Updated study tips for Exam VI, Spring 2013
Know disease, dx, medical tx, and nursing interventions for each topic.
Chapter 21: Genitorurinary
Glomerulonephritis
•	Glomerulonephritis is damage to the glomeruli. This damage causes altered filtration and function in the kidneys.  It can be caused by acute poststreptococcal infection, in which the glomeruli are damaged as a result of immune processes.
•	Dx:
Health History: s/s include fever, lethargy, headache, decreased urine output, abdominal pain, vomiting, anorexia.  
Phyical exam: Increased blood pressure, mild edema, increased work of breathing or cough, crackles in lungs, "gallop" heart sound.
Lab & Dx tests: Urine dipstick test will reveal hematuria and proteinuria.  Urine may show hematuria, exhibited by tea, cola, or dirty green colored urine.  Serum creatinine and BUN may be normal or elevated.  ESR is elevated.
•	Medical Tx:
No specific medical treatment.  treatment is aimed at maintaining fluid volume and managing HTN.  This may involve antihypertensives, such as labetalol and nifedipine, and diuretics.If it is due to current strep infection, antibiotic therapy will be necessary.
•	Nursing interventions:
Administer medications as ordered.
Monitor B/P frequently.  
Maintain sodium and fluid restrictions as prescribed during initial edematous phase.  
Weigh child daily on same scale wearing same amount of clothing.
Monitor I & Os.  Monitor increasing urine output and color for improvement.
Neuro evaluation, as HTN may cause encephalopathy and seizures.
Evaluate fatigue, children are usually fatigued wth this disease.  Cluster care to allow rest and provide age appropriate activities.  
Children with mild cases may be managed at home.  Patient and family education r/t monitor urine output and color, take B/P measurements, restrict diet, no strenuous activity until resolved.
If renal involvement progresses, dialysis may become necessary.
Avoid use of NSAIDs, as antiprostaglandin action of NSAIDs may cause a further decrease in GFR.
Nephrotic syndrome
•	Nephrotic syndrome occurs because of increased glomerular membrane permeability, which increases the amount of protein lost in the urine.  It can be congenital, idiopathic, and secondary.  
Congenital nephrotic syndrome is inherited, rare, and occurs primarily in families of Finnish descent.  Prognosis is poor, tho there is some success with early, aggressive tx and advances of kidney transplants in infants.
Secondary nephrotic syndrome may occur secondary to another condition such as systemic lupus erythematosus, Henoch-Schonlein purpura, or diabetes.
Idiopathic nephrotic syndrome is the most common form, occurs more in males than females, with 70% of cases occuring by age 5.
Complications include anemia, infection, poor growth, peritonitis, thrombosis, and renal failure.
•	Pathophys.  Increased glomerular permeability results in the passage of larger plasma protein (albumin) in the urine and decreased protein and albumin in the blood.  This loss of albumin in the blood (hypoalbuminemia) results in a change in osmotic pressure, and fluid shifts from the blood stream to the interstitial tissue, causing edema.  This decrease in blood volume causes the kidneys to conserve sodium and water, causing more edema.  The liver responds to the protein loss by increasing production of lipoproteins.  This causes hyperlipidemia as the excess lipids created cannot be excreted in the urine.  
•	Dx
Health Hx: nausea or vomiting, recent weight gain, hx of periorbital edema upon waking pregressing to generalized edema thruout day, weakness or fatigue, irritability or fussiness.  Past Medical history for risk factors such as intrauterine growth retardation, age younger than 3 years, male sex.
Physical exam: observe edema (periorbital, generalzied, or ascites).  Inspect skin for stretched, tight appearance, pallor, or skin breakdown r/t edema.  Obtain height and weight.  Note increased resp. rate or increased work of breathing r/t ascites and edema.  Note B/P, may be elevated, but usually normal unless in renal failure.  Auscultate heart and lung sounds, abnormalities r/t to fluid overload.  Palpate skin and abdomen for edema/ascities.
Lab/DX Tests: Urine dipstick will reveal marked proteinuria.  Infrequently, mild hematuria may also be present.  Serum protein and albumin levels will be low.  Serum cholesterol and triglyceride levels are elevated.  With continued nephrotic syndrome, creatinine and BUN may become elevated.
•	Medical treatment: Corticosteroids.  IV albumin may be used for severe edema.  Diuretics are also used during edematous phase.  Long term therapy is usually required to indece remission.  Steroid responsive MCNS has favorable prognosis.  If not responsive to steroids, immunosuppressive therapy such as cyclophosphamide, cyclosporine A, or mycophenolate mofetil may be necessary.
•	Nursing inter.
Promoting diuresis. 
-Administer corticosteroids as ordered.  Taper or weaning doses at end of corticosteroid regimine.  
-Administer diuretics if ordered (furosemide-Lasix).  Increase potassium in diet or with supplements if child has potassium loss as result of furosemide treatment.  
-Monitor urine output and amount of protein in the urine by dipstick.
-Weigh child daily on same scale with same amount of clothing.
-Assess edema.
-Measure pulse rate and B/P q 4 hours to detect hypovolemia r/t from excessive fluid shifts.  Enforce fluid restrictions as ordered.
-In cases of severe hypoalbuminemia, IV albumin may be administered.  Admin a diuretic (furosemide) immediately after to allow for optimal diuresis and prevent fluid overload.
Preventing infection.
-Monitor childs temp.  Admin pnumococcal vaccine and prophylactic antibiotics as prescribed.  Delay administering live vaccines until at least 2 weeks after corticosteroid theray ceases.
Encouraging adequate nutrition and growth.
-fuid restriction, sodium intake may be restricted in the edematous child to prevent further fluid retention.  Encourage protein rich snacks.
Educating the family.
-Teach parents how to give medications and how to perform the urine dipstick technique for detecting protein, encourage to keep track of dipstick results.  Child may return to school, but should avoid contact with sick playmates.  If exposed to illness, should monitor temp and dipstick results more frequently to identify relapse in nephrotic syndrome.
Providing emotional support.
-Often a chronic condition, may have remission and relapses.  cycle of relapse and remision can take emotional toll on family.  Frequent hospitalizations can also create stress.  child may experience social isolation because must avoid exposure to infections.  Self esteem issuses may arise from edema and weight gain, short stature, and "moon face" associated with chronic steroid use.  Provide emotional support to child and family, encourage efforts to maintain treatment plan.  introduce child to other children with chronic renal conditions.
UTI
•	Urinary Tract Infection.  occurs most often as result of bacteria ascending to the bladder via the urethra.  Occurs in 3% of children.  Most common in males up to 1 year of age, after 1 year, is most common in females.  Females shorter urethra allows bacteria to have easier access to bladder, also close proximity of urethral opening to vagina and anus.  In infants, may present with fever, irritability, vomiting, failure to thrive, or jaundice.  Children may present with fever and vomiting, dysuria, frequency, hesitancy, urgency, and/or pain.
•	Pathophys.
E. coli most common cause.
Urinary statis, urine retention after voiding, decreased fluid intake, and alkaline urine all increase bacterial growth after introduction of bacteria.  If left untreated, may progress to pyelonephritis, a more serious infection.
•	DX
-Health Hx. S/S: fever, nausea or vomiting, chills, abdomen back or flank pain, lethargy, jaundice (neonate), poor feeding (infant), urinary urgency or frequency, burning or stinging upon urination (infant may cry with urination, toddler may grab the diaper), foul smelling urine, poor appetite (child), enuresis or incontinence in a previously toilet-trained child, blood in the urine.
-PMH: previous UTI, obstructive uropathy, inadequate toileting hygiene, VUR, constipation, urine holding or dysfunctional voiding, neurogenic bladder, uncircumcised male, sexual intercourse, pregnancy, chronic illness.
-Physical Exam: in neonate or youn infant, observe for jaundice or increased resp rate.  In infants and children, inspect perineal area for redness or irritation.  Observe urine for visible blood, cloudiness, dark color, sediment, mucus, or foul odor.  Note pallor, edema, or elevated blood pressure.  Palpate the abdomen, note distended bladder, abdominal mass, or tenderness, particularly in the flank area.  
LAB/DX TESTS:
-Urinalysis (clean catch, suprapubic, or cateterized) may be positive for blood, nitrites, leukocyte esterase, white blood cells, or bacteria.
- Urine culture: will be positive for infecting organism.
-Renal ultrasound: may show hydronephrosis if child also has a structural defect.
-VCUG - not usualy peformed until the child has been treated with antibiotics for at least 48 hours, as infected urine tends to reflux up the ureters anyway.
•	Medical TX: Oral or IV antibiotics, depending on severity of infection.  Urine culture and sensitivity determines the appropriate antibiotic.  A 7-14 day course of antibiotics is often prescribed.  Adequate fluid intake is necessary to flush bacteria from the bladder.
•	Nursing:
-Eradicate infection: Admin antibiotics as prescribed.  Child with protracted vomiting r/t the UTI or with suspected pyelonephritis will require hospitalization and IV antibiotics.  Infant younger than 8 weeks wiht fever, UTI, and concerning history should also be hospitalized and given IV antibiotics.  Urge patent to complete entire course, even when child feels better.  Admin IV fluid as ordered, or encourage generous oral fluid intake.
-Providing comfort: Andmin antipyretics (acetaminophen or ibuprofen) to reduce fever.  A heating pad or warm compress may help relieve abdomen or flank pain.  If child is afraid to urinate due to pain, encourage voiding in a warm sitz or tub bath.
-Preventing recurrence of infection: Encourage parents to return for repeat culture to ensure eradication of bacteria.
-Patient education: Drink plenty of fluids, drink cranberry juice to acidify urine, avoid caffiene wihcih irritates the bladder, urinate frequently and don't "hold it", avoid bubble baths, wipe from front to back after voiding, wear cotton underwear, avoid wearing tight pants or jeans, wash perineal area daily with soap and water, while menstruating change pads frequently, void immediately after sex.
CHAPTER 22: Neuromuscular
Myelomeningocele
•	Most severe form of neural tue defects, ocurs in approx 1 in 4,000 live births.  Is a type of spina bifida cystica, and clinical the therm spina bifida is often used to reer to myelomeningocele.  The meninges herniate thru a defect in the vertebra.  In this form, the spinal cord often ends at the point of the defect, resulting in absent motor and sensory function beyond that point.  The child may also have accompanying hydrocephalus.  Usually require multiple surgical procedures.  Also at increased risk for developing a latex allergy due to frequent catheterizations.  Learning problems and seizures common, but 70% of survivors have normal intelligence.  Due to advances in medical treatment, life expectancy has increased.  With aggressive treatment mortality rate is 10-15%, most deaths occur before the age of 4.
•	Pathophys.  Exact cause unknown. Risk factors include maternal drug use, malnutrition, and a genetic predisposition.  The neural tube fials to close at the end of the 4th week of gestation.  An external sac like protrusion that encases the meninges, spinal fluid, and sometimes nerves is presnet on the spine.  It can be located anywhere on the spinal cord, but 75% are located in the lumbosacral region.  Degreee of neurologic deficit will depend on the location.
•	DX.
-HH: risk factors: lack of prenatal care, lack of preconception and/or prenatal folic acid supplementation, previous child born with neural tube defect or family hx of neural tube defects.
-Physical Exam: Visible external sac protruding from spinal area, identified upon delivery.  Assess if sac covering is intact.  Assess neurologic status and associated anomalies.  Asess movement of exremeties and anal reflex.  Flaccid paralysis, absence of deep tendon reflexes, lack of response to touch and pain stimuli, skeletal abnormalities such as club feet, constant dribling of urine, and relaxed anal sphincter may also be found.
LAB/DX TESTS
-may be detected prenatally around 16-18 weeks gestation by ultrasound, blood test that detects AFP increases, or by analysis of amniotic fluid for AFP increases.
-Dx tests to evalute brain and spinal cord involement are: MRI, CT, ultrasound, and myelography.
•	Medical TX.
-surgical closure will be perfomed ASAP after birth.  Goal of early surgical intervention is to prevent infection and minimize further loss of function.  Ongoing managment is complex, with multidisciplinary approach and lifelong care being necessary.
•	Nursing interventions.
Preventing infection.
-risk for infection r/t presence of the meningeal sac and potential for rupture is a central nursing concern in teh newborn with myelomeningocele. Until surgical intervention, goal is to prevent rupture or leakage of CSF from sac.  It is important to keep the sac moist, and to prevent trauma and pressure to the sac.  Use sterile saline-soaked gauze to keep the sac moist.  Immediatly report seepage of clear fluid.  Position the infant in the prone position or supported on side to avoid pressure on the sac.  Place infant on warmer or isolette to avoid use of blankets (pressure).  Monitor infant in isolette or warmer for increased drying or cracking of the sac.  Keep sac free of feces and urine.  This may include positioning, or placin a piece of plastic wrap below the meningocele.  After surgery, maintain prone or sidelying position to allow incision to heal, and contiue to keep feces and urine away from incision.
Promoting urinary elimination
-Children often have bladder incontinence, depending on level of lesion.  One of most common causes of neurogenic bladder - failure of the bladder to either store urine or empty completely.  Causes loss of control over voiding.  Spastic type is hyperreflexive and yields frequent release of urine, but incomplete emptying.  Hypotonic type bladder is weak and flaccid, stretches to hold large amounts of urine, causing constant dribbling of urine from urethra.  Both types cause stasis and retention, putting the child at risk for UTI and reflux of bladder contents back up into the ureters and kidneys resulting in renal scarring and insufficiency. 
-Goals of management are to promote optimal continence and prevent renal complications.  Clean intermittent catherization to promote bladder emptying, medications such as oxybutynin chloride (Ditropan) to improve bladder capacity, prompt recognition and treatment of infections, and in some children surgical interventions such as continent urinary reservoir or vesicostomy to facilitate urinary elimination.
-Assess urinary function.  Determine child's pattern and success of toilet training, both for bladder and bowel.  Assess cognitive/developmental level.  Observe genital area for dribbling of urine from urethra, noting odor of urine if present.  Note redness of urethra or exoriation in diaper area.  Palpate abdomen for presence of distended bladder, fecal mass, or enlarged kidneys.  Determine level of paralysis or paresthesia.
-Performing clean intermittent catheterization.  Can teach parents.  Wash hands, clean genitalia, apply water based lube, perform catheterization (2-3 inches for girls, 4-6 inches for boys), ensure complete emptying (move catheter, press on lower abdomen, or have child lean forward slightly), wash reusable catheter after use with soapy water inside and out, rinse well and allow to dry, store in ziptop plastic bag or other clean container, sterilize daily.  Can teach to the child when developmentally ready (6-7 years).
-Use only latex free catheters and gloves for catherization, as high incidences of latex allergies occur.
Promoting bowel elinimation.  
-Depending on level of lesion, many children can develop some type of bowel continence.  Bowel training with the use of timed enemas or suppositories along with diet modifications can allow for defecation at predetermined times once or twice a day.
Promoting adequate nutrition. 
-Assist the family in assuming as normal a feeding position as possible.  Encourage parents to interact as much as possible with the infant by talking to and touching during feeding to help promote intake.  Infant may or may not be able to be held preoperatively.  If held, take precautions for pressure on the sac.  
Preventing latex allergic reaction.
-Sensitivity to latex or natural rubber is very common.  increased risk r/t multiple exposures to latex during surgical procedures and bladder catheterizations.  Latex free environment should be creaeted.  The FDA requries all medical supplies with latex be labelled, but not consumer products.  
Maintaining skin integrity.
-Address risk for altered skin integrity r/t infant's prone position and impaired mobility.  Prone position puts constant pressure on knees and elbows, may be difficult to keep infant clean of urine and feces.  Diaper may be contraindicated to avoid presure on the sac.  Place a pad under infant and change it frequently.  Place infant on special care mattress and synthetic sheepskin can reduce friction.  
Child and Family Education
-Serious disorder that affects multiple body systems and varying degres of deficits.  Lifelong.      
Duchenne muscular dystrophy
Cerebral palsy
Guillain-Barré Syndrome
Myasthenia Gravis
Fractures and cast care
Traction
Scoliosis
Clubfoot
Acne
Eczema
Burns
Impetigo
Diabetes
Precious puberty
Delayed growth or growth hormone deficiency