When assessing a child with acute Poststreptococcal glomerulonephritis which symptoms should the nurse anticipate to be present?

Capstone Med Surg Assessment

1.A nurse is teaching a client about using a continuous positive airway

pressure (CPAP) device to treat obstructive sleep apnea. Which of the

following information should the nurse include in the teaching?

It delivers a present amount of airway pressure throughout the breathing

cycle

2.A nurse is providing discharge teaching to a client following a heart

transplant. Which of the following information should the nurse include in

the teaching?

Shortness of breath might be an indication of transplant rejection

3.A nurse is caring for a client who has syndrome of inappropriate

antidiuretic hormone (SIADH) and is receiving 3 % sodium chloride via

continuous IV. Which of the following laboratory finding should the nurse

identify as an indication that the SIADH is resolving?

Urine specific gravity 1.020

4.A nurse is teaching a client about fecal occult blood testing (FOBT) for the

screening of colorectal cancer. Which of the following statements should

the nurse include in the teaching?

You should avoid taking corticosteroids prior to testing

5. A nurse is preparing a client for a colonoscopy. Which of the following

medications should the nurse anticipate the provider to prescribe as an

anesthetic for the procedure?

Propofol

6.A nurse is planning care for a client who has acute pancreatitis. Which of

the following interventions should the nurse include in the clients plan?

Select all that apply.

Monitor blood glucose levels

Maintain NPO status until pain-free

Manage acute pain

Genitourinary System overview 

Urinary System: -Excretes Wastes. ;-Maintains acid-base, fluid, and electrolyte balance.

Kidneys ; Ureters ;Bladder Urethra Reproductive System: Internal and external organs that promote conception and healthy development of a fetus.

Development and Biologic Variations in the Pediatric Patient

Urinary: All nephrons present at birth. Renal growth: -Most takes place during first 5 years. Full size by adolescence. Renal efficiency -> Increases as child matures. Bladder capacity and control. Increases from

. Children less than 2 years old cannot maintain bladder control due to

Development and Biologic Variations in the Pediatric Patient part 2 

-Kidneys do not reach maturity until age 2 years. -Kidney’s size large in proportion to abdomen. : easily damaged & prone to kidney trauma - Less protection of kidneys by ribs and fat padding. -More vulnerable to kidney trauma from compression force to abdomen.

Development and Biologic Variations in the Pediatric Patient part 3

Renal blood flow is slower. Absorption of amino acids is limited. Autoregulation is not fully developed; therefore concentration of urine is not as effective. Increased risk for dehydration due to immaturity.

Development and Biologic Variations in the Pediatric Patient: reproductive system 

Reproductive System: -Functionally immature until puberty. -Genitalia (except clitoris in girls) enlarge gradually through childhood.

Renal System Assessment: physical & health HX 

Physical assessment: Palpation, percussion. Health history: Previous UTIs, calculi, stasis, retention, pregnancy, STDs, bladder cancer. ;Medications (i.e. antibiotics, anticholinergics, antispasmodics). Urologic instrumentation. ;Urinary hygiene. Patterns of elimination. - how often are going? they need to go at least every 2 hrs, ask child if they need to go every 40 min & after drinks, make sure they are going every 2 hrs, ? previous UTI

average urine output and if not meet = risk for dehydration 

Infant: 2-3 ml/kg/hr Toddler/preschooler: 2 ml/kg/hr School-age child: 1 – 2ml/kg/hr Adolescent: 0.5-1 ml/kg/hr

diagnostic tests for the renal system: Intravenous pyelogram (IVP) 

-Contrast medium injected intravenously -Excreted through kidneys -Serial x-rays -Patient has feeling of warmth : tell parents - Prior to test: NPO, check for allergies, need venous access : check shellfish allergy , need patent IV Avoid use of word “dye” with children

diagnostic tests for the renal system: Voiding cystourethrogram(VCUG)

-Contrast medium instilled in bladder via catheter - Catheter removed : the patient has to pee on the x-ray table - X-rays taken before, during, & after voiding - don't tell kids before the procedure what will happen

diagnostic tests for the renal system: cystoscopy 

-Direct visualization of bladder through -Requires anesthesia -NPO & other pre-op routines -Assess ability to void post procedure teach parents there may  be some blood in urine afterwards

diagnostic tests for the renal system: renal ultrasound & renal scan 

-Radioactive agent injected intravenously -Collected in kidney -Area is scanned

Epidemiology of Genitourinary Disorders

-Most often in children < 7 years. ; Often secondary to congenital anomaly. ;Most common non congenital disorder is UTI-increased risk females until puberty. Lower GU abnormalities occur in boys and girls. Some disorders have a distinct gender association-UTI/VUR=Girls. Boys have a higher incidence of structural defects of GU organs. Multiple congenital anomalies are associated with GU Defects.

select all that apply with the epidemiology of genitourinary disorders/factors associated with UTI 

- poor hygiene - observe urine flow - congenital abnormality 

-2nd in prevalence after URIs affecting 7% of girls and 2% of boys before age 6 years. - Within first year of life, males with UTIs are more likely to have an anatomic basis for infection.
-2-6 years -> Peak incidence not caused by structural anomalies.

Gram Negative Organism: Escherichia coli (60% to 80% of cases). -Other organisms: klebsiella, staphylococcus aureus, pseudomonus. - Other contributing factors: Anatomic Physical Chemical

-Anatomic: female, short straight urethra, close proximity to rectum. . -Females have a 10-30 times greater risk than m.ales -urinary stasis (incomplete bladder emptying may result from reflux). -Congenital anomalies. -Impaired immune response.

Lower tract infections involves lower urinary tract. Examples:

inflammation of the bladder.

= inflammation of the urethra. Manifestations: usually none

Clinical Manifestations: neonate with UTI

-Non-specific symptoms -Hypothermia -Sepsis -Poor feeding, vomiting -Frequent urination -Jaundice -Dehydration -Enlarged kidneys or bladder - at risk for mengitits

clinical manifestations: infant with UTI 

Non-specific symptoms Vomiting Irritability Fever Poor feeding Strong-smelling urine Persistent diaper rash- causes bacterial irritation to skin

clinical manifestations: child under 2 yrs of age for UTI

Similar to adult ; Urgency, frequency ;Enuresis or wetting pants in previously-trained child -Burning on urination; toddler may hold fro:nt of diaper and cry; older child may try to avoid urinating :pt grabs front of the diaper ; pee burns Fever Foul-smelling urine

diagnostic evaluation for UTI

High degree of suspicion. RED FLAG: (burning painful , concetrated urine. Incontinence in a toilet-trained child. ; Strong smelling urine. ; Frequency or urgency. H&P. Dipstick :Identify presence of blood, nitrates, WBCs, leukocyte esterase, and bacteria. Urinalysis and culture and sensitivity. : access prior to giving antibiotics

diagnostic evaluation for UTI part 2 

-Clean-catch is preferred. - U-bag for collection from child. -for u/a it is not sterile; wipe from front to back ; Specimen obtained by catheterization or suprapubic needle aspiration has more accurate results(for culture)-May be necessary when clean-catch cannot be obtained. Sensitivity testing determines susceptibility to antibiotics Imaging studies for suspected obstruction IVP or abdominal CT .

collection of specimen for UTI

-Urine specimens should be collected via catheterization technique in non-toilet-trained infants or children. -older children samples for urinalysis should be obtained by the least invasive route, such as midstream clean catch. -The perineum should be prepped before collection of urine via mid-stream, clean-catch technique to reduce the incidence of contamination. If a urine specimen is to be sent for culture, the specimen should be collected via urinary catheterization. Sent immediately to the lab.

Normal Urinalysis: critical value over phone read back to make sure to correct. 

-pH 5 to 9. Specific gravity 1.001 to 1.035. Protein <20 mg/dl. Urobilinogen up to 1 mg/dl. None of the following: this should not be in urine Glucose Ketones ;Hgb ;WBCs (few) RBCs ; Casts Nitrites

Therapeutic Management for UTI: goals of treatment 

-Eliminate current infection. -Identify contributing factors to reduce risk of recurrence. - Prevent urosepsis. Preserve renal function.

Therapeutic Management for UTI:

-Antibiotic therapy depends on laboratory culture and sensitivity tests. -Empiric therapy on the basis of the child's history and presenting symptoms may be necessary when fever or systemic illness complicates UTI. -Antibiotics: penicillins, sulfonamides (SMX-TMP), cephalosporins, nitrofurantoin, tetracyclines. All antibiotics may cause side effects or may be ineffective secondary to bacterial resistance. Standard practice-Renal U/S, VCUG, and if necessary IVP. Teach Urinary Tract Infection Prevention

nursing management for UTI: teach UTI prevention 

-Identification of children with UTI and education of parents and children regarding prevention and treatment of infection. -A careful history regarding voiding habits, stooling pattern, and episodes of unexplained irritability may assist in detecting less obvious cases of UTI.  -Collecting an appropriate specimen is essential when the nurse suspects infection - responsibility to take every precaution to obtain acceptable, clean-voided specimens. -Prepare children for these tests performed to detect anatomic defects as appropriate for their age.

nursing management for UTI part2 -CVA tenderness is indicative of pyloric infection

Teach the patient and parents the appropriate dosage and scheduling and provides suggestions for administration of the agent. Encourage adequate fluid intake for the prevention and treatment of UTI, since bacterial eradication from the urinary tract is partially dependent on urine flow and voiding frequency. Have children avoid caffeinated or carbonated beverages because of their potentially irritative effect on the bladder mucosa. 

Prevention is the most important goal in both primary and recurrent infection. ;Most preventive measures are simple, ordinary hygienic habits that should be a routine part of daily care.  Investigate any signs of intestinal parasites (e.g., scratching between the legs and around the anal area) and treat them appropriately.  Advise sexually active adolescent girls to urinate as soon as possible after intercourse to flush out bacteria introduced during sex play.  Also teach parents and older children health practices that prevent UTI.

Etiology of vesicoureteral reflux (VUR)

Refers to the retrograde flow of bladder urine into the ureters. Increases potential for infection. Primary vs. secondary reflux. -70% of kids have a spontaneous resolution 

primary causes of vesicoureteral reflux (VUR)

Short or absent intravesical ureter. Absence of adequate detrusor backing. Lateral displacement of the ureteral orifice. Paraureteral (Hutch) diverticulum

secondary causes of vesicoureteral reflux (VUR)

Cystitis or UTI. Bladder outlet obstruction. Neurogenic bladder. Detrusor instability.

incidence of vesicoureteral reflux (VUR): tall girls have increased incidence of shorter urther 

Increased incidence in males in utero and during neonatal period. -School Age: increased incidence in girls. -Familial tendency exists, 1/3 of siblings of child with VUR also have it. - 70% with VUR has spontaneous resolution. -Associated with UTIs.

-Backflow of bladder urine into ureters as pressure increases (full bladder or during voiding). -Severity of VUR determines risk for pyelonephritis and kidney damage. -Five grades of reflux according to severity.

5 - point grading system : grades I and II

Grade I : Mildest form of VUR.  Urine enters the ureter but does not travel all the way up to the kidney. The ureters look normal in size. Grade II  Urine travels all the way up the ureter and enters the part of the kidney where urine is collected before it drains to the ureter (renal pelvis). The ureters and renal pelvis appear normal in size.

5 - point grading system: grades III and IV 

Grade III Similar to grade II except the ureters and/or the renal pelvis appear abnormal in size or shape. Grade IV Similar to Grade III except the ureter is grossly enlarged- risk for permanent damage

5 - point grading system: grade V

Most severe form of VUR. Similar to grade IV, except the ureter is also twisted and curved. Renal pelvis is also enlarged and its normal structural details are no longer detectable.

5 - point grading system low vs high grade 

Low Grade (I or II): 80% chance will resolve in early childhood. High Grade (III, IV,V): may or may not be self limiting. Serious renal sequelae secondary to infection.

clinical manifestations of VUR 

-Does not cause any specific signs or symptoms unless complicated by UTI. -Almost always asymptomatic unless it has led to a kidney infection (febrile UTI). -Present with S&S of a UTI: Fever ;Dysuria Frequency or urgency Nocturia ;Hematuria ;Flank pain

goals of management of VUR

Allow normal renal growth. To prevent UTI and pyelonephritis. To prevent renal failure. Nursing: Assess BP (hydronephrosis) - increased BP Palpate abdomen (hydronephrosis)

therapeutic management of VUR

Grade I or II: Radiologic surveillance in anticipation that will resolve within 3-5 years. Antibiotics for infection. High Grade III-V: Re-implantation. - urter/better position to prevent reflux

Postoperative Nursing Care of VUR

Routine Post Operative Care. Bladder Spasms: especially problematic 1-2 days post-operatively. nursing:Meticulous maintenance and monitoring of urethral catheter, ureteral stent or suprapubic tube. (complications) Monitor for S&S infection, urine output, character of urine. Diet: High CHON (protein- helps with  wound healing), increased fluids.

Teaching parents regarding importance of antibiotic therapy in treatment of infection. Long-term ABX prophylaxis. Follow-up.

incidence of Acute Glomerulonephritis (AGN)

One of the most common acute renal syndromes. More likely to occur in early school age child. Peak onset: 6-7 years. Males 2x more likely to develop APSGN. Most cases are postinfectious and have been associated with pneumococcal, streptococcal, and viral infections.

Acute Poststreptococcal Glomerulonephritis (APSGN) overview 

-APSGN is the most common of the noninfectious renal diseases in childhood. -Symptoms present 10-21 days following throat or skin infection with a certain nephrogenic strain of group A beta- hemolytic streptococcus. -APSGN can occur at any age but primarily affects early school-age children, with a peak age of onset of 6 to 7 years. -It is uncommon in children younger than 2 years of age.

RED FLAG: nsg assessment for APSGN

Evaluate a child who presents with the following: Periorbital edema, which parents may report is worse in the morning. Loss of appetite. Decreased urinary output. Cola- or tea-colored urine. Antecedent streptococcal infection.

hallmark characteristics of APSGN

-Oliguria- having a small amount of urine -Edema - Hematuria - blood in urine -Proteinuria - protein in urine - Hypertension -always with AGN Circulatory congestion

clinical manifestations of APSGN

Preceded by “mild cold” or an infection (~10 days). Sudden onset of mild proteinuria, hematuria, periorbital edema. Urine is smoky brown secondary to hematuria. Irritable, general malaise, flank, mid abdominal pain, fever. Acute HTN (headache, vomiting, somnolence, other CNS changes). Manifestations of fluid overload.

diagnostic evaluation of AGN 

Urinalysis (hematuria, proteinuria, and increased specific gravity); negative urine culture. Reveals normal electrolyte (sodium, potassium, and chloride ions) and carbon dioxide levels. BUN and Creatinine. Strep culture (positive in few cases). 24 hour urine for creatinine clearance and CHON excretion. Blood pressure evaluation.

diagnostic evaluation of AGN  additional 

Antistreptolysin O (ASO) titer. Antibody responses to the extracellular products of the streptococci provide indirect evidence of previous streptococcal infection. Chest X-Ray. Reveals characteristic generalized cardiac enlargement, pulmonary congestion, and pleural effusion during the edematous phase of acute disease. Kidney biopsy. In atypical cases.

clinical course of AGN : acute edematous phase 

Usually persists from 4 to 10 days, but may persist for 2 or 3 weeks. Child remains listless, anorexic, and apathetic. Weight fluctuates, the urine remains smoky brown, and the blood pressure may suddenly reach dangerously high levels

clinical course of AGN 1st signs of improvement : cluster care : daily wts & frequent BP checks 

Small increase in UOP with a corresponding decrease in body weight. With diuresis the child begins to feel better, the appetite improves, and BP decreases to normal with the reduction of edema. Gross hematuria diminishes, in part because of dilution of the red blood cells in the more dilute urine, but microscopic hematuria may persist for weeks or months. Blood urea nitrogen (BUN) and creatinine levels decrease during diuresis and usually return to normal. A slight to moderate proteinuria may persist for several weeks.

medical management of AGN 

No specific treatment is available for AGN, but recovery is spontaneous and uneventful in most cases. Management consists of general supportive measures and early recognition and treatment of complications. Daily Weights***, VS, BP, I & O. Dietary restriction of fluids, NA, K -> UOP significantly reduced (<2 to 3 dl/24 hr).

additional medical management of AGN

HTN -> loop diuretics and antihypertensives. Diuretics -> helpful if significant edema and fluid overload are present, but not in renal failure (limited value since little sodium reaches the distal tubules as a result of the reduced filtration rate). Culture family and treat. Assess for complications: CNS, seizures. Family Teaching.

Careful Assessment: Disease status Vital signs (including frequent measurement of blood pressure) Fluid balance behavior.

Nephrotic syndrome overview 

Etiology: unknown. Massive proteinuria, hypoalbuminemia, hyperlipidemia, and edema Produced by massive loss of urinary protein. Can develop during the course of several different renal or systemic diseases. Three Major Forms: Congenital – rare. Primary Nephrotic Syndrome - restricted to glomerular injury. Secondary Nephrotic Syndrome - develops as part of a systemic illness.

epidemiology of nephrotic syndrome 

Majority are Primary (90-95%). Minimal Change Nephrotic Syndrome (MCNS). Seen at any age but is predominantly a disease of the preschool child. Usually develops in 2-3 year old children. Occurs rarely in children > 8 years. 3/100,000 children. Boys affected 2x more often than girls.

Pathophysiology of nephrotic syndrome 

-Damage to glomerular capillaries -> increased capillary permeability to CHONS (especially albumin) = PROTEINURIA*. Loss of CHONS -> HYPOALBUMINEMIA* (hypoproteinemia).  Hypoproteinemia -> Increased hepatic synthesis of proteins and lipids = HYPERLIPIDEMIA*. Hypoalbuminemia -> decreased plasma oncotic pressure -> movement of intravascular fluid into the interstitial space = EDEMA*. *Hallmark Symptoms

REG flag: nursing assessment of nephrotic syndrome 

Evaluate a child who presents with the following: Periorbital, gonadal, or lower extremity edema. Weight gain greater than that expected based on previous pattern. Decreased urinary output. Pallor, fatigue.

4 hallmark symptoms of nephrotic syndrome 

Proteinuria > 3+ dipstick Hypoalbuminemia Hyperlipidemia Edema Ascites Hypovolemia

clinical manifestations of nephrotic syndrome

First Sign: periorbital edema. Increased weight. Decreased urinary output: urine is frothy/foamy. - at risk for sepsis Ascites, pleural effusion, labial or scrotal swelling. BP usually normal or slightly low.

clinical manifestations of nephrotic syndrome: additional information 

GI (secondary to edema of intestinal mucosa) -> diarrhea, anorexia, malabsorption . Malnutrition -> hair change, pallor or shiny skin, prominent veins. Irritable, lethargic, fatigued. Susceptibility to infection especially pneumonia, cellulitis, septicemia.

diagnostic evaluation of nephrotic syndrome 

Based on the history and clinical manifestations (edema, proteinuria, hypoalbuminemia, and hypercholesterolemia in the absence of significant hematuria and hypertension). If renal biopsy is performed, it provides information regarding the glomerular status and type of nephrotic syndrome, the likely response to drugs, and the probable course of the disease.

management goals of nephrotic syndrome 

Decrease protein loss. Balance nutrition. Restore normal metabolic function. Prevent or treat infection.

medical management of nephrotic syndrome

Hospitalization for initial episode and for dx and initiating treatment, limited activity. Supportive care Diet Protein-rich diet. Low sodium. Fluid restrict if edema is severe.

medical management of nephrotic syndrome additional information 

Steroids. - no vaccines for 2 wks  after Diuretics. Immunosupressants if recurrent unresponsive to steroids (cyclophospahmide). at risk for infection Family teaching regarding disease and management. Recurrences: may or may not require hospitalization - keep track of dipstick at home

Streptococcal antibody titers: elevated  BP: elevated Edema: primarily periorbital &peripheral circularaly congestation common proteinura: mild ro moderate hematuria : gross or microsopic RBC casts : present; azotemia present K levels : normal or increased ; protein levels minium reducations ; lipid levels: normal; peak onset age: 5 to 7 yrs

nephrotic syndrome clincial manifestations 

Streptococcal antibody titers: normal BP: normal or decreased Edema: generalized or severe circularaly congestation  absent proteinura: massive hematuria :  microsopic or none RBC casts : absent ; azotemia absent K levels : normal   ;protein levels : marked decrease ;lipid levels: elevated ;peak onset age: 2 to 3 yrs

Hemolytic Uremic Syndrome (HUS) overview 

Acute renal disease characterized by a triad of manifestations. Hemolytic anemia Thrombocytopenia Acute renal failure Etiology: occurs after an infection in the digestive system caused by the Escherichia coli bacterium found on contaminated food like meat, dairy products, and juice

epidemiology of Hemolytic Uremic Syndrome (HUS) 

Ninety percent of children with HUS who receive careful supportive care survive past the initial stages of the condition. Most of those will have no long-term effects. Between 10 percent and 30 percent of the survivors will have kidney damage.

pathophysiology of Hemolytic Uremic Syndrome (HUS) :Platelet aggregation within damaged blood vessels or the damage and removal of platelets = THROMBOCYTOPENIA.

Primary site of injury appears to be the endothelial lining of the small glomerular arterioles. The endothelium becomes swollen and occluded with the deposition of platelets and fibrin clots (intravascular coagulation). Red blood cells are damaged as they move through the partially occluded blood vessels -> spleen removes these fragmented red blood cells = ACUTE HEMOLYTIC ANEMIA. Fibrinolytic action on the precipitated fibrin causes these fibrin-split products to appear in the serum and urine. 

diagnostic evaluation of Hemolytic Uremic Syndrome (HUS) 

Triad of anemia, thrombocytopenia, and renal failure is sufficient for diagnosis. Proteinuria, hematuria, and urinary casts. Elevated BUN and serum creatinine levels. Low hemoglobin and hematocrit and a high reticulocyte count (confirms the hemolytic nature of the anemia).

clinical manifestations of hemolytic uremic syndrome (HUS) 

Prodromal Period:Episode of abdominal pain, diarrhea (~bloody) and vomiting. Hemolytic Process:Persists for several days to 2 weeks. Anorexic, irritable, and lethargic. Marked and rapid onset of pallor accompanied by hemorrhagic manifestations such as bruising, purpura, or rectal bleeding. Severely affected = anuric and often hypertensive.

medical management of hemolytic uremic syndrome (HUS) 

Direct treatment toward control of the complications and hematologic manifestations of renal failure. (decreased K && phos = renal failure) Initial supportive measures -> managing renal failure: Fluid replacement. Treatment of hypertension. Correction of acidosis and electrolyte disorders. Early hemodialysis, PD, or continuous hemofiltration -> any child who has been anuric for 24 hours or oliguria with uremia or hypertension and seizures.

Defects of the External Genitourinary Tract overview 

Cryptorchidism ; Hydrocele ;Inguinal hernia ;Hypospadias ;Epispadias -Bladder Exstrophy ; Phimosis ;Chordee Ambiguous Genitalia

cryptorchidism (undescended testes) Etiology/Incidence

One or both testes fail to descend through inguinal canal into scrotum. Occurs in 4-5% of full-term infants. Premature infants have higher incidence (~30%). Exact reason not known. ? mechanical, hormonal, chromosomal, enzymatic. Majority descend spontaneously during 1st year. - warm room so testes doesn't retract

cryptorchidism (undescended testes) : pathophysiology 

Testes usually descend during 7th to 9th month of gestation. Sperm production is decreased. Inguinal hernia common. Complications: Sterility. Malignancy (testicular cancer in adolescents/young adults). palpate down ingenial canal & feel for little peanuts in the scrotum

clinical manifestations of cryptorchidism (undescended testes)

Testes not palpable or not easily guided into scrotum. Ascent above scrotum of previously descended testis. True absence of both testes is rare.

diagnosis of cryptorchidism (undescended testes)

Testes retract into inguinal canal if exposed to cold or child is upset. :Examine child in warm room. Be sure child is calm. Can be located with ultrasound, CT scan, MRI. May require surgical exploration by laparoscopy. If neither testis palpated, presence can be evaluated by hormonal stimulation and measurement of testosterone response.

medical management of cryptorchidism (undescended testes)

Initial management by observation, since testes often descend spontaneously during 1st year. Hormone injections (B-HCG or testosterone) to try to bring the testicle into the scrotum Treatment of choice is surgical correction, age 1-2 years. Orchidopexy = testis brought down and sutured in place. Most common complications are bleeding and infection. Purpose is to preserve testicular function, appearance of scrotum, and screening for malignancy (TSE).

Painless swelling of scrotum caused by collection of fluid. Surgical repair indicated if progressively enlarging or persistent and spontaneous resolution not accomplished by 1 year.

Hypospadias: Opening of urethral meatus is below normal placement on glans of penis.

Common anomaly of penis = 1 in 500 males. May be accompanied by downward curvature of penis (chordee). Associated anomalies include undescended testes and inguinal hernias. Hereditary component. Teratogens. Inadequate testosterone. 20% of affected males have undescended testicles-suppression of hormone secretion.

Opening of urethral meatus is above normal placement on glans of penis. Less common than hypospadias. Often associated with bladder exstrophy = eversion of posterior bladder wall through anterior bladder wall and lower abdominal wall (“turned inside out”).

nursing assessment of epispadias 

Check genitalia. Check for undescended testicles. Assess abdomen since increased risk of upper UT anomalies. Assess urine stream particularly in older child. Do Not Allow Circumcision. -infants can feel pain give sweeties to release endorphins

Surgical repair. Usually between 6-12 months. If 2 step procedure, stage 2 should be done 3-6 months after initial surgery. If early intervention is not feasible wait until after 2 1/2 years.

Post-Operative Nursing Care of epispadias 

Routine post op care. Focus assessment on urinary diversion, wound care, pain management, and activity restriction. Abx and urine acidifying agents such as Vitamin C. Assess for bladder spasms and administer appropriate meds such as Ditropan. Double diapering = protect urethra and stent; keep area clean. prevent contamination Diet: high CHON, Fluids. Complications: stricture formation, meatal stenosis.

bladder exstrophy overview 

Eversion of posterior bladder through anterior bladder wall and lower abdominal wall. Associated with open pubic arch. Medical Management: Preserve renal function. Attain urinary control. Provide adequate reconstructive repair. Improve sexual function.

A male newborn is found to have exstrophy of the bladder. The nurse should evaluate the infant for which of the following? Select all that apply. : Hypospadias Epispadias Cryptochidism Acute tubular necrosis ; Bilateral inguinal hernias

Epispadias and bilateral inguinal hernias are frequent anomalies associated with exstrophy of the bladder. Hypospadias, cryptorchidism, and acute tubular necrosis are not.

A child has been admitted to the hospital with a diagnosis “rule out nephrotic syndrome.” The nurse would assess the child or which of the following symptoms? a) Hematuria
b)Edema c)Petechial rash d) Dehydration

Edema is the major clinical symptom of nephrotic syndrome. The child may gain twice his/her normal weight in severe cases. Dehydration is the opposite of what the patient is experiencing.

The nurse is caring for a toddler who is not toilet trained. The nurse practitioner has ordered intake and output measurement. The nurse will most likely measure the urine using which method? a) Estimating UOP as small, moderate, or large and recording it on the chart. b) Weighing each wet diaper and recording the weight as the amount of UOP. c)Subtracting the weight of a dry diaper from a wet diaper and recording the amount. d)Determine UOP by the number of diaper changes in each 24-hr period.

Diapers are weighed on a gram scale before using them and after removal (1 gm = 1 ml). The weight of the dry diaper is then subtracted from the weight of the wet diaper to determine the UOP.

The nurse has provided the parents of a preschoolers with information about UTIs and how to reduce their recurrence. Which statement from the parents indicate they understood the information? Select all that apply. a)“ I should try to get her to drink a lot of water and juices.” “ b)I will buy her underwear made with cotton.” c)“Soaking in a bubble bath will reduce irritation.” d) “If I notice her starting to wet the bed again, I need to have her checked for another UTI.” e)“I should avoid giving her cranberry juice as it has been shown to make the urine more acidic.”

Drinking an increase amount of fluids helps flush microbes from the bladder. Cotton does not trap moisture. Bed-wetting may be a sign of a UTI. Bubble baths are irritating to the meatus and increase the incidence of UTIs. Cranberry may acidify urine or may prevent bacteria from sticking to the bladder wall.

The nurse would include which of the following in the care of a child with acute glomerulonephritis? Select all that apply? carefully handling edematous extremities. Measuring the blood pressure to monitor for hypertension. Providing fun activities if the child is on bedrest. Monitoring the urine for hematuria. Encourage fluid intake.

Glomerulonephritis can be associated with HTN; therefore, MUST check blood pressures. Children are no longer confined to bedrest. Severe edema of the extremities is not generally seen in glomerulonephritis.

A urinalysis is ordered for a child with a throat culture positive for group-A beta-hemolytic streptococcus (strep throat). when the mother asks why this test is being ordered, what would the nurse appropriately include in the response? a)The UA will indicate whether an HIV infection is also present. b)UTIs are common with streptococcal infections and need to receive prompt treatment. c)Pyelonephritis is a potential complication of antibiotic therapy. d) Group-A beta-hemolytic streptococcus infections can be followed by the complication of acute glomerulonephritis.

UA allows for early diagnosis and treatment of AGN, which is a serious complication following a group-a beta-hemolytic streptococcus infection. HIV screening is done initially by enzyme-linked immunosorbent assay (ELISA). UTIs are not commonly associated with streptococcal infections. Pyelonephritis is an infection of the pelvis of the kidney, and is often a complication of ascending infection from the urinary bladder.

What would the nurse select as an appropriate nursing diagnosis for an infant with unrepaired exstrophy of the bladder? a)Disorganized Infant Behavior. b)Impaired Parent-Infant Attachment. c)Urinary Retention. d)Risk for Infection.

The open the bladder allows bacteria to enter the urinary system, and UTIs are common. Disorganized behavior does not apply. Although there is a risk for Impaired Parent-Infant Attachment at the time of birth, this diagnosis is written as an actual nursing diagnosis, and there is no evidence to support this with the information given. The unformed bladder does not hold urine, so urinary retention would not be an appropriate diagnosis.

A child has been admitted to the unit with acute glomerulonephritis. What test does the nurse anticipate will be ordered to confirm the diagnosis? a)Antistretolysin-O (ASO) titer. b)UA. c)Blood cultures. d)White blood cell (WBC) count.

The ASO titer indicates a preceding infection with group-a beta-hemolytic streptococcus, which can lead to glomerulonephritis as a complication. The UA would show hematuria, but this alone would not be diagnostic of AGN. Blood cultures may be negative as the infection preceded the illness by 1-3 weeks. A WBC count could be elevated with any inflammatory or infectious process in the body, and thus is not diagnostic for glomerulonephritis.

The nurse practitioner prescribes that a urine culture be obtained on an infant who is not toilet trained. The nurse implements which of the following as the best means of collecting this urine specimen? a)Perform a straight catheterization. b)Apply a urine collection bag. c)Use diaper analysis. d) Perform Foley catheterization.

Catheterization is necessary as this will provide a specimen that is not contaminated by microrganisms outside the urinary bladder. The urine does not need to be obtained at the time of voiding. Clean-catch urine specimens, such as those obtained using a urine collection bag, are less reliable urine samples; therefore, catheterization is preferred. Diaper analysis is not valid for performing a culture. A Foley catheter is an indwelling urinary catheter and is unnecessary for obtaining a urine culture.

A 14-year-old is being treated for chronic renal failure. The nurse would assist the child in making food selections that are part of which prescribed diet? a)High-sodium. b)High-protein. c)Low-sodium. d) Low-fiber.

With the inability to secrete urine, electrolytes will build up in the blood, including sodium and potassium. The child should be on a low-sodium, low-potassium diet with restricted fluids and proteins. Fiber is necessary for GI function.

The nurse would place highest priority on which nursing activity in managing a young child diagnosed with UTI? a) Provide adequate nutrition to prevent dehydration. b) Prevent enuresis. c) Administer ordered antibiotics. d) fluids to provide kidney rest.

UTIs are ascending in nature, and untreated UTI can lead to acute pyelonephritis with resulting in kidney scarring and damage. Early diagnosis and prompt antimicrobial therapy will prevent or minimize permanent renal damage. Dehydration are not a primary concern, although increased fluid intake will help flush the urinary system. Enuresis can occur as a symptom of UTI in a young child, but this should resolve as the infection is treated. Fluid should be increased rather than decreased to help eliminate microrganisms from the urinary bladder.

When reviewing a UA report of a child with acute glomerulonephritis, the nurse expects to note which of the following? a) Decreased creatinine clearance. b)Decreased specific gravity. c) Proteinuria. d) Decreased erythrocyte sedimentation (ESR).

The presence of protein in the urine is a prime manifestation of acute glomerulonephritis. Decreased creatinine clearance would be found with renal failure. Decreased urine specific gravity would be found with dilute urine, but this is not an associated finding with glomerulonephritis. ESR is a blood test that is non-specific indicator of inflammation.

While a child is receiving prednisone for treatment of nephrotic syndrome, the nurse determines that it is important to assess the child for which of the following? a) Infection. b) Urinary retention. c) Easy bruising. d) Hypoglycemia.

Prednisone is a synthetic corticosteroid that depresses the immune response and increases susceptibility to infection. Steroids mask infection, therefore, the child must be assessed for subtle signs of infection. Urinary retention is not a concern with administration of a corticosteroid. Easy bruising would be of concern if the child were taking an anticoagulant or antiplatelet medication. Hyperglycemia, rather hypoglycemia, would be a possible in the child taking corticosteroids.

The nurse is admitting a 12-year-old girl to the hospital prior to surgery. The nurse practitioner has ordered a UA. What should the nurse do to ensure that proper procedure is followed for obtaining the specimen? a)Encourage fluids to 1000ml prior specimen collection. b) Cleanse the specimen container with antiseptic prior to collecting the specimen. c) Allow the urine to cool to room temperature before taking it to the lab. d) Provide information about specimen collection before it is obtained.

Education about proper specimen collection technique will minimize contamination of the urine sample and help ensure accurate results. It is unnecessary to increase fluid intake prior to specimen collection. The specimen container is not cleansed, although the urinary meatus will be cleansed. The specimen should be sent immediately to the lab to prevent urine degradation.

The parents of a child diagnosed with glomerulonephritis asked the nurse why the child needs a daily weight. The nurse includes which benefit of measuring daily weight. a) Determine if the child’s caloric intake is adequate. b)Indicate the need for dietary restriction of sodium and potassium. c )Keep track of possible loss or gain of fluid retained in body tissue. d) Track the amount of fluid ingested each day.

With glomerulonephritis, the kidneys’ ability to filter to reabsorb salt and water is altered, resulting in edema. Weight can be an easy and effective measure to determine the current fluid load.Adequacy of caloric intake can be determined by weight gain, but a daily weight would not be required.Fluid gain or loss is best detected using daily weight measurements. Serum levels of sodium and potassium would be monitored to detect need for their restriction in the diet, and this would be of concern with renal failure. Monitoring of ingested fluids is done by documenting PO intake.

A child has been diagnosed with acute renal failure secondary an infectious organism. The nurse would question a prescription for which medication? a)Aqueous PCN. b) Gentamycin. c)Hydralazine. d)Prednisone.

Gentamycin is an aminoglycoside antibiotic that is nephrotoxic. Nephrotoxic drugs should be avoided ina child with acute renal failure. PCN, propanolol, and prednisone do not belong to drug groups that are particularly nephrotoxic.

The newborn has been diagnosed with cryptorchidsm, and the nurse practitioner has explained treatment options to the parents. The nurse reinforces which point about the treatment plan when questioned by the parents? a)Surgery will be done before age 6 months. b)Drugs to stimulate peristalsis may be given to indirectly exert a downward pushing effect on the undescended testes. c)There will heightened monitoring for testicular cancer until 10 years of age. d)The infant will be observed at this time because the testes may descend spontaneously.

In most cases, testes descend spontaneously by 3 months of age. Surgery is done near one year of age, to allow time for testes to descend spontaneously while preventing further damage and avoiding psychological consequences for the child. Drugs that increase GI motility will not be effective in treating undescended testes. The risk of testicular is higher in children who have undescended testes, but the occurrence is after puberty necessitating diligent testicular self-examination at that time and onward.

A child has been admitted to the unit with nephrotic syndrome. In speaking with the mother, she reports that a cousin had AGN last year. The mother asks how these two diseases compare, as they both affect the kidneys. The nurse’s response would include which piece of information? a)Both disorders produce smoky colored urine. b)Both disorders cause greatly reduced UOP. c)Both disorders have a genetic basis. d)Both disorders require treatment with antibiotic therapy.

AGN : Decreased UOP. ;Smoky urine. Postinfectious disease w/ no genetic basis. Nephrotic Syndrome
Decreased UOP. Clear and frothy urine. Do not use antibiotics

The mother of an infant who underwent surgery to repair hypospadias asks the nurse why the infant is double-diapered. The nurse would respond that this method of diapering: a)Protects the urinary stent that has been put in place. b)Adequately measures the urinary output. c)Provides for maximum absorption of urine. d)Provides optimal protection of perineal skin from infected urine.

A double-diapering technique will help to protect a urinary stent following repair of hypospadias or epispadias. The inner diaper collects the infant’s stool, while the outer one collects urine.

In a child with acute renal failure, the nurse would help to prevent hyperkalemia by limiting which foods in the child’s diet? a) Grains, cheese, and citrus fruits. b)Potatoes, tomatoes, and oranges. c)Cereals, processed sugars, and wheat. d) Rice, leafy green vegetables, and carbonated beverages.

Potatoes, tomatoes, and oranges have high levels of potassium.

A child has been admitted with AGN. All of the following tests are positive for AGN. The nurse concludes which laboratory tests is most indicative of this disease? a)Elevated antistreptinolysis (ASO). b)Elevated erythrocyte sedimentation rate (ESR). c)Presence of hematuria according to UA. d) Elevated creatinine concentrations

An elevated ASO titer indicates a recent streptococcal infection, which is a precursor of AGN. An elevated ESR indicates inflammation and is associated with many diseases. Hematuria is simply blood in the urine, which has many causes. Creatinine concentrations. Reflect the functioning of the kidney.

The mother of a child at the renal clinic asks why a radiological evaluation is performed on all children who have had one documented UTI. What information would the nurse include as the best explanation for use of x-ray? a)It rules out structural abnormalities. b)It confirms the absence of bacterial colonies after microbial therapy. c)It determines which kidney was infected. d) It determines the probability of the infection recurring.

Radiological evaluations done after a documented UTI in children reveal structural abnormalities in 1-2% of girls and 10% of boys. Radiological tests cannot confirm bacterial colonies, determine the site of an old infection, or help predict whether infection will reoccur

Used routinely to screen for weight issues Use begins at 2 years of age and throughout adulthood. Can be calculated on-line at various sites including www.cdc.gov Good teaching site for parents: http://www.cdc.gov/healthyweight/assessing/bmi/childrens_bmi/about_childrens_bmi.html

Series of percentile chart curves used to plot out pediatric growth by weight and height. With infant head circumference is also used Charts have been adopted internationally by WHO

Tests To Assess Growth: effects of growth = problems - nutrition, polio, tests to test if abnormal growth pattern

Analysis of growth chart Renal: BUN, Creatinine, urinalysis Electrolytes & Blood Glucose Thyroid: TSH, T3 and T4 Infection: C-reactive protein (CRP) and Erythrocyte sedimentation rate (ESR) Anemia: Hgb and Hct, iron (Fe) levels if indicated Growth hormone levels ; Radiographs: bone age studies, CT, MRIs ;Genetic studies

Endocrinology Definition: The study of hormones that travel through the body via the bloodstream to a target organ not in the immediate vicinity of the organ that released the hormone

Endocrine Physiology: function 

controls or regulates metabolic processes governing several body functions including: Energy production Growth Fluid and electrolyte balance Response to stress Sexual reproduction

Health History Physical Examination Laboratory Studies and Diagnostic Tests

Health History-Cardinal Symptoms and red flags in the endocrine system 

Changes in Growth ;Changes in Activity ;Changes in Appetite Changes in Elimination ;Visual Disturbances Fatigue ; Intolerance to heat or cold Nausea and vomiting ; Mood changes

Nursing Diagnoses for endocrine disorders 

Altered Growth and Development Altered Mobility ; Altered Fluid & Electrolytes Altered Cardiac Output ; Altered Renal Function Activity Intolerance Impaired Adjustment ;Potential for Injury Body Image Disturbance

Physiology-Control of Hormone Secretion: The hormones bind with receptors on the target cells (eg. Catecholamines). The target cell response is reflected thru production and

Hypothalamus: control pituitary gland by: -Hormonal signals -Neuronal signals Pituitary Gland: responsible for stimulation and inhibition of target glandular secretions The endocrine system and the nervous system maintain homeostasis. the pituitary gland controls endocrine function (respect the pituitary gland) The endocrine glands produce hormones that get secreted into bloodstream and they exert a stimulatory or inhibitory effect on target tissues or glands.

Growth Hormone Deficiency-hypopituitarism

Definition: GH deficiency from diminished or deficient secretion of GH from the pituitary Etiology: usually idiopathic; developmental defects, autoimmune, tumors

/Principle anterior and posterior pituitary hormones and target organs part 1 

The thing about the endocrine system is that the hormone secretion by the endocrine glands are controlled through a negative feedback system….hence ; A fall causes an activation of the regulator endocrine glands and a release of stimulator hormones ;Elevations in blood concentration of target cell hormones can cause inhibition of hormone secretion  Elevations in blood concentration of target cell hormones can cause inhibition of hormone secretion

/Principle anterior and posterior pituitary hormones and target organs part 2: also also be caused by hormone producing tumors (adenomas).

Endocrine disorders are manifested as states of hormone deficiency or hormone excess ; Underlining pathophysiology is either primary, the gland is diseased itself secondary, the secreting gland releases abnormal amounts of hormone because of disease in a regulator gland (pituitary) or tertiary, the secreting gland releases inappropriate hormone because of hypothalmic dysfunction(and the pituitary is stimulated abnomally) ;Important to recognize that abnormal hormone concentrations may

Normal Growth with growth hormone 

GH (growth hormone) is secreted most during sleep Growth occurs in episodic increments Seasonal variation Fastest growth is in utero Size from 0-2 years may not correlate with childhood and adult heights

GH(growth hormone)  deficiency

Least common cause of short stature, but important to recognize Incidence: 1:10,000 Most children have idiopathic but must consider pituitary tumor

Assessment-Signs and Symptoms/ clinical manifestations of growth hormone issue

Neonatal hypoglycemia/hyperbilirubinemia and/or microcephaly Short stature Delayed skeletal maturation, dentition, sexual development (FTT) Skeletal proportions are normal but child appears younger than their age : treat them age appropriate Later in life, premature aging is common

Other Common Findings in Children with GH Deficiency

Normal birth weight and height Thin hair Slow nail growth High pitched voice\increased peri-umbilical fat Midline Defects

Laboratory and Diagnostic Tests of GH

Bone X-Rays Overnight Sleep studies of GH secretion GH stimulation test Trial of Exogenous GH

Recombinant human GH via SC injection, 6-7days/week Treatment should not be delayed Therapy is associated with risk of malignancies, leukemias, lymphoma - it is difficult for mom to give shots can become painful at swollen sites and that are tender with shots given everyday

Nursing Management for GH

Identify Growth problems ;Help parents set realistic goals based on age and abilities. Encourage parents to avoid infantalizing child Teach parents proper administration and side effects of medication ; Nutritional Teaching ;Reassure and support Assist child in coping with impaired growth Children should be managed by endocrinologist. Height and weight plotted every three months for monitoring growth ; Thyroid functions test monitored closely

DeGeorge Syndrome overview 

Immunodeficiency disease where Thymus is affected causing T cell deficiency Genetic defect in chromosome 22 Cause poor development of several body system; cardiac, immune, cleft palate, low levels of calcium- big indicator of the disease , ; developmental delay and growth and emotional/behavioral problems. wide set eyes - tested via genetic testing

Treatment for DeGeorge Syndrome

Calcium supplementation, replacement of parathyroid hormone Correction of cardiac defect Monitoring of immune function Severity of cardiac defect and immune deficiency determine prognosis

Precocious Puberty overview 

Definition: development of sexual characteristics before the typical onset of puberty Girls: breast development before 7.5 years Boys: pubic hair before 8.5 years Ethnic Variations: Black and Hispanic girls < 6 years White girls < 7 years

Etiology of precocious puberty 

5x more likely in girls than boys Girls, most likely a normal variant = genetic Boys, most likely pathologic Can be either central or peripheral Central: stems fro hypothalamus/pituitary Peripheral: stems from gonads, peripheral tumor, or exogenous hormones

assessment finding of precious puberty   

Development of pubertal events i.e., breast buds, phallic enlargement, body hair, facial hair, acne, body odor and voice deepening History may reveal head trauma, exposure to steroids or gonadotropins, H\A, visual disturbances or motor in coordination Family history: precocious puberty, congenital adrenal hyperplasia, neurofibromatosis, and thyroid disease

nursing management of precocious puberty 

Administer prescribed medications Central: Lupron, a synthetic analogue of LHRH(,Luteinizing Hormone Releasing Hormone) q 4 weeks Support and Guidance : parent teaching Detailed explanation of the disorder Dress and activities should be age appropriate Mental capability is congruent with chronological age

Definition: chronic condition caused by inadequate thyroid hormone - common in premature infants May be acquired or congenital One of the most common endocrine problems in children infant may have a low birth wt

Thyroid hormones promote normal myelination during brain development in the first two to three years of life and normal skeletal growth Regulates metabolism

Congenital Hypothyroidism

Thyroid deficiency present at birth Neonatal Screening in all states Incidence- 1:4000 newborns Can be permanent or transient Permanent: defective embryonic development of the gland. problem with development of glands Transient: intrauterine transfer of goiter inducing substances

Assessment Findings of congenital hypothyroidism

Prolonged Jaundice Lethargy Constipation Decreased gastric motility Feeding Problems Thick, dry, mottled skin that feels cold to touch, dry skin Coarse, dry listless hair

assessment of congenital hypothyroidism con't 

Facial Features Depressed nasal bridge Short forehead Puffy eyelids Large tongue Abdominal distention Umbilical hernia everything with hypothyroidism is slow, thick and enlarged 

clinical manifestations of congenital hypothyroidism 

Hyporeflexia - low tone Bradycardia Hypothermia Hypotension with narrow pulse pressure - decreased BP Anemia Widely patent cranial sutures with delayed closure “Good Baby” Minimum crying Excessive sleeping

Congenital Hypothyroidism screening and treatment

Importance of Screening for early detection :Initial screening at 2-6 days of age-T4 ;If initial screening is positive (decr. T4), then TSH checked Lifelong thyroid replacement Synthroid(give 30 min before eating)  ;Levothroid Drug may be crushed and added to small amount formula Can be given through nipple or with a small syringe slowly within the buccal area, allowing time for adequate swallowing

congenital hypothyroidism what occurs with no treatment 

**If not treated, congenital hypothyroidism can lead to severe mental retardation** Decreased thyroid hormone—delayed development of the nervous system If caught early and replacement given, child will have normal physical growth and intelligence

nursing management of congenital hypothyroidism 

Early Detection!!! Educate parents and care givers Monitor for S&S drug overdose Monitor growth and development Provide Reassurance and support If child has a goiter, monitor for airway obstruction

Type 1 DM : ( sometime ages 6,7,8,9 etc) Autoimmune disease ;Triggered by a stressor such as a cold/viral illness  ; Complete lack of insulin production by beta cells of pancreas;Heredity is a prominent factor in the etiology  Type 2 DM Largely genetic ;Result of unhealthy American diet—obesity—insulin resistance

incidence of diabetes in childhood 

Peak incidence usually occurs during puberty Girls: 10-12 years Boys: 12-14 years Another smaller peak occurs between 5-6 years of age

With a deficiency of insulin, glucose is unable to enter a cell and remains in the blood, causing hyperglycemia When serum glucose levels exceed the renal threshold, glucose spills into the urine (glycosuria) Cells break down protein for conversion to glucose by the liver (glucogenesis) (see ketones in the urine )

presenting signs and symptoms of diabetes  type 1 

Classic presentation in childhood (type 1 DM) is the polys Polyuria - increased urine Polydypsia - increased thirst Polyphagia- increased hunger

When glucose is unavailable for cellular metabolism, the body breaks down alternate sources of energy Ketones are released, and excess ketones are eliminated in the urine (ketonuria) or by the lungs (acetone breath) Ketones in the blood are strong acids that lower the serum pH and produce ketoacidosis Leads to metabolic acidosis

Kussmaul Respirations: pursed lip breathing 

Hyperventilation characteristic of metabolic acidosis, resulting from the respiratory system’s attempt to eliminate excess CO2 by increased depth and rate

Which symptom is associated with with acute Poststreptococcal glomerulonephritis?

Which finding is likely in a child admitted with acute Poststreptococcal glomerulonephritis?

Which of the following would be symptoms of glomerulonephritis in a child?

Which of the following would most likely be noted in a child with acute glomerulonephritis?