Genitourinary Dysfunction Adapted from Kara Potter Introduction Components

Genitourinary Dysfunction Adapted from Kara Potter

Introduction Components of the Urinary System ◦ ◦ Kidneys Ureters Bladder Urethra

Urinary Tract

Functions of the Kidneys Fluid volume concentration and regulation p. H regulation Blood Pressure regulation Detoxification and elimination of waste products Regulation of Erythropoiesis Synthesis of prostaglandins Metabolism of Vitamin D

Physiology Nephrons are the functional unit of kidney ◦ Glomerulus Filters the fluid out of the blood ◦ Tubules Reabsorption Converts fluid to urine Urine moves to the pelvis of the kidney

Physiology Bladder ◦ Ureterovesical sphincter prevents urine reflux ◦ Total capacity approximately 1 liter Prostate ◦ Surrounds the male urethra

Difference between Children & Adults Kidney development not complete until about 1 year old Glomerular filtration & absorption do not reach adult levels until between 1 -2 years of age Kidneys grow in size until body growth complete In utero – kidneys produce urine that contribute to amniotic fluid volume

Difference between Children & Adults Loop of Henle short ◦ Reduces reabsorption of sodium & water Excrete water at a lower rate than adults Hydrogen ion excretion is reduced Acid secretion is lower for the first year of life Plasma bicarbonate levels are low Sodium excretion is reduced in newborn Infant have diminished capacity to reabsorb glucose

Deficits in Development Ambiguous genitalia Hypospadias Cryptorchidism Exstrophy of the bladder

Exstrophy of the bladder Description – rare congenital defect in which the bladder extrudes through the lower abdominal wall ◦ Occurs in 1 - 40, 000 newborns ◦ More common in boys 3: 1

Exstrophy of the bladder ◦ Etiology Failure of abdominal wall to close Upper urinary tract and testes & ovaries are usually normal Exposure to air & trauma during delivery leads to inflammation & renal damage

Exstrophy of the bladder Appearance ◦ ◦ ◦ Bladder appears as a mass of bright red tissue Urine continually leaks from open urethra Females have a bifid clitoris Males a short, stubby penis & glans is flattened Epispadias & bilateral inguinal hernias are also common

Exstrophy of the bladder Treatment ◦ Surgical reconstruction Performed in stages First surgery is usually completed in 24 -48 hours 2 ½ - 3 ½ years old reconstruction of bladder neck 4 -6 of age ureteral construction ◦ Prone to neoplasms because bladder epithelium is abnormal

Exstrophy of the bladder Nursing Management ◦ Prevent infection & trauma to exposed bladder Wrap bladder mucosa with sterile plastic wrap Frequent cleaning of area Apply skin sealant to protect skin from leaking urine

Exstrophy of the bladder Nursing Management ◦ Post-op Wound & pelvis immobilization Suprapubic Catheter Urinary stents – promote drainage of urine Medication to reduce bladder spasms Avoid abduction of the infant’s legs Family support Monitor peripheral circulation Provide meticulous wound & skin care

Exstrophy of the bladder Nursing Management ◦ Post-op I&O Monitor blood & urine chemistries Administer antibiotics as ordered Administer pain meds Promote bonding Teach

Diagnostic Test Urine, Blood, & Radiologic Testing ◦ Urinalysis – single most important test Volume Infants + Children 1 ml/kg/hr Polyuria, oliguria, anuria

Diagnostic Tests Urinalysis ◦ Obtain by Urine bag – unreliable Midstream clean-catch void Catheterization Suprapubic aspiration

Vesicoureteral Reflux Flow of bladder urine back into the ureters ◦ With voiding bladder urine is swept back up into the ureters and then emptied back into bladder after voiding increases the chance of and causes febrile urinary tract infections

Reflux Types ◦ Primary Due to a congenital condition that affects the ureterovesical junction Familial pattern ◦ Secondary Due to an UTI or obstruction Reflux with an infection is the most common cause of pyelonephritis in children Conservative management High incidence of spontaneous resolution over time

Urinary Tract Infections (UTI) May involve urethra, bladder, ureters, or kidney May present with or without symptoms Peak incidence between 2 -6 years of age ◦ Females greater incidence of UTI Female shorter urethra Male antibacterial properties of prostate secretions ◦ Exception newborn male – uncircumcised

UTI Etiology ◦ Can be bacterial, viral, or fungal in origin E. coli responsible for 80% of UTI’s Proteus, Psudomonas, Klebsiella, Staphylococcus aureus, haemophilus ◦ Great risk of scarring if 1 st infection occurs during infancy

UTI Etiology ◦ Normal Anatomy ◦ Urinary stasis – most important factor Reflux Anatomic abnormalities Ureteral or bladder compression Over-distention of bladder Neurogenic or voluntary Dysfunctional voiding

UTI Etiology ◦ Extrinsic factors Constipation Catheterization Administration of antimicrobial agents Tight clothing or diapers Poor hygiene Local inflammation Bath oils & bubble bath

UTI Signs & Symptoms Vary with Age ◦ ◦ Poor feeding Vomiting Incontinence Frequent urination

UTI Management ◦ Obtain urine specimen ◦ Start Antibiotic therapy Culture & sensitivity ◦ Pyelonephritis & fever Admit to hospital IV antibiotics for 48 hours Urine cultures Monthly for 3 months Than every 3 months for 6 months

UTI Management ◦ Surgical correction if structural defect ◦ Renal scarring can occur with initial infection May do radiologic evaluation ◦ Vesicoureteral Reflux or recurrent infection – long term suppressive antibiotic therapy ◦ Complications – Sepsis, abscess formation & death

UTI Nursing Implications ◦ Education Diagnosis Preserve renal function Treatment Eliminate infection Prevent spread of infection to other systems Prevention Identify & remove contributing factors

Acute Pyelonephritis Inflammation of renal organs Caused by bacteria, fungi, or protozoa Usually begins with an infection of lower urinary tract Pre-existing factors are often present Reoccurrence can lead to scaring and poor kidney function

Pyelonephritis

Manifestations Variable ◦ From mild fatigue ◦ To sudden onset of fever, chills, flank pain, malaise, dysuria, urinary urgency, urinary freequency ◦ CVA pain Symptoms usually subside after a few days, but bacteriuria and pyuria persist

Tests Urinalysis CBC Urine cultures Blood cultures with sever cases IVP or CAT scan Ultrasonography

Management Can either be outpatient or there can be a short hospitalization for IV antibiotics Antibiotics Maintain adequate fluid intake Use NSAID’s and antipyretics PRN Phenazopyridine Follow up culture

Pyelonephritis Chronic Pyelonephritis ◦ Shrunken atrophic kidney that has lost function as a result of reoccurring infection ◦ Diagnosed by imaging studies Urethritis ◦ Inflammation of the urethra ◦ Usually due to viral or bacterial infection

Pyelonephritis NANDAS

Nephrotic Syndrome Diffuse glomerular damage Possible immunological component

Nephrotic Syndrome Symptoms ◦ ◦ ◦ ◦ ◦ Massive proteinuria Hypoalbuminemia Hyperlipidemia Pitting Edema Waxy pallor of the skin Anemia Anorexia Irritability Amenorrhea or abnormal menses Hematuria may be present

Nephrotic Syndrome Types of Nephrotic syndrome ◦ Minimal change Nephrotic Syndrome (MCNS) 80% of cases Predominantly affects preschool children Cause is unknown – but usually follows a viral upper respiratory infection

Nephrotic Syndrome Types of Nephrotic Syndrome ◦ Secondary Occurs after or in association with glomerular damage Acute or chronic glomerulonephritis During course of collagen vascular diseases Major symptom of renal disease in pedi client with AIDS

Nephrotic Syndrome Types of Nephrotic Syndrome ◦ Congenital Caused by recessive gene on an autosome Characteristics Small for gestational age, proteinuria, edema Does not respond to usual therapy Usually die within the first two years of life

Nephrotic Syndrome Pathophysiology ◦ Metabolic or chemical disturbance in basement membrane of the glomeruli Causes increased permeability to proteins Leads to hyperalbuminuria Reduces Hypoalbuminemia Decreased colloidal osmotic pressure Ascities Hypovolemia Stimulates renin-angiotensin system–ADH & aldosterone Increased reabsorption of sodium and water

Nephrotic Syndrome Treatment ◦ Objective to reduce excretion of urinary protein ◦ Principally supportive I&O, daily weights, abdominal girth Skin care Frequent position changes Monitor vital signs Sodium restrictions with edema No fluid restriction Corticosteroid therapy High protein diets are no longer used due to the excreted protein causing further kidney damage

Treatment ◦ Corticosteroid therapy Prednisone – safest & most inexpensive Continue until urine free from protein & normal for 10 -14 days Need to discontinue corticosteroids gradually

Nephrotic Syndrome Effects of Corticosteroid Therapy ◦ Increased risk of Infections Growth retardation Cataracts Obesity Bone demineralization GI Bleeds Hyperglycemia Hypertension

Nephrotic Syndrome Treatment ◦ Immunosuppressant Therapy To induce long term remission Oral alkylating agent such as Cytoxan Can be withdrawn abruptly Limit visitors with any type of infections ◦ Diuretics Do not always work Use with respiratory problems, hyponatremia, skin breakdown

Nephrotic Syndrome Administer plasma volume expanders to raise osmotic pressure Change position frequently Good skin care Prognosis is good ◦ Self-limiting disease

Nephrotic Nursing Diagnosis ◦ Risk for Impaired skin integrity r/t edema and decreased circulation ◦ Risk for infection r/t urinary loss of gammaglobulins and immunosuppressive therapy ◦ Fluid volume excess r/t decreased excretion of sodium and fluid retention

Kidney Failure Results in substances accumulating in the blood & eventually the tissue fluid Can happen within days Need to replace nonfunctioning kidneys ◦ Dialysis ◦ Kidney transplant

Renal Failure Etiology Prerenal Intrarenal Postrenal

Acute Renal failure clinical course Initiating phase ◦ From time of insult till sighns and symptoms become apparent Oliguric phase ◦ Usually from day 7 -14 Diuretic phase ◦ Increased urinary output ◦ Risk for hypovolemia, hypotension, hyponatremia, hypokalemia, dehydration Recovery phase ◦ Starts when GFR increases

Clinical Manifestations What do You think?

Nutritional Management Protein Restriction Sodium and Potassium restriction Phosphate restriction

Chronic Kidney Disease (CKD) Progressive irreversible loss of kidney function Defined ◦ GFR <60 ml/min ◦ Presence of kidney damage Leading causes ◦ 1 - Diabetes mellitus ◦ 2 - HTN

CKD Manifestations Urinary system Metabolic disturbances ◦ Waste product accumulation ◦ Altered carbohydrate metabolism ◦ Elevated triglycerides Electrolyte ◦ ◦ ◦ Hyperkalemia Sodium Calcium Phosphate Magnesium Metabolic Acidosis

CKD manifestations Hematologic Cardiovascular Respiratory GI Neurologic Muskuloskeletal Integumentary Reproductive Endocrine Psychological

CKD Therapy Correct fluid volume Nutritional therapy Erythropoietin therapy Calcium supplementation/ phosphate binders Antihypertensive therapy Lower potassium Adjust drug dosage to renal function

NANDAS Fluid Volume Excess Risk For Injury Imbalanced Nutrition Less Than Body Requirements Risk For Infection

References Adams, M. P. , & Urban, C. Q. (2013), Pharmacology : Connections to nursing practice (2 nd ed. ) Boston: Pearson Education, Inc. Hockenberry, M. J. & Wilson, D. (2011). Nursing care of infants and children (9 th ed. ). St. Louis, MO: Mosby. Lewis, S. , Heitkemper, M. & Dirksen, S. (2011). Medical Surgical Nursing: Assessment and Management of Clinical Problems (8 th ed. ). St. Louis, MO: Mosby