a period of months to years3. Commonly affects preschoolers, boys more often than girls4. Pathophysiology1. Plasma proteins enter the renal tubule and are excreted in the urine, causing proteinuria.
2. Protein shift causes altered oncotic pressure and lowered plasma volume.3. Hypovolemia triggers release of renin and angiotensin, which stimulates increased secretion of aldosterone;aldosterone increases reabsorption of water and sodium in distal tubule.4. Lowered blood pressure also stimulates release of ADH, further increasing reabsorption of water; together with ageneral shift of plasma into interstitial spaces, results in edema.5. Prognosis is good unless edema does not respond to steroids.2. Medical management1. Drug therapy1. Corticosteroids to resolve edema2. Antibiotics for bacterial infections3. Thiazide diuretics in edematous stage2. Bed rest3. Diet modification: high protein, low sodium3. Assessment findings1. Proteinuria, hypoproteinemia, hyperlipidemia2. Dependent body edema1. Puffiness around eyes in morning2. Ascites3. Scrotal edema4. Ankle edema3. Anorexia, vomiting, and diarrhea, malnutrition4. Pallor, lethargy5. Hepatomegaly4. Nursing interventions1. Provide bed rest.1. Conserve energy.2. Find activities for quiet play.2. Provide high-protein, low-sodium diet during edema phase only.3. Maintain skin integrity.1. Do not use Band-Aids.2. Avoid IM injections (medication is not absorbed into edematous tissue).3. Turn frequently.4. Obtain morning urine for protein studies.5. Provide scrotal support.6. Monitor I&O, vital signs and weigh daily.7. Administer steroids to suppress autoimmune response as ordered.8. Protect from known sources of infection.Acute Glomerulonephritis1. General information1. Immune complex disease resulting from an antigen-antibody reaction2. Secondary to a beta-hemolytic streptococcal infection occurring elsewherein the body3. Occurs more frequently in boys, usually between ages 6-7 years4. Usually resolves in about 14 days, self-limiting2. Medical management1. Antibiotics for streptococcal infection2. Antihypertensives if blood pressure severely elevated3. Digitalis if circulatory overload4. Fluid restriction if renal insufficiency5. Peritoneal dialysis if severe renal or cardiopulmonary problems develop3. Assessment findings1. History of a precipitating streptococcal infection, usually upper respiratory infection or impetigo2. Edema, anorexia, lethargy3. Hematuria or dark-colored urine, fever 4. Hypertension5. Diagnostic tests1. Urinalysis reveals RBCs, WBCs, protein, cellular casts2. Urine specific gravity increased3. BUN and serum creatinine increased4. ESR elevated5. Hgb and hct decreased4. Nursing interventions1. Monitor I&O, blood pressure, urine; weigh daily.2. Provide diversional therapy.3. Provide client teaching and discharge planning concerning1. Medication administration2. Prevention of infection3. Signs of renal complications4. Importance of long-term follow-upHydronephrosis1. General information1. Collection of urine in the renal pelvis due to obstruction to outflow

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