Chapter 46 Renal/Urinary Tract Disorders Review A&P Review normal urinalysis & child’s output-

pg 1347 Review diagnostic studies Dialysis covered in critical care-procedure

same for children

Exstrophy of the Bladder Midline closure defect during first 8 weeks

of embryonic life Bladder lies open & exposed on abdomen Pic 1354

Assessment-revealed by fetal sonogram Bladder appears bright red & continually

drains urine from open surface Epispadius may also be present-males Mgt-surgical repair

Preop-keep exposed bladder covered by a sterile plastic bowel bag

Prevent skin from excoriation Infants legs may be flexed & brought

together & wrapped to prevent further separation of the symphysis

Position on back

Postop- one or two step procedure Position infant on back or in infant seat,

prevent contamination from feces, indwelling or suprapubic catheter inserted to allow new bladder to rest. Immediately postop-urine may be blood tinged but should clear after couple of hours.

Antispasmodics, antibiotics & analgesics, bracing of pubic bones(4-6 weeks)

Hypospadius Urethral opening not at end of penis but

on lower aspect Pics 1355 Assess for other defects Mgt-don’t circumcise-foreskin may be

needed for surgical repair Postop-urinary urethral catheter-may

notice painful bladder spasms as long as the catheter is in place (3-7 days)

Analgesics, antispasmodics

UTI Assessment-dysuria, frequency, burning &

hematuria Low grade fever, abdominal pain &

enuresis Pyelonephritis-high fever, abdominal or

flank pain, vomiting & malaise Mgt-antibiotics, analgesics, increased

fluids. Teaching-1356

Reflux Retrograde flow of urine from bladder to ureters

r/t defective valve Assess-history of repeated UTI’s, voiding

cystogram Mgt-double voiding techniques, prophylactic

antibiotics, corrected by cystoscopy Postop-suprapubic catheter & 2 ureteral stents-

observe closely every hour for first 24 hrs & then every 4. Note color & amount of drainage-initially bloody but will clear in 24-48h.Analgesics & antispasmodics, sterile drsg to absorb leaking urine-no tub baths until suprapubic site closed completely

Hydronephrosis Enlargement of the pelvis of the kidney

with urine as a result of back pressure in the ureter generally caused by obstruction

Children usually asymptomatic, may have repeated UTI’s, elevated BP, flank & abdominal discomfort

Tx-surgical correction of obstruction

Enuresis Usually nocturnal Children older than 5 need evaluated for

an organic cause Assess for-stress, abdominal pain, UTI Mgt-Limit stress, limit fluids after dinner

(not if sickle cell ). May be prescribed DDAVP. May need bladder stretching exercises

Kidney Agenesis Absence of a kidney often has Potter’s

syndrome( misshapen low set ears & stiff, inflexible lungs from the lack of amniotic fluid in utero).

Polycystic kidney-”Potter facies”-wide spaced eyes, epicanthal folds, flattened nose & small jaw. May be associated with a cerebral aneurysm. Tx-surgical removal of kidney or transplantation

Renal hypoplasia-small, underdeveloped kidneys-transplantation

Prune Belly Syndrome

Pic 1361 Severe urinary tract dilation mainly in

boys Three symptoms: deficiency of usual

abdominal muscle tone; bilateral undescended testes; dilated faulty development of the bladder & upper urinary tract

Kidney transplantation

Acute Glomerulonephritis Assessment-usually 5-10 yrs of age post

strept infection All children who had impetigo, strept

infections should have a urinalysis 2 weeks post infection to evaluate for glomerulonephritis

Sudden onset of hematuria & proteinuria-urine appears tea colored, reddish-brown or smokey

Abdominal pain, low grade fever, edema, N&V or headache

Elevated protein, elevated ESR rate, Bun & creatinine increase, mild anemia due to increased blood volume

Mgt-course 1-2 weeks-quiet play-return to school after kidney function is normal. Daily wts, I&O

Diet, antibiotics & diuretics usually not ordered unless heart failure occurs=Lasix, digoxin, semi-fowlers, & oxygen

Chronic glomerulonephritis May follow acute glomerulonephritis or nephrotic

syndrome Alport’s syndrome-progressive chronic

glomerulonephritis inherited as an autosomal dominant disorder

Acute symptoms of edema, hematuria, hypertension or oliguria.

TX-symptomatic-antihypertensives, bedrest, diuretics, corticosteroids

Prognosis poor. May need dialysis or transplantation

Nephrotic Syndrome ( Nephrosis) Altered glomeruli permeability d/t fusion of

the glomeruli membrane surfaces causing abnormal loss of protein in urine

Three forms: congenital: secondary (sickle cell, SLE; or primary

Four characteristic symptoms: proteinuria; edema; low serum albumin; hyperlipidemia

Assess-periorbital edema usually most prominent when they wake up, ascites-clothes don’t fit, skin becomes pale, stretched & taut

Table-pg1364

Mgt-corticosteroids such as prednisone-give every other day. Cytoxin for immunosupprssion if don’t respond to corticosteroids

Foods high in potassium-1365 Foods high in potassium especially if

receiving diuretics, fluid & sodium may be restricted during acute phase.

Keep child in semi fowlers-more comfortable & reduces periorbital edema

Hemolytic-Uremic Syndrome Occurs during summer in children 6mon-

4yrs of age following recent Ecoli infection Transient diarrhea, fever, hematuria,

oliguria, edema, petechiae Supportive tx to maintain heart & kidney

function ie peritoneal dialysis Most recover completely but some have

chronic renal impairment or may die

Renal Failure Oliguria-output <1ml/kg/wt/hr Azotemia, uremia, hyperkalemia Tx-IVF’s, diuretics, daily wts, I&O, diet-low

pro, K,& Na & high in CHO Peritoneal or Hemodialysis Kidney transplantation