POWERPOINT: GU peds

The goals of surgical repair of Hypospadias/epispadias:

(1) placement of the urethral meatus at the end of the glans penis with satisfactory caliber and configuration for a urinary stream (enabling the child to void in a standing position) (2) release of chordee to straighten the penis (enabling future sexual function) (3) satisfactory cosmetic appearance of the penis

s/s of cystitis in school age (mnemonic)

(Can U Eat Franks Fish And Drink Dripping Hot FUDGY Fudge) Cloudy urine Urgency enuresis Fever Frequency Abdominal pain Dysuria Dehydration Hematuria FLANK PAIN Foul-smelling urine

s/s of cystitis in preschooler (mnemonic)

(Can U Eat Franks Fish And Drink Dripping Hot Fudge) Cloudy urine Urgency enuresis Fever Frequency Abdominal pain Dysuria Dehydration Hematuria Foul-smelling urine

s/s of cystitis in infants (mnemonic)

(Did Vanessa Put Franks Large Fish Inside Fridge) Diarrhea Vomiting Poor feeding Foul-smelling diapers Lethargy Fever Irritability Failure to gain weight

s/s of pyelonephritis (mnemonic)

(He-Feels Very Nice & Chill About Meeting Crazy Frank) High Fever Vomiting nausea chills abdominal pain moderate to severe dehydration costovertebral angle tenderness flank pain

Urinary Track Infections (2)

* Cystitis- (lower UTI- bladder) * Pylonephritis-(upper UTI- kidneys)

the 3 main reasons for kidney inflammation

*Acute glomerulonephritis (AGN) *Scarring ---pyelonephritis *Obstructions/ malformation: ---kidney stones in adults; UPJ in kids; ureterocele; posterior urethral valves (PUVs), and stenosis or hypoplasia of the ureterovesicular junction

N/C of VUR

--assess child's habits & routine --urinary catheter will be placed & urine will be bloody initially but clear in 2-3 days --hydrate (IV fluids to maintain adequate urine output) --Educate the family about the administration of medications including prophylactic antibiotics and antispasmodics if needed --educate parents on increasing fiber intake d/t antispasmodics causing constipation --notify Dr. if abdominal or back pain, or swelling and redness of the incision --avoid active play for 3 wks (child can take a showers)

N/C of Hydrocele/hernia COME BACK- go to nursing lab https://nurseslabs.com/hydrocele/

--assessment --explaining the disorder and its treatment, --providing preoperative and postoperative teaching, care, and support. --Proper holding of child?

N/C of cryptorchidism

--focuses on maintaining comfort and preventing infection ---pain management & applying ice to site --Encourage bed rest, and monitor voiding --giving sponge bath to child 2 days after surgery --making sure no medicine or ointment is applied over incision --educating pts: avoid straddling and active play for 3 weeks --monitor for infection

N/C of Testicular torsion

--involves psychologic support for the child and family related to the need for emergency surgery and concern about the child's future fertility (usually it only effects one testis so it should not affect fertility) --proper care of the incision --pain management. --no heavy lifting for 4 weeks --no strenuous activity for 2 wks

N/C of nephrotic syndrome

-Relieving edema. -Improving nutritional status (childs favorite foods) -Maintaining skin integrity. -Conserving energy. -Preventing infection (avoid crowds) -monitor weight, I&Os, F&Es

circumcision -type of surgery -when to wait -benefits

-Surgery - elective or corrective -Wait if physical anomalies: Hypospadias/epispadias -Benefits with std/hiv transmission; ease of hygiene, prevents UTIs and penile cancer

N/C of AGN

-assess BLOOD PRESSURE!, weight and I&Os -seizure precaution r/t high BP -no fluids, protein, sodium or potassium -monitor hematuria & proteinuria -change position for periorbital & dependent edema -assess for pulmonary effusion (crackles, dyspnea, cough) -assess CNS: change in LOC

Physiologic changes that may occur as a result of hydronephrosis: (5)

-decreased GFR -metabolic acidosis -polyuria/polydipsia -urinary STASIS -renal failure -Cessation of glomerular filtration occurs when the pressure in the kidney pelvis equals the filtration pressure in the glomerular capillaries. To compensate, the blood pressure increases to increase the glomerular filtration pressure; how- ever, increasing pressure on the glomeruli leads to cell death. -Metabolic acidosis results when the distal nephrons' ability to secrete hydrogen ions is impaired. -Impairment of the kidney's ability to concentrate urine results in polydipsia and polyuria. -Obstruction results in urinary stasis, promoting bacterial growth. -Restriction of urinary outflow causes progressive renal damage and chronic renal failure if untreated.

N/C of Nephritis/hydronephrosis

-discuss concerns about how the disorder will affect the child's long-term renal functioning. Postoperative: -monitoring vital signs & I&Os -observing for signs of urine retention (decreased output & bladder distention) -since many children are discharged with stents or catheters: Teach parents how to change dressings, double-diaper, care for catheters, assess pain and give analgesics -recognize signs of possible obstruction or infection. -Parents should encourage the child to participate in age-appropriate activities. However, children should avoid contact sports because of their potential to injure the bladder.

side effects of long term steroid use

-increase blood glucose -weight gain -growth restriction -moon face -malaise -immunosuppressant: risk for infection and delayed wound healing

physiologic changes related to AGN:

-thickened glomerulus -damaged tissue cells of the glomeruli capillaries -decreased glomerular filtration rate (GFR) -increase vascular permeability ---RBC excretion HEMATURIA --mild proteinuria -retention of sodium & water ---expanding intravascular & interstitial compartments=> EDEMA & HTN

a child contracts strep throat and then develops signs of APIGN after ______________ (how long after?)

2-3 weeks (10-21 days)

Structural - reproductive (4)

Cryptorchidism/orchiopexy Testicular torsion Hydrocele/hernia Phimosis

in AGN: ____________ occurs as a result of an immune complex reaction that localizes on the glomerular ______________ this damage causes increase vascular permeability which leads to a leakage of ________ & ________ resulting in a low serum _________ & _________ and high _____________

Glomerular damage Capillary wall leakage of RBC & protein low serum H&H & serum protein high BUN/creatinine

the 3 tools used in circumcision

Gomco clamp plastibell mogen clamp

genetic/ congenital anomalies involving the abnormal location of the urethral meatus

Hypospadias/epispadias

12-year-old Caroline has recurring nephrotic syndrome; which of the following areas of potential disturbances should be a prime consideration when planning ongoing nursing care? a. body image b. sexual maturation c. muscle coordination d. intellectual development

a. body image

the two things that are prevented during utero in bladder extrophy

abdominal wall closure fusion of the pelvis (wide split at symphysis pubis)

CLINICAL MANIFESTATIONS of AGN

asymptomatic abrupt onset flank/midabdominal pain irritability malaise fever HEMATURIA tea colored urine periorbital edema (occurs early) dependent edema (feet/ankles) EDEMA may progress in severity to cause: -pulmonary congestion -ascites. Acute HYPERTENSION may lead to: -headache -nausea -vomiting -lethargy -seizures -other CNS symptoms. Oliguria may or may not be present

Nurse Jeremy is evaluating a client's fluid intake and output record. Fluid intake and urine output should relate to which way? a. fluid intake should be double the urine output b. fluid intake should be approximately equal to urine output c. fluid intake should be half the urine output d. fluid intake should be inversely proportional to the urine output

b. fluid intake should be approximately equal to urine output

Which of the following conditions most commonly causes acute glomerulonephritis? a. congenital conditions leading to renal dysfunction b. prior infection with group A streptococcus with the past 10-14 days c. viral infection of the glomeruli d. nephrotic syndrome

b. prior infection with group A streptococcus with the past 10-14 days Acute glomerulonephritis is most commonly caused by the immune response to a prior upper respiratory infection with group A Streptococcus. Glomerular inflammation occurs about 10-14 days after the infection, resulting in scant, dark urine and retention of body fluid. Periorbital edema and hypertension are common signs at diagnosis.

Dr. Jones prescribes corticosteroids for a child with nephritic syndrome. What is the primary purpose of administering corticosteroids to this child? a. to increase blood pressure b. to reduce inflammation c. to decrease proteinuria d. to prevent infection

c. to decrease proteinuria Option C: The primary purpose of administering corticosteroids to a child with nephritic syndrome is to decrease proteinuria. Option A: Corticosteroids have no effect on blood pressure. Option B: Although they help reduce inflammation, this is not the reason for their use in patients with nephritic syndrome. Option D: Corticosteroids may predispose a patient to infection. REALLY?

the inflammation in AGN effects the

capillary wall

Surgical correction of Phimosis

circumcision (if they refuse surgery, give steroid cream)

what should we delay if a NB has a Hypospadias/epispadias:

circumcision NO CIRCUMCISION- might need to use extra foreskin for surgery

N/C of circumcisions

comfort/pain proper void watch q 15 min petroleum jelly- super moist to prevent sticking to diaper prevent infection

undescended teste

cryptorchidism (occurs when one or both testes fail to descend through the inguinal canal into the scrotum. may be the result of a congenital defect of the gonads, a narrow inguinal canal, short spermatic cord, adhesions, insensitivity to gonadotropins, or lack of maternal gonadotropins)

inflammation of the kidney due to accumulation of urine in the renal pelvis as a result of obstructed outflow

Nephritis/hydronephrosis * Inflammation (including AGN, uti, stones) * Leads to obstruction/scarring -possible renal failure

Renal Issues (6)

Nephritis/hydronephrosis Pediatric acute glomerulonephritis Nephrotic syndrome Hemolytic uremic syndrome Polycystic kidney disease Renal Failure WATCH KHAN ACADEMY!

idiopathic kidney disorder that causes your body to excrete too much protein and albumin in your urine

Nephrotic syndrome

Nephrotic syndrome -nursing assessment: -nursing diagnosis: -nursing interventions:

Nursing Assessment -Observe for edema/ pitting edema- Note any swelling about the eyes or the ankles and other dependent parts. -Weigh and measure. -vital signs including blood pressure. -Inspect the skin for pallor, irritation, or breakdown -examine the scrotal area of the male child for swelling, redness, and irritation. Nursing Diagnoses -Excess fluid volume related to fluid accumulation in tissues and third spaces. -Risk for imbalanced nutrition: less than body requirements related to anorexia. -Risk for impaired skin integrity related to edema. -Fatigue related to edema and disease process. -Risk for infection related to immunosuppression. -Deficient knowledge of the caregiver related to disease process, treatment, and home care. -Compromised family coping related to care of a child with chronic illness. Nursing Interventions -Monitoring fluid intake and output. -Accurately monitor and document intake and output -weigh the child at the same time every day, on the same scale in the same clothing -measure the child's abdomen daily at the level of the umbilicus. -Improving nutritional intake. -Offer a visually appealing and nutritious diet -consult the child and the family to learn which foods are appealing to the child -serving six small meals my help increase the child's total intake better. -Promoting skin integrity. Inspect all skin surfaces regularly for breakdown -turn and position the child every 2 hours; protect skin surfaces from pressure by means of pillows and padding; -protect overlapping skin surfaces from rubbing by careful placement of cotton gauze -bathe the child regularly a sheer dusting of cornstarch maybe soothing to the skin. -Promoting energy conservation. -Bed rest is common during the edema stage of the condition; -balance the activity with rest periods and encourage the child to rest when fatigued; -plan quiet, age-appropriate activities that interest the child. -Preventing infection. Protect the child from anyone with an infection: staff, family, visitors, and other children; handwashing and strict medical asepsis are essential; and observe for any early signs of infection.

risk for sepsis (4)

Over 65 Under 1yr Weak immune systems Chronic conditions

an infection starts as a local inflammatory response then once it leaves the original site and there is two or more abnormal ranges (temp, HH, RR, WBC) it is considered ___________________

SIRS (systemic inflammatory response syndrome)

most commonly bacteria found in UTIs

e. coli

the urethral canal is open on the dorsal surface

epispadias

cryptorchidism may cause __________ and they have an 30-50% increased risk for _____________. later in life.

fertility issues/sexual functioning testicular cancer

characteristics in Nephrotic syndrome

frothy urine PROTEINURIA hyperlipidemia edema anorexia- malnutrition some hematuria slow onset unrecognizable symptoms

what grade of VUR does dilation occur

grade III

reasons for UTIs

holding in too long- retention/stasis structural issues- neurogenic bladder improper hygiene constipation dehydration

the urethral canal is open on the ventral surface

hypospadias

Kids vs. Adults Ureters: nephrons & kidneys: GFR: electrolytes & acid & base: Reproductive: Bladder capacity/control: medications:

in kids: Ureters: shorter, less absorption nephrons & kidneys: wont reach adult size until adoles.; immature functioning, GFR: less filtration rate; electrolytes & acid & base: easily dehydration Reproductive: immature Bladder capacity/control: smaller, cant hold as much; work on training and control medications: cant process meds as much as adults

inguinal Hernias can become ________________ when a bit of bowel becomes trapped in the inguinal opening and the blood supply is constricted. -therefore _____________ is considered a huge concern and is considered a medical __________

incarceration (incarcerated risk) -necrosis -medical emergency

s/s of inguinal Hernias in infants & children

infants: irritability, poor feeding, and abdominal distention child: pain both: edematous, erythematous scrotum accompanied by fever, vomiting, and bloody stools -Palpable fullness: soft & nontender

TX of inguinal Hernias COME BACK

inguinal, scrotal, and sclerotherapy. (Efforts are made to reduce the hernia before surgery by applying pressure on the affected side, followed by semiurgent surgery. If the hernia cannot be reduced, emergency surgery is performed)

Surgical repair of Bladder exstrophy goals:

internalize the bladder close the abd repair genitalia goals: --Closure of the bladder and abdominal wall --Urinary continence, with preservation of renal function --Creation of functional and normal-appearing genitalia --Correction to promote later sexual functioning

features of nephrotic syndrome -liver may....?

liver may try to compensate for loss of protein by -increasing cholesterol -increasing clotting factors???

The goals of surgical correction or diversion are to...

lower the pressure within the collecting system, which reduces renal damage, and to prevent stasis, which decreases the risk of infection.

Testicular torsion is considered a ____________ and need to be fixed w/in __________ --if its not fixed with in time, it can cause ______

medical emergency w/ in 6 hours --tissue necrosis (Testicular torsion is an emergency condition in which the testis suddenly rotates on its spermatic cord, cutting off its blood supply.)

11) Which assessment finding would necessitate action by the nurse for a 10-month-old child who is 4 hours postoperative for the placement of a urethral stent? 1. Bloody urine 2. One void since returning from surgery 3. Bladder spasms responding to pharmacologic intervention 4. Double diapering from the previous shift

Answer: 2 Explanation: 1. Bloody urine is expected in the immediate postoperative period. 2. A 10-month-old child will void more often than 1 time in 4 hours. This could indicate the stent is occluded. The surgeon should be notified. 3. This is a normal finding. 4. This is a desired finding and does not need to be reported to the surgeon. lecture question found in main TB ch. 52 #11 https://quizlet.com/288716229/pediatrics-51-52-gi-gu-flash-cards/

Which clinical manifestations should the nurse anticipate upon assessment for a preschool-age child with a urinary tract infection (UTI)? 1. Headache, hematuria, and vertigo 2. Foul-smelling urine, elevated blood pressure (BP), and hematuria 3. Urgency, dysuria, and fever 4. Severe flank pain, nausea, and headache

Answer: 3 Explanation: 1. Hematuria might be present, but there will be no complaints of headache or vertigo. 2. While foul-smelling urine and hematuria can be present, there is no elevated BP, headache, or vertigo. 3. Clinical manifestations of UTI in a preschool-age child include fever, urgency, and dysuria. 4. There could be flank pain, although the preschooler might be unable to describe it. There will be no complaints of headache. (question asked in class & found in main TB ch. 52)

reflex of urine that prevents emptying of the bladder and because urine returns to the bladder, it creates a reservoir for bacterial growth (frequent utis)

vesicoureteral reflux (VUR)

rare congenital defect in which the posterior bladder wall extrudes through the lower abdominal wall (inside out bladder)

Bladder exstrophy (Failure of the abdominal wall to close during fetal development results in eversion and protuberance of the bladder wall along with a wide separation of the rectus muscles and the symphysis pubis. The upper urinary tract is usually normal. The bladder mucosa appears as a mass of bright-red tissue, and urine continually leaks from the ureters onto the skin)

Structural - urinary (3)

Bladder exstrophy Hypospadias/epispadias Vesicoureteral reflux (VUR)

tx of VUR

Bladder training or Surgical correction

Clinical Tip of Hypospadias/epispadias:

Clinical Tip When children are not able to achieve continence, some type of urinary diversion may be created. A vesicostomy is a procedure in which an opening is created from the bladder to the skin. The urine drains from the opening (stoma) to the child's diaper or a drainage bag. In the Mitrofano procedure, a reservoir for urine and a stoma are created so that children can catheterize themselves through the umbilicus (see Chapter 54).

what is the definite diagnosis of VUR

voiding cystourethrogram (VCUG) (A renal ultrasound &/or dimercaptosuccinic acid (DMSA) scan may also be used to rule out other issues first)

a fluid-filled mass in the testes

Hydrocele (Most hydroceles resolve spontaneously by reabsorption by 1 year of age)

insensible fluid loss:

what is excreted by the lungs (respiration-CO2) , skin (diaphoresis/perspiration)

a child has renal insufficiency and he is currently sick with an acute gastrointestinal illness is at greater risk for ____________

FLUID LOSS/ DEHYDRATION

Hydrocele vs Hernia (inguinal)

Hydrocele * scrotal and/or inguinal swelling * peritoneal Fluid in scrotum Hernia (inguinal) * scrotal and/or inguinal swelling * abdominal contents in scrotum * incarceration risk (Inguinal hernias can become incarcerated when a bit of bowel becomes trapped in the inguinal opening and the blood supply is constricted. concern for necrosis)

AGN culprit

Group A beta strep (The incidence of acute postinfectious glomerulonephritis (APIGN) is highest in children between 2 and 6 years of age, and the disorder is more common in boys than in girls)

is a condition that affects the blood and blood vessels and is one of the most common causes of acute renal failure

Hemolytic uremic syndrome

scrotal and/or inguinal swelling and abdominal contents in scrotum

Inguinal Hernia (painless inguinal or scrotal swelling of variable size that occurs when abdominal tissue, such as bowel, extends into the inguinal canal. An inguinal hernia is found in 3.5% to 5.0% of full-term infants and 9% to 11% of preterm infants and occurs more often in boys than girls by a 8:1 ratio)

sepsis can effect:

Lungs kidney skin gut

Congenital characteristics of Bladder exstrophy males: females:

Males - undescended testes, short stubby penis, glans flattened Females - bifid (split) clitoris

Most common glomerular inflammation

Pediatric acute glomerulonephritis (AGN)

N/C of Hypospadias/epispadias: Preop: postop:

Preoperative: --RELIEVE ANXIETY: teaching can relieve some of their anxiety about the future appearance and functioning of the penis Postoperative: --PROTECT SITE: care focuses on protecting the surgical site from injury (returns from surgery with the penis wrapped in a simple dressing, and a urethral stent or catheter for urinary drainage) --STENT: ensure that the stent does not get removed --IMMOBILIZE: no activity for 2 wks --HYDRATION: Encourage fluid intake to maintain adequate urinary output and patency of the stent --Strict DOCUMENTATION of intake and output is essential to detect postoperative complications --MUST PEE WITHIN 1 HR: notify dr. if there is no urine after one hour post surgery --PAIN MANAGEMENT: tx bladder spasms with anticholinergics (oxybutynin) & acetaminophen --antibiotic tx until stent is removed --Discharge teaching about care of the reconstructed area, DOUBLE DIAPERING to protect the operative site, fluid intake, medication administration, avoiding showers until stent/cath is removed and signs and symptoms of infection

Spontaneous testicular rotation of spermatic cord

Testicular torsion

Children and sepsis (3)

Triage Tools: to identify abnormal vital signs Sepsis Screenings EMR (electronic medical record): once its been documented

Nursing care for UTIs

Why is it happening? Figure it out (physiological assessment) I & O. Book says: - Psychologic Assessment (specially assessment) - Admin meds -Rehydration - Assess Renal Fx. - Education - Frequent voiding minimizes urine stasis.

diagnosis of Testicular torsion

duplex ultrasonography

Alaric was diagnosed with minimal-change nephrotic syndrome; which of the following signs and symptoms are characteristics of the said disorder? a. HTN, edema, hematuria b. HTN, edema, proteinuria c. gross hematuria, fever, proteinuria d. poor appetite, edema, proteinuria

d. poor appetite, edema, proteinuria Option D: Clinical manifestations of nephrotic syndrome include loss of appetite due to edema of intestinal mucosa, proteinuria, and edema. Options A, B: Hypertension alone or accompanied by hematuria is associated with glomerulonephritis. Option C: Gross hematuria is not associated with nephrotic syndrome. Fever will occur only if infection also existed.

is a surgery to move an undescended (cryptorchid) testicle into the scrotum and permanently fix it there.

orchiopexy (wait 1 year to see if testes descend on its own first)

surgery of Testicular torsion

orchiopexy- both sides (the testis is untwisted and stitched to the side of the scrotum in the correct position. The procedure is usually performed bilaterally to prevent future torsion in the other testis. If the testicle does not regain blood flow or is already necrotic, it is removed via orchiectomy)

the foreskin over the glans penis cannot be retracted.

phimosis -cant clean under foreskin & cuts off circulation -phimosis is a normal finding in uncircumcised infants and young males

diagnosis of hydrocele/hernia

physical examination at birth or in early infancy. Ultrasonography, Duplex ultrasonography & radiography -Palpation of the scrotum reveals a round, smooth, non- tender mass, which is noted with either a hernia or hydrocele. -Parents may report an intermittent bulge in the groin or swelling in the scrotum. Swelling associated with a hernia may become more apparent with straining and reduced in size when quiet or asleep.

abnormal folds of mucosa in the male urethra and are a significant cause of end-stage renal disease in children

posterior urethral valves (PUVs)

N/C of Bladder exstrophy Preop: intraop: postop:

preop: --prevent infection & trausma to exposed bladder w/ plastic wrap to keep the bladder mucosa moist until surgery is performed. --clean daily & protect from leaking urine with a skin sealant intraop: --maintain aseptic tech postop: --prevent and monitor signs of infection: redness, drainage & edema --comfort, pain assessment, antibiotics --education & emotional support: child self esteem & confidence w/ sexual identity --promote infant bonding --maintaining proper alignment: avoid abduction of the infants leg --monitor peripheral circulation --provide meticulous wound and skin care --monitor renal function: I&Os & blood and urine chemistries --observe for signs of obstruction: increase bladder spasms, decrease urinary output, hematuria

diagnostic criteria for nephrotic syndrome

proteinuria >3.5 mg/day serum albumin < 2.5 g/dL edema

renal scarring can result from ____________ because of the ischemic effects of infection. renal scaring has been associated with ________ & __________

pyelonephritis hypertension & chronic renal failure

removal of an obstructed segment of the ureter and reimplantation into the renal pelvis

pyeloplasty

Manifestations of Testicular torsion

rapid onset severe pain in scrotum/abd scrotum erythema nausea & vomiting scrotal swelling that is not relieved by rest or scrotal support (Symptoms generally start when the child is sleeping or inactive, but they can occur after trauma, sexual activity, or exercise)

The 3 culprits of Sepsis

s. aureus e. coli strep

PYELONEPHRITIS (or frequent/undiagnosed UTIs) can cause __________ and this obstruction can turn into ______________ or cause ___________ where they can effect ____, ______, _______ and ________

scarring hydronephrosis sepsis

When SIRS has been confirmed (blood cultures) and theres documentation of the positive evidence of infected bloodstream. it is considered _______________ when multiple organs are involved plus hypotension. it is considered ____________

sepsis septic shock

tx of Nephrotic syndrome

steroids: oral prednisolone -for 6-8 wks

in AGN what color is the urine

tea color

tx of AGN

tx underlying cause strep: antibiotics HTN: antihypertensives edema: diuretics Clinical Tip: Antibiotics are not a treatment for APIGN. Instead, antibiotics are prescribed to treat the original infection (such as strep throat) if the infection is still present.

VCUG (voiding cystourethrogram) procedure:

under fluoroscopy, they catheterize the child, push the contrast up into the bladder, and wait to see if fluid backs up. -placed on prophylaxis antibiotics

sac of tissues obstructs flow of urine

ureterocele

MOST COMMON CAUSE OF HYDRONEPHROSIS IN NEWBORNS

ureteropelvic junction obstruction (UPJ) (is the most common site of obstruction of the upper urinary tract in infants and children)

in VUR urine is backing up possible from _________ ,___________, __________ or ___________

urethral dilation retention- kids holding in to long Frequent UTIs genetic issue