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Genitourinary Disorders. Jan Bazner-Chandler CPNP, CNS, MSN, RN. Urinary Tract Infection. Most common serious bacterial infection in infants and children Highest frequency in infancy Uncircumcised males have a ten-fold incidence . Etiology. Anatomic abnormalities

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genitourinary disorders

Genitourinary Disorders

Jan Bazner-Chandler

CPNP, CNS, MSN, RN

urinary tract infection
Urinary Tract Infection
  • Most common serious bacterial infection in infants and children
  • Highest frequency in infancy
  • Uncircumcised males have a ten-fold incidence
etiology
Etiology
  • Anatomic abnormalities
  • Neurogenic bladder – incomplete emptying of bladder
  • In the older child: infrequent voiding and incomplete emptying of bladder or constipation
  • Teenager: sexual intercourse due to friction trauma
uti females
UTI - Females
  • Most common in females
    • Short urethra
    • Improper wiping
    • Nylon under pants
    • Current guidelines – do ultrasound with first UTI followed by VCUG if indicated
uti males
UTI – Males
  • Infant males
    • Needs to be investigated
      • VCUG – ureteral reflux
      • Ultrasound of kidneys – hydronephrosis or polycystic kidneys
    • Higher in un-circumcised males
un circumcised males
Un-circumcised males
  • Instruct parents to gently retract foreskin for cleansing
  • Do not force the foreskin
  • Do not leave foreskin retracted or it may act as tourniquet and obstruct the head of the penis resulting in emergency circumcision
assessment uti
Assessment: UTI
  • Neonate: jaundice, fever, failure to thrive, feeding, vomiting
  • Infant: irritability, poor feeding, vomiting, diarrhea, strong odor to urine
  • Childhood: vomiting, diarrhea, abdominal or flank pain, fever, enuresis, urgency, frequency, strong odor to urine
diagnosis
Diagnosis
  • Urinary Tract Infection
    • Pyuria – white blood cells in urine
    • Culture of urine – grows out bacteria
  • Urosepsis: Blood culture and urine culture grow out the same organism
  • Pyelonephritis:
    • Elevated white blood cell count
    • Elevated C-reactive protein and erythrocyte sedimentation rate
multidisciplinary interventions
Multidisciplinary Interventions
  • Antibiotic therapy for 7 to 10 days
    • E-coli most common organism 85%
    • Amoxicillin or Cefazol or Bactrim or Septra
  • Increase fluid intake
  • Frequent voiding
  • Acetaminophen for pain
  • Teach proper cleansing
urethritis
Urethritis
  • Urethral irritation due to chemicals or manipulation
  • Most common in females
  • Bubble bath, scented wipes, nylon under wear
  • Self-manipulation
  • Child abuse
voiding disorders
Voiding Disorders
  • Delay or difficulty in achieving control after a socially acceptable age.
  • Enuresis
    • Nocturnal = at night
    • Diurnal = during the day
    • Secondary = relapse after some control
toilet training readiness
Toilet Training Readiness
  • 12 months no control over bladder
  • 18 to 24 months some children show signs of readiness
  • Some children may not be ready until around 30 months
enuresis
Enuresis
  • Involuntary discharge of urine after the age by which bladder control should have been established, usually considered to be age of 5 years.
enuresis1
Enuresis
  • Familial history
  • Males outnumber females 3:2
  • 5 to 10% will remain enuretic throughout their lives
  • Rule out UTI, ADH insufficiency, or food allergies
pharmacologic interventions
Pharmacologic Interventions
  • Pharmacological intervention:
    • Desmopressin synthetic vasopressin acts by reducing urine production and increasing water retention and concentration
    • Tofranil: anticholinrgic effect – FDA approval for treatment of enuresis
      • Side effect may be dry mouth and constipation
      • Some CNS: anxiety or confusion
      • Need to be weaned off
multidisciplinary interventions1
Multidisciplinary Interventions
  • Diet control
    • Reduce fluids in evening
    • Control sugar intake
  • Bladder training
    • Praise and reward
    • Behavioral chart to keep track of dry nights
    • Alarm system
ureteral reflux
Ureteral Reflux
  • Males 6 to 1
  • Genetic predisposition
  • Present as UTI or FTT
  • Diagnostic tests
  • Antibiotics if indicated
  • Surgery to re-implant ureters
hydronephrosis
Hydronephrosis
  • Water on kidney
  • Due to obstruction
  • Congenital anomaly
  • Goals of care to maintain integrity of kidney until normal urinary flow can be established.
ambiguous genitalia
Ambiguous Genitalia
  • Genital appearance that does not permit gender declaration.
extrophy of bladder
Extrophy of Bladder
  • Congenital malformation in which the lower portion of abdominal wall and anterior bladder wall fail to fuse during fetal development.
assessment
Assessment
  • Visible defect that reveals bladder mucosa and ureteral orifices through an open abdominal wall with constant drainage of urine.
surgical management
Surgical Management
  • Surgery within first hours of life to close the skin over the bladder and reconstruct the male urethra and penis.
  • Urethral stents and suprapubic catheter to divert urine
  • Further reconstructive surgery can be done between 18 months to 3 years of age
multidisciplinary interventions2
Multidisciplinary Interventions
  • Preserve renal function: prevent infection
  • Attain urinary control
  • Re-constructive repair
  • Sexual function
long term complications
Long Term Complications
  • Urinary incontinence
  • Body image
  • Inadequate sexual function
hypospadias
Hypospadias
  • Most common anomaly of the male phallus
  • Incomplete formation of the anterior urethral segment
  • Urethral formation terminates at some point along the ventral fusion line.
  • Cordee – downward curve of penis.
newborn
Newborn
  • Circumcision not recommended.
  • Foreskin may be needed for reconstructive surgery.
surgical interventions
Surgical Interventions
  • Release of tight chordee
  • Placement of urethra opening at head of penis
  • Surgery recommended at around six to nine months of age
  • Long term outcomes:
    • Leaking at the site
    • Body image
cryptorchidism
Cryptorchidism
  • Hidden testicle
  • 3 to 5% of males
  • High incidence in premature infants
  • Goals of treatment:
    • Preserve testicular function
    • Normal scrotal appearance
multidisciplinary interventions3
Multidisciplinary Interventions
  • Most testes spontaneously descend.
  • Surgical procedure, orchiopexy, if testicles do not descend into the scrotal sac by 6 to 12 months of age
  • Hormone therapy – human chorionic gondadotropin
  • Slightly higher risk of testicular cancer if untreated
  • In the teen or adult the testicle would be removed
testicular exam
Testicular Exam
  • Monthly testicular self-examination is recommended for all males beginning in puberty, but is essential in males with history of undescended testicle.
testicular torsion
Testicular Torsion
  • Rotation of the testicle
  • Spermatic cord twists and obstructs circulation to the testis
  • Left testicle affected more
    • Longer cord on left side
assessment1
Assessment
  • Sudden severe pain in the scrotal area
  • Highest incidence on left side due to longer cord on that side
goals of treatment
Goals of Treatment
  • Surgical intervention
    • To relieve obstruction
  • Preserve the testicular function
  • Secure testicle to avoid further twisting
acute renal failure arf
Acute Renal Failure (ARF)
  • Pre-renal, resulting from impaired blood flow to or oxygenation of the kidneys.
  • Renal, resulting from injury to or malformation of kidney tissues.
  • Post-renal, resulting from obstruction of urinary flow between the kidney and urinary meatus.
renal failure
Renal Failure
  • Newborn causes:
    • Congenital anomalies
    • Hypotension
    • Complication of open heart surgery
renal failure1
Renal Failure
  • Childhood causes:
    • Dehydration
    • Glomerular nephritis / Nephrotic Syndrome
    • Nephro-toxicity / drug toxicity
assessment arf
Assessment: ARF
  • Sudden onset
  • Oliguria
    • Urine output less than 0.5 to 1 mL/kg/hour
  • Volume overload due to retained fluid
    • Hypertension, edema, shortness of breath
  • Acidosis
  • Electrolyte imbalance and dehydration
diagnostic tests
Diagnostic Tests
  • Decrease RBC due to erythropoietin
  • Urea and Creatinine elevated
  • GFR (glomerular filtration rate) most sensitive indicator of glomerular function.
goals of treatment acute renal failure
Goals of Treatment: Acute Renal Failure
  • Reduce symptoms
  • Supportive care until renal function returns
  • Medications – corticosteroids
  • Dietary restrictions - sodium
  • Dialysis if indicated
complications of peritoneal dialysis
Complications of Peritoneal Dialysis
  • Peritonitis
  • Pain during infusion of fluids
  • Leakage around the catheter
  • Respiratory symptoms
    • Abdominal fullness from too much fluids
    • Leakage of fluid to chest from hole in diaphragm
nephrotic syndrome nephrosis
Nephrotic Syndrome / nephrosis

Etiology is not know, it is felt to be the result of an alteration of the glomerular membrane, making it permeable to plasma proteins (especially albumin).

assessment2
Assessment
  • Generalized edema
  • Edema is worse in scrotum and abdomen (results in ascites)
  • Dramatic weight gain
  • Pale, fatigue, anorexic
  • Urinary output decreased
  • Urine foamy and frothy with elevated SG
diagnostic evaluation
Diagnostic evaluation
  • Proteinuria
    • * 4+ urine in urine
  • Hypoalbuminemia
  • Hypercholesterolemia
    • * Fat cells in blood

BUN and Creatinine normal unless renal damage

multidisciplinary interventions4
Multidisciplinary Interventions
  • Diuretics (during acute phase lasix would be given after IV albumin)
  • Fluid restriction if edema severe
  • Low sodium / high protein diet
  • Daily weights
  • Strict intake and output
corticosteroid therapy
Corticosteroid Therapy
  • High dose prednisone
  • Taper when protein loss in urine decreases
  • Current recommendations to keep on low dose every other day for up to 6 months
  • If relapse or remission not obtained will try cytotoxic medications
side effects of cortisone therapy
Side Effects of Cortisone Therapy
  • Hirsutism
  • Moon face with ruddy cheeks
  • Acne
  • Dorsocervical fat pads
  • Ecchymosis (easy bruising)
  • Truncal obesity
  • Mood swings – inability to sleep
  • Increase appetite
moon face
Moon Face

High-dose

corticosteroid therapy

produces a characteristic

“moon face” appearance.

nursing interventions for long tern use
Nursing Interventions for long tern use
  • Prednisone prescribed every other day
  • Instruct to take in the morning
    • Long Term Use - Prednisone every other day in the am
  • Take with food: can cause GI upset
  • Do not stop taking medication until instructed to do so
  • Medication needs to be tapered
  • Monitor for infection
glomerulonephritis
Glomerulonephritis
  • Immune complexes become entrapped in the glomerular membrane.
  • Symptoms appear 1 to 2 weeks after a Strep A skin or throat infection.
clinical manifestations
Clinical Manifestations
  • Hematuria / red cells casts
  • Facial edema
  • Brown or frothy urine
  • Mild proteinuria
  • Hypertension
multidisciplinary interventions5
Multidisciplinary Interventions
  • Low sodium / high protein
  • Anti-hypertensive drugs
  • Diuretics
  • Antibiotics if + throat culture or blood culture
  • Monitor blood pressure
  • 24 hour urine for Creatinine clearance
teaching
Teaching
  • Culture sore throats
  • Take antibiotics for full course prescribed
  • Do not share medications with others in family