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Monday, 29 August 2011

GENITOURINARY SYSTEM PEDATRICS


GENITOURINARY SYSTEM

       Nephrons continue to develop after birth
       GFR is 30% below adult level at birth
        reaches normal level by age 2 years
        tubular function immature at birth;  reach adult level
            by age 2 years
        urethra shorter in children and more prone to ascending
            infection

UNDESCENDED TESTES (Cryptorchidism)
        unilateral or bilateral absence of testes in scrotal sac
        testes normally descend at 8 months of gestation
        increased incidence in those  with genetic disorder
        75% will descend spontaneously by age 1 year

Assessment:
        unable to palpate testes in scrotal sac

Management:
        if testes remains in abdomen, damage to testes is possible because of increased
        chorionic gonadotropin
        orchipexy:  surgical procedure to retrieve and secure testes placement; performed between ages 1-3 yrs

Nursing Management:
        provide treatment options
        support parents if surgery will be done
        post op:  avoid disturbing the tension mechanism
        avoid contamination of incision

HYPOSPADIAS
        urethral opening located anywhere along the ventral surface of penis

Assessment:
        urinary meatus misplaced
        inability to make straight stream of urine

Management:
        minimal defects – no intervention
        neonatal circumcision delayed, tissue maybe needed for corrective repair
        surgery at age 3-9 months

Nursing Intervention:
        diaper normally
        provide support for parents
        post op: check pressure pressure dressing
        monitor catheter drainage

PHIMOSIS
        an abnormal narrowing of the foreskin so that it cannot  be retracted over the glans penis
        may be present at birth or may develop as a result of poor hygiene with accumulation of smegma

Management:
        Prevention – regular pulling the foreskin back and cleaning
        circumcision

Nursing intervention:
        circumcision care:
  1. Close observation for bleeding
  2. Ice application
  3. Administration of analgesics

ENURESIS
        involuntary passage of urine after the age of control is expected (4 years)
        types:
  1. Primary – in children who have never achieved control
  2. Secondary:  in children who have developed complete
            control
      May occur anytime but most frequent at night
      More common in boys
      No organic cause

      Etiologic possibilities:
  1. Sleep disturbances
  2. Delayed neurologic development
  3. Immature development of bladder
  4. Psychologic problems

Assessment:
      PE normal
      History of repeated voluntary urination management:
        bladder retention exercises
        drug therapy
  1. TCA – imipramine
  2. Anticholinergics

Nursing Intervention:
        Provide information/counseling to family:
  1. Confirm that this not conscious behavior and that the     child is not purposely misbehaving
  1. Assure parents that they are not responsible and that this is a relatively common problem
      Involve child in care; give praises and support with small accomplishments
  1. Age 5-6 years – can strip wet beddings
  2. Age 10-12 years – can do laundry and change bed
      Avoid scolding and belittling the child

EXSTROPHY OF THE BLADDER
        congenital malformation ; nonfusion of abdominal
            and anterior walls of the bladder during embryologic
            development
        anterior surface of bladder lie open on abdominal wall

Assessment:
        Associated structural changes
  1. Prolapsed rectum
  2. Inguinal hernia
  3. Widely split symphysis
  4. Rotated hips

      Associated anomalies
  1. Epispadias
  2. Cleft scrotum or clitoris
  3. Undescended testes
  4. Chordee (downward deflection of the penis)

Management:
        reconstructive surgery
        urinary diversion
        delayed until 3-6 months

Nursing intervention: Preop:
        Provide bladder care; prevent infection
  1. Keep area as clean as possible
  2. Change diaper frequently; keep loose fitting
  3. Wash with mild soap and water
  4. Cover exposed bladder with vaseline gauze

Postop:
       Design play activities to foster toddler’s need for autonomy
            -  child will be immobilized for extended period of time
      Prevent trauma; as child gets older and more mobile,
            trauma is more likely

NEPHROTIC SYNDROME         
        autoimmune process
        structural alteration of glomerular membrane
        results in increased permeabilityb to plasma proteins
        course:  exacerbations and remissions over a period of months to years
        commonly affects preschoolers; boys>girls

Assessment:
  1. Proteinuria
  2. Hypoproteinemia
  3. Hyperlipidemia
  4. Dependent edema
      Puffiness around the eyes in morning
      Ascites
      Scrotal edema
      Ankle edema
  1. anorexia, vomiting, diarrhea
  2. Pallor, lethargy
  3. Hepatomegaly

Management:
        drug therapy
  1. Corticosteroids
  2. Antibiotics
  3. Thiazide diuretics

Nursing Intervention:
      Provide bed rest
  1. Conserve energy
  2. Find activities for quiet play

      Provide high protein, low sodium diet – during edema phase
      Maintain skin integrity
      Avoid IM injections – meds not absorbed in edematous tissues
      Obtain morning urine for protein studies
      Provide scrotal support
      Monitor I and O, vital signs
      Daily weight
      Administer as ordered
      Protect from sources of infection

ACUTE GLOMERULONEPHRITIS
        immune complex disease
        beta hemolytic strep
        More frequently in boys; 6-7 years
        resolves in 14 days
        self limiting

Assessment:
  1. History of strep infection (URTI or impetigo)
  2. Edema, anorexia, lethargy
  3. Hematuria or dark colored urine
  4. Fever
  5. Hypertension
  6. Diagnostic tests:
      Urinalysis – rbc,wbc,protein, cellular casts
      Urine specific gravity increased
      BUN, crea increased
      ESR elevated
      Hgb, Hct decreased

Management:
        antibiotics
        Antihypertensives
        digitalis – if with CHF
        fluid restriction
        peritoneal dialysis – if severe renal complication occurs

Nursing Management:
1.  Monitor I and O, BP
  1. Weigh daily
  2. Provide diversional activity
  3. Provide client teaching and discharge planning
      Medication administration
      Prevention of infection
      Signs of renal complications
      Importance of long term follow up

WILM’S TUMOR (NEPHROBLASTOMA)
         large, encapsulated tumor that develops in the renal parenchyma,
         more frequently in left kidney
         originates during fetal life
         peak age : 1-3 years
Assessment:
         non tender mass, usually midline near liver
         hypertension
         hematuria
         test: IVP
Nursing intervention:
  1. Do not palpate abdomen – to avoid dissemination of CA cells
  2. Handle child carefully when bathing and giving care
  3. Provide care for the client with a nephrectomy
  4. Provide care for the child receiving chemotherapy

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