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Genitourinary

Genitourinary. Elisa A. Mancuso RNC-NIC, MS, FNS Professor of Nursing. Kidneys. Detoxify blood and eliminates waste Produce erythropoietin Regulate blood pressure Maintains fluid and electrolyte balance Essential for life process Huge blood supply ✔ in accidents/ trauma. Hormones.

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Genitourinary

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  1. Genitourinary Elisa A. Mancuso RNC-NIC, MS, FNS Professor of Nursing

  2. Kidneys • Detoxify blood and eliminates waste • Produce erythropoietin • Regulate blood pressure • Maintains fluid and electrolyte balance • Essential for life process • Huge blood supply • ✔ in accidents/trauma

  3. Hormones Erythropietic Stimulating Factor • Released when low serum O2 • Stimulates production of RBC’s • ↡ ESF = Anemia and prolonged PT/PTT

  4. Hormones Renin • ↡ BP or ↡blood volume • Stimulates production of Angiotension I →Angiotension II • Vasoconstriction and ↟ BP • ↑Aldosterone by adrenal cortex • Reabsorbes Na & H2O

  5. Urinary Assessment • √Voiding pattern & output = 1-2ml/kg/hr Oliguria <1cc/kg/hr (infants) and <0.5cc/kg/hr children Anuria- No production of urine. Indicates serious renal dysfunction Diuresis- ↑ urinary output. R/O hyperglycemia Glucose threshold is 160 mg ↑ urination and glycosuria.

  6. Urinary Assessment Color Clear/straw Darker Concentrated from dehydration or bilirubin Hematuria-blood UTI, stones, trauma or glomerulonephritis PH ↑ (Alkalinic) with ↓K+ Clarity Clear →Cloudy “Pyuria” indicates infection

  7. Urinary Assessment Pain • Burning on urination- UTI • Dull achy pain - kidney disease • Sharp, colicky pain-kidney stones • Cystitis • Suprapubic pain or pain after voiding

  8. Urinary Function Studies Urinalysis- U/A C & S = Culture and sensitivity Identify organism Specific gravity 1.005-1.020 Infant <1.010 Children 1.010-1.030 Fluid challenge test 20-50cc/kg/hour then √ output Blood Urea Nitrogen (BUN) 5-18 Creatinine 0.3-1mg/dl most reliable test for glomeruli function Glomerular Filtration Rate GFR • Renal Function = 70-160cc/min. • Infant has lower rate till 2 years of age.

  9. Renal Function Studies • Ultrasound- renal or pelvic • Intravenous Pyelogram IVP • Renal angiography • Cystoscopy • Voiding Cysto Urethra Gram VCUG • Renal Biopsy

  10. Urinary Tract Infections Ascending infection Bacteria → urethra → bladder (cystitis) Bladder → ureters → kidney (pyelonephritis) • Fecal bacteria causes 80% UTI’s • Peak incidence @ 2-6 years of age • without structural problems

  11. Etiology • Girls urethra smaller & closer to anus • ↑ risk when wipe back to front • Boys non-circumsized or have phimosis • Urinary stasis • Structural defect or obstruction • Vesicouretal Reflux or Hydronephrosis • Incomplete bladder empting RT • Constipation or toilet training (holding it in) • Sexually active adolescent girls

  12. Clinical signs • Burning • Frequency • Dysuria • Suprapubic, flank or abdominal pain • Incontinence • Foul smelling urine • Fever • Infants may present with high fever, “chills”, vomiting, diarrhea or irritability

  13. Diagnosis • UA and C & S to identify organism • Clean catch or bagged urine • Area must be cleaned properly! • Urinary catheterization or supra-pubic tap. Sterile procedure! • Repeat C&S after medication completed • To verify med was effective

  14. Antibiotic Therapy Sulfonamides: Co-trimoxazole (Bactrim DS/Septra/TMP-SMX). √ Sulfa allergies. ↑ PO intake. Not for infants less than 2 months. Cephalosporins: Ceclor po/ Rocephin IV/IM. Resistant or severe UTI’s or pyelonephritis. (IV) meds for hospitalized pt’s. Penicillins (PCN): Ampicillin po/IV, amoxicillin, augmentin ✔ PCN allergies (Ampicillin and amox not as sensitive) Repeat Culture to assess efficacy of med.

  15. Analgesic Therapy Phenazopyridine HCL (pyridium) Antispasmotic. Local anesthetic action on urinary mucosa. Only use for pain & older children >6years SE-orange urine and can stain contact lenses. Motrin 5-10 mg/kg/dose q 6-8 hr Tylenol 10-15 mg/kg/dose

  16. Therapy ↑ Hydration 2 – 4 liters/day • Acidic juices: cranberry and OJ Encourage frequent voiding Appropriate hygiene • Wipe from front to back • No bubble baths

  17. Hydronephrosis Congenital or Acquired RT reflux or calculi • Obstruction @ ureto-pelvic junction: • Renal pelvis and calyces dilated with urine. • ↓ urine flow leads to • stasis, infections or calculi • Infants may spontaneously resolve • Diagnosis • Renal ultrasound or IVP

  18. Clinical signs • Colicky, flank pain • May radiate to groin • N/V • Possible palpable mass • Pyuria • Fever

  19. Therapy • ↑ Fluids-2.5 liters/day • Hygiene • ↑ Increase voiding • Surgery • Stent @ obstruction site

  20. Polycystic Kidney Disease • Autosomal dominant disorder 90%. • Disease progresses in adulthood. • Autosomal recessive • Severe disease in childhood • Cyst formation & renal enlargement • Cysts filled with • glomerular filtrate, solutes and fluids • Renal blood vessels and nephrons compressed • Functional tissue is destroyed → • kidney failure

  21. Clinical Signs • Flank pain • Hematuria • Proteinuria • Nocturia • Frequent UTI’s and renal calculi • HTN and impaired renal blood flow • Protruding abdomen

  22. Therapy • Renal ultrasound • IVP • CT Scan • ↑ Fluid Intake 2-2.5 L/day • Prevents infection • Antihypertensive Meds Beta blockers-atenolol or propanolol Ca Channel Blockers-procardia or verapamil Dialysis or kidney transplant

  23. Acute Glomerulonephritis • Antigen/antibody reaction to infection • Group A ß hemolytic strep. • Most common in boys 4 - 7years of age • Peaks in winter and spring • “Wire Mesh Trap”

  24. Pathophysiology • Antibodies made against strep toxin • AG/AB complex trapped in glomerulus • Leukocytes infiltrate the area • Adheres to basement membrane • ↑ Inflammation =↓ GFR • Damaged Glomerulus • Leakage of RBC’s and Protein • Small hemorrhages on cortical surfaces • Kidneys become enlarged and pale

  25. Clinical Signs & Symptoms • Cardinal sign = Hematuria 4+ • Tea colored urine RT ↑ ↑ RBCs being excreted • Proteinuria +3/+4 • Oliguria • ↑ Temperature • ↑ Na+ and H2O Re-absorption→ ↑↑ BP • ↑ Periorbital/facial edema +3/+4 in AM. • Dependent edema/extremities in PM. • ↑ Weight gain • Circulatory congestion RT pulmonary edema

  26. Diagnosis • + ASO titers >250 todd units • Reflects recent strep infection • Past 10-14 days • ↑ ESR • ↑ BUN & ↑ Creatnine • ↑ Specific Gravity 1.20-1.30 • ↓ Albumin = Hypoalbunemia • ↑ K+ due to impaired GFR • ↑ NH4 (Azotemia)

  27. Treatment • Isolation Precautions! • Bed rest (6-12 weeks) • Stable electrolytes, BUN & BP • Medications; • PCN 10 day therapy • only for + current strep • Hydralazine (Apresoline)– • vasodilator (↑ renal & cerebral flow) • √ V/S, BP & Neuro status • Furosemide (Lasix)– Loop diurectic • Inhibits re-absorption of Na & Cl • √ Lytes √ I&0 & √ weight

  28. Treatment • Fluid Balance • Oliguria = Fluid restriction (I =O) • Promote voiding • Diuresis = Improvement → Dehydration • Nutrition • ↑ Carbohydrates • ↓ Na+ and K+ • Moderate protein • (Protein → Urea → ↑↑ BUN) • Energy for tissue repair

  29. Nephrotic Syndrome • Most common glomerular injury in kids • Idiopathic 85% • Boys 2x > Girls • Age 2-4 years • Viral infection 7 days before onset • Acquired secondary • Acute Glomerulonephritis →Toxic Nephrosis • Systemic disease SLE or HIV. • Major presenting symptom of pt with AIDS • “Swiss Cheese Syndrome”

  30. Pathophysiology • ↑↑ Glomerular Permeability to plasma proteins • ↑↑ Urinary excretion of protein & albumin • Proteinuria +3/+4 = Hypoproteinemia (-) N balance • Albuminuria +3/+4 = Hypoalbuminemia • ↓↓ Plasma Osmotic Pressure → ↓↓ Vascular Volume • Stimulates Renin → Angiotensin → ADH & Aldosterone Na & H2O retained → Edema • ↑↑ Interstitial Fluid (abdomen & extremities) • Hyperlipidemia (450-1500) • ↓↓ Serum protein activates hepatic lipid synthesis • Fat streaks in glomeruli & ↓↓ GFR • Lipid granules in urine “sparkly”

  31. Signs and symptoms • Pitting Edema- Presenting symptom • Periorbital in AM –Dependent in PM • Back, Abdomen & Scrotum • Gradual weight gain • Ascites • ↑ Abd girth & ↓ Respiratory function • Oliguria • Dark and “frothy” (Lipid Granules) • Skin waxy and white from anemia • Malnutrition • ↓ Intestinal absorption • (-) N balance • Blood pressure WNL or ↓ RT Hypovolemia

  32. Prognosis • Self-Limiting: Resolves 1-2 weeks • Prolonged recovery 12 - 18 months • Exacerbations of symptoms • Risk of relapse = 50% after 5 years • 80% will have favorable outcome

  33. Therapy • Assess V/S for shock! √ HR & BP • Strict I&O & Daily weight • √ urine- protein, albumin & SG • Bed rest • ↑ Risk for skin breakdown RT edema • Sheepskin, reposition q 2h • Nutrition • ↑ Calories, ↑ Ca+, ↑ Protein & ↓ Na+

  34. Medications • Prednisone 2mg/kg/day ÷ qid • ↓ Inflamation & Proteinuria • Diuresis (7-21 days) ↓ protein excretion • Monitor SE: • Hyperglycemia ↓ Growth GI bleeding • Diuretics • Furosemide (Lasix) 1-2mg/kg/dose • Mannitol IV 0.25-0.5 mg/kg/dose q4h • ▲ Osmotic Pressure ↑ GFR • Reabsorbs H2O, Na & Cl Salt Poor Albumin (SPA) 5-25% 1-2 gm/kg/day • Plasma expander & replenishes albumin

  35. Hypospadias • 1-300 births • 10-15% have 1st degree relative • Urethral opening located behind glands on ventral (underside) surface • “Kids wet their sneakers” • ↑↑ Severity closer to body wall

  36. Treatment • No circumcision! • May use foreskin for repair later • Urology consult • Reconstructive surgery @ 6-18 mos • Testosterone prior to ↑ penile size • Indwelling catheter → leg bag • Home care instructions important

  37. Epispadias • Rarer than hypospadias • Urethral opening located behind glans penis on dorsal (upper) surface • “Kids wet their faces” • Same Treatment as for hypospadias

  38. Cryptochidism • Failure of 1 or both testes to descendabdomen→ inguinal canal→ scrotal sac • Inguinal hernia and small scrotal size • Retractile testes- “Reducible” • Overactive cremasteric reflex. • Manually can be brought down to scrotal sac.

  39. Therapy • Wait for 1st birthday for spontaneous descent • 75% spontaneously descend • HCG 1000 units IM x 3 doses • Facilitates descent • Surgery-orchioplexy • Bring testes into scrotal sac

  40. Enuresis Unable to control bladder function (Nocturnal bed wetting) • Primary • Never been dry @ night • Secondary • Most common, previously dry and now accidents @ night • Delayed CNS maturation • Unable to detect bladder fullness and control voiding • UTI • Family history • Hypercalciuria • ↑↑ Ca in urine → bladder irritation → painful urination

  41. Therapy • R/O UTI or ↑↑ Ca • Behavior modifications • No drinking at bedtime • Void prior to bedtime • Imagery of full bladder Medications • TCA’s • Imipramine (Tofranil) 10-25mg q HS • Nortrypyline (Pamelor) 10-35 mg q HS • Antidiuretic • DDAVP Desmopressin Acetate 0.2-0.6 mg q HS • Diuretic • Chlorothiazide (Diuril) 20 mg/kg/24H • ↑↑ Ca reabsorption

  42. Testicular Torsion • 4000 males @ peak age 13 • Twisting of spermatic cord • ↓↓ blood flow to testes • Testes can survive only 6-12 hours with-out blood flow • Gangrene & necrosis sets in • Surgical emergency

  43. Signs and symptoms • Acute onset! • Severe testicular pain • Scrotum swollen, red & warm • Abdominal pain N & V • ↓Cremasteric reflex • Surgery • Untwist and secure cord to prevent further torsions • Orchiectomy • Remove gangrene testicle

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