PEDIA FINALS NOTES #3 Murillo 2018-2019

Care of Client with Renal & Urinary Disorder 9. Administer an antispasmodic Ditropan for painful
bladder spasms, Tylenol an analgesic while the catheter
Hypospadias is in place, usually 3 to 7 days.
10. Prepare the parents for future surgical procedures
- is a urethral defect in which the urethral opening is to release the chordae & potentially extensive plastic
not at the end of the penis but on the ventral surgery.
(lower)aspect of the penis.
11. Teach the parents how to apply the testosterone
- The meatus may be near the glans, midway, or
back at the base of the penis. cream, if prescribed.
- The degree of hypospadias may be minimal or 12. Prepare the parents & child for each surgical
maximal. procedure & encourage them to verbalize any of their
- Many newborns with hypospadias have an concerns.
accompanying short chordae causing the penis to
curve downward. Hypospadia
- This is a common anomaly occurring in 1 in 300
male newborns.
- Hypospadias may be familial & may occur from a
multifactorial genetic focus.
- Surgical intervention, meatotomy- urethra is
extended to a normal position, to establish better
urinary function is done in the newborn.
- At 12 to 18 months of age, the infant may have
the adherent chordae released.
- Extensive plastic surgery is usually delayed until
the child is 3 to 4 years of age.
- Pharmacologic intervention to encourage penis
growth & make future plastic surgeries easier can
be done by applying testosterone cream..
- Surgical intervention should be done before
school age to allow the child to appear normal to
his classmates.
- Later in life a repair of the meatal opening Is
necessary to avoid infertility.
- After surgical intervention for hypospadias, a child
is expected to be normal in both urinary &
reproductive functions unless accompanying
anomalies of the penis are present.

Assessment Findings:
- Penile opening on ventral surface
- Downward penile curvature

Nursing Implications:
1.Inspect all male newborns at birth for hypospadias for
cryptorchidism, undescended testes, which is often
found With this defect.
2.Establish sex determination with a Barr body analysis
from a buccal cell smear or full sex cell karyotyping if
the penis defect is extensive.
3.Assist parents in accepting the medical diagnosis of
hypospadias & reassure them that eventually the child
will have normal urinary & probably reproductive
function.
4.Explain to parents that a circumcision is not done on a
child with this defect because the foreskin may need to
be used in the future with plastic reconstruction.
5.Openly discuss the defect with the parents to ease their
ability in discussing it.
6.Encourage the parents to verbalize their feelings
regarding the defect.
7.Inform the parents of the initial surgical procedure
necessary to establish better urinary function.
8.Help parents to become familiar with the urinary
catheter placed after this surgery to keep tension off the
urethral sutures.

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PEDIA FINALS NOTES #3 Murillo 2018-2019
- Peri-orbital & peripheral edema
Epispadias - Vomiting
- is an opening of the urinary meatus on the - Low-grade fever
dorsal or superior surface of the penis. - If cardiac involvement occurs the child will have
- Orthopnea
- Cardiac enlargement
Glomerulonephritis, Acute Poststreptococcal (APSG)
- Enlarged liver
- An inflammation of the glomeruli of the kidney - Pulmonary edema
secondary to beta-hemolytic group A - T wave inversion
streptococci. - PR interval prolongation
- APSG, the most common form of - Heart failure (occur with extreme circulatory overload)
glomerulonephritis in children. - Encephalopathy
- An autoimmune disorder arising after an - Cerebral symptoms
- Hypoalbuminemia secondary to massive proteinuria
infection with untreated streptococcal
- Low serum complement
pharyngitis. - Mild anemia
- Tissue damage occurs from a complement - Elevated erythrocyte sedimentation rate
fixation reaction in the glomeruli (complement - Elevated blood urea nitrogen & creatinine levels
is a cascade of proteins activated by antigen - Elevated antistreptolysin O (anti- DNase B)
antibody reactions & actually plugs or
obstructs glomeruli). Nursing Implication:
1. Teach the parents & child about the disease & its
progression, treatments & procedures to be
- IgG antibodies against Streptococcus may be
performed, & their rationale.
detected in the blood stream of children with
2. Offer support & guidance to parents, & explain that
acute glomerulonephritis.
this is generally self-limiting disease.
- Intravascular coagulation in minute renal
3. With uncomplicated APSG, allow the child to engage in
vessels occurs.
quite play activities with gradual increase of level of
- Ischemic damage leads to scarring &
activity.
decreased glomeruli formation. This results in a
4. Monitor the child’s cardiovascular & pulmonary status.
reduction in the glomerular filtration rate
5. Assess heart rate & respiratory rate & lung sounds
leading to an accumulation of sodium & water
every 4 hours.
in the blood stream .
6. Evaluate the child’s neurological status & watch for
- Inflammation of the glomeruli increases
increasing lethargy..
permeability, allowing protein molecules to
7. To detect changes in fluid status, weigh the child
escape into the filtrate leading to protein loss
everyday.
- .APSG is generally self- limiting & resolves
8. Measure fluid intake & output.
spontaneously within a few weeks.
9. Monitor all signs of fluid status, such as edema.
- 2% of children do not completely recover from
10. Prevent fluid retention by restricting dietary
APSG but develop chronic nephritis.
sodium.
Types:
 Acute 11. Maintain fluid restrictions secondary to oliguria.
 Chronic 12. Treat accompanying complications of
hypervolemia.
13. Administer digoxin for cardiac decompensation.
14. Administer antihypertensive medications as
needed.
15. Keep in mind that protein restriction may be
necessary secondary to elevated BUN; however, a
Acute Post-streptococcal Glomerulonephritis child losing large quantities of protein may need high-
protein diet.
Assessment Findings: 16. Most children do well on a normal diet.
*(Signs and symptoms APSG occur 1 to 2 weeks after 17. Administer antibiotics for active streptococcal
streptococal infection) infection.
18. Position the child in a semi-fowler’s
- Sudden onset of hematuria
- Proteinuria 19. Position if congestive heart failure occurs.
- Urine sediment with white blood cells; epithelial cells; 20. Administer oxygen as prescribed.
& hyaline, granular, & red blood cell casts 21. Limit competitive activity until kidney function has
- Oliguria returned to normal.
- Elevated urine specific gravity 22. Be aware that proteinuria & impaired clearance of
- General malaise urea & creatinine may remain for as long as 2 months.
- Anorexia
23. Teach parents to be aware that increases in urine
- Abdominal pain
- Weight gain protein for 2 months do not indicate reinfection or the
- Hypertension recurrence of the disease.
- Headache
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PEDIA FINALS NOTES #3 Murillo 2018-2019
24. Prepare parents for the small chance of APSG 5. Encourage the family to find alternative noncompetitive
leading to a more chronic disease, & allow them to sports for the child who cannot engage in those
verbalize their fears & concerns. activities.
6. Promote the child’s renal function by maintaining fluid &
Nursing Diagnosis: electrolyte balance.
- Situational low-self-esteem, related to feelings 7. Monitor the child’s weight daily & have the family notify
of responsibility for onset of serious illness.
the physician if greater than 2 kg weight gain in 1 day.
Outcome identification:
- Child will verbalized appropriate positive 8. Instruct the parents to keep track of urine output.
aspects about self & intact appropriately with 9. Advise the family & child on dietary Modifications that
others in 1 month. will be necessary; this may include a high- CHO,
Outcome evaluation: moderate –fat, low CHON diet.
- Child states feelings about becoming ill; 10. Ensure adequate caloric intake.
discusses future plans & ways to maintain 11. Teach the parents & child about vitamins & drugs
health; participates in care.
necessary to limit effects of phosphorus & calcium
disturbance, such as vitamin D analogs & calcium
Glomerulonephritis, Chronic
supplements .
- is an irreversible disorder characterized by
slow, progressive loss of renal function with 12. Ensure that the family understands about all of the
nephron damage. actions & potential side effects of the drugs
- This disorder is caused by anatomic administered.
abnormality, heredity nephritis, or polycystic 13. Restrict sodium & fluid for a child with
disease or may be idiopathic. hypertension.
14. Administer antihypertensives as prescribed &
- It occasionally may follow acute evaluate family & child’s understanding of the
glomerulonephritis or nephrotic syndrome, but medications
it also occurs as a primary disease. 15. Administer folic acid & iron supplements as
- Progression of the disease varies with the prescribed for the anemic child.
cause. 16. Explain the purpose & side effects of corticosteroid
- Eventually, compensatory mechanisms fail, & use, & help the child to accept the long-term side effects
chronic renal insufficiency or end- stage renal of this therapy.
disease occurs. 17. Monitor for & help the family to understand subtle
- Treatment is aimed at symptomatic relief, with signs of infection.
drugs such as hydralazine or diuretics to treat
hypertension & corticosteroids to reduce
inflammation. 18. Administer antibiotics as necessary & adjust dose
- These patients have an increased susceptibility as prescribed according to renal function.
to infection, which is further aggravated when 19. Explain the purpose & side effects of corticosteroid
on corticosteriods. use & help the child to accept the long-term side effects
of this therapy.
Assessment Findings: 20. Monitor for & help the family to understand Subtle
- Proteinuria signs of infection.
- Elevated BUN & serum creatinine 21. Emphasize to the parents the importance of
- Hyperphosphatemia reporting the earliest signs of infection.
- Hypocalcemia 22. Administer antibiotics as necessary. & adjust dose
- Hyperkalemia
as prescribed according to renal function..
- Metabolic acidosis
- Edema with fluid & sodium retention 23. Explain to the parents & child about different types
- Anemia of dialysis that may be required.
- Azotemia-an excess of urea & other nitrogenous 24. Detect & manage complications of dialysis therapy.
wastes in the blood stream. 25. Support the family & child throughout this chronic
- Hypertension disease.
- Hematuria or oliguria 26. Honestly respond to questions regarding prognosis
without renal transplantation.
Nursing Implication:
1. Refer any child found to have proteinuria on routine 27. Help the family & child find ways to adapt to living
examination for further investigative workup. with a chronic illness.
2. Educate the parents & the child regarding chronic
glomerulonephritis, & support them in accepting Complications:
this disease. 1. Heart Failure
3. Encourage the family to find alternative Sports for 2. Hypertensive Encephalopathy
the child who cannot engage in those activities. 3. Pulmonary Edema
4. Promote the child’s renal function by maintaining 4. Renal Failure
fluid & electrolyte balance. 5. Nephrotic Syndrome

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PEDIA FINALS NOTES #3 Murillo 2018-2019
Glomerulonephritis, beta-hemolytic group A Streptococcal 3. Isolate the child for the first 24 hours of treatment
for scarlet fever to prevent spread of infection.
Glomerulonephritis 4. Be alert for signs & symptoms of
- (an inflammation of the glomeruli of the kidney glomerulonephritis 1 to 3 weeks after scarlet rash
secondary to beta- hemolytic group A streptococci) has occurred.
is a rare disorder that occurs as a sequela to
5. Offer support & guidance to parents, & explain all
scarlet fever in only 2% to 30% of children.
- A reduction in the glomerular filtration rate leads to treatments that the child requires.
an accumulation of sodium & water; increased 6. Monitor the child ‘s cardiovascular & pulmonary
glomeruli permeability secondary to inflammation status; assess heart rate & respiratory rate & lung
leads to protein loss. sounds every 4 hours.
- This occurs 1 t0 3 weeks following the rash 7. Evaluate the child’s neurologic status, & watch for
associated with scarlet fever. increasing lethargy.
- Beta-hemolytic group A streptococcus grows in 8. To detect changes in fluid status, weigh the child
children’s bodies & produces a number of toxins. everyday & measure fluid intake & output.
- Erythrogenic toxin is the toxin responsible for the
rash of scarlet fever. 9. Monitor for all signs of fluid status, such as edema.
- The occurrence of acute glomerulo-nephritis in 10. Prevent fluid retention by restricting dietary
children with scarlet fever is not related to the sodium.
severity of the scarlet fever but to the body’s 11. Treat accompanying complications of
reaction to the toxins produced by the hypervolemia.
streptococcus. 12. Administer antihypertensive medications as
- There is no immunization available for scarlet needed.
fever.
13. Keep in mind that protein restrictions may be
Assessment Findings: necessary secondary to elevated BUN; however, child
- Sudden onset of hematuria losing large quantities of protein may need a high-
- Proteinuria protein diet. Most children do well on a normal diet.
- Oliguria 14. Position child in a semi-fowler’s position if
- Elevated urine specific gravity congestive heart failure occurs.
- General malaise
15. Administer oxygen as prescribed.
- anorexia
- Abdominal pain
- Weight gain 16. Limit competitive activity until kidney function has
- Hypertension returned to normal.
- Headache 17. Keep in mind that proteinuria & impaired clearance
- Peri-orbital & peripheral edema of urea & creatinine may remain for as long as 2
- Vomiting months.
- Low-grade fever
18. Teach parents to be aware that increase in urine
If cardiac involvement occurs the child will have: protein for 2 months do not indicate reinfection or the
recurrence of the disease.
 Orthopnea
 Cardiac enlargement 19. Prepare parents for the small chance that the acute
 Enlarged liver infection can become a chronic disease & allow them to
 Pulmonary edema verbalize their fears & concerns.
 T wave inversion
20. Nephrotic syndrome(Nephrosis)
 PR interval prolongation
 Heart failure (occur with extreme circulatory 21. Description
overload) 22. Also called Nephrosis, is altered glomeruli
permeability caused by fusion of the glomeruli
 Encephalopathy membrane surfaces. It cause abnormal protein in the
 Cerebral symptoms (possible) urine.
 Hypoalbuminemia secondary to massive
23. Immunologic mechanisms are involved in the
proteinuria
 Elevated ESR process. The cause may be hypersensitivity to an
 Elevated BUN & creatinine levels antigen- antibody reaction or an autoimmune process; a
T cell dysfunction may be responsible.
Nursing Implications:
1. Stress to the parents the importance of giving the Nephrotic syndrome in children occurs in 3 forms:
child a full course of antibiotic, usually penicillin for
scarlet fever to prevent the complication of 1. congenital
glomerulonephritis.. 2. secondary
2. Explain to the parents & child the potential for 3. idiopathic (primary)
sequela related to scarlet fever.
- Minimal change nephrotic syndrome is the type
most often seen in children; with this,As the
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PEDIA FINALS NOTES #3 Murillo 2018-2019
name implies, little scarring of glomeruli 13. Obtain frequent blood studies on children receiving
occurs. long-term diuretic therapy, as prescribed.
- Age of peak incidence of the idiopathic 14. Be sure to administer a rapidly acting diuretic, as
nephrotic syndrome is 2 to 3 years; the
prescribed, after an albumin
syndrome occurs more often in males than in
females.
15. Infusion to prevent fluid overload & congestive
Assessment Findings( Signs & Symptoms): heart failure.
16. Caution the parents of a child receiving
- Proteinuria ( single dipstick of 1 to 4 & 24 hour cyclophosphamide (Cytoxan) not to be misled into
up to 15 g of protein believing that their child has cancer because he or she
- Peri-orbital edema
is receiving a chemotherapeutic drug.
- Ascites( parents child’s clothes do not fit
around middle)
- Anorexia and vomiting 17. Perform frequent changes to prevent skin
- Pale, stretched, taut skin breakdown of edematous skin.
- Elevated sedimentation rate 18. Check the child’s clothing to make sure that the
- Marked scrotal or labial edema elastic band around the waist is not too tight.
- Diarrhea 19. Check boy’s scrotum & apply oft gauze between
- Irritability
skin surfaces to prevent skin irritation & breakdown.
- Low serum albumin -hypoalbuminemia)
- Hyperlipidemia(increased blood lipid level)
20. Position the child with the head elevated in a semi-
fowler’s position to reduce peri-orbital edema.
Diet: 21. Be aware that the medication should be
- Provide a low to moderate protein and sodium administered orally if possible, & IM injections should
diet that is adequate in carbohydrates and be kept at a minimum because medications are poorly
calories
absorbed from edematous skin.
Nursing implication:

1. Perform a thorough history & physical assessment to Nursing diagnosis

establish baseline. - Imbalanced nutrition, less than body
requirements, related to poor appetite,
2. Obtain necessary blood & urine samples, as prescribed.
restricted diet, & protein loss.
3. Obtain vital signs. Outcome identification
4. Administer oral prednisone, as prescribed, to reduce - Child will demonstrate adequate intake of
proteinuria rapidly & consequently edema. nutrients for growth needs throughout course
of illness.
5. Teach the parents first to test the child’s urine for Outcome evaluation
protein with a dipstick method & to keep an accurate - Child follows normal growth curve on standard
assessment scale.
chart showing the pattern of protein loss.
6. Tell the parents that approximately once a week
they need to collect a 24-hour urine specimen
from the child to measure total protein loss.

7. Assure the parents that prednisone therapy every

other day is best for the child to prevent them
from changing the schedule from everyday or giving
Wilm’s tumor
twice the calculated dose by adding extra tablets on
alternate days.
Wilm’s Tumor (nephroblastoma)
8. Help the parents design a reminder chart for the - is a malignant tumor that rises from the
refrigerator or the bathroom door metanephric mesoderm cells of the upper pole
of the kidney or a tumor involving the kidneys.
9. To help them remember when to administer the It accounts for 20% of solid tumors in childhood
medication. with no increased incidence for sex or race.
10. Be certain that the parents & child know that the  Discovery usually occurs
prednisone causes a cushingoid appearance ( moon between 6 months & 5 years
face, extra fat at the base of the neck, & increased of age (peak at 3 to 4 years).
body hair). - Wilm’s tumor occurs in
11. Caution the parents to plan ahead when getting association with
refills of the prescriptions so that congenital anomalies,
such as aniridia (lack of
12. The prednisone therapy is not stopped abruptly color of the iris), cryptorchidism, hypospadias,
because they ran out of the medication, causing pseudohermaphroditism, cystic kidneys,
adrenal insufficiency. hemangioma, & talipes deformity.
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PEDIA FINALS NOTES #3 Murillo 2018-2019
- Prognosis is best if cells are mostly differentiated -Tumor extending beyond the kidney but completely
epithelial cells are undifferentiated stromal cells. removed or resected surgically
- Metastasis is most often to the lungs, regional -Regional spread of disease beyond the kidney with
lymphnodes, liver bone & eventually brain. residual abdominal disease postoperatively.
-Metastases to the lung, liver, bone, distant lymph nodes
Assessment Findings or S/S: or other distant sites or hematogenous metastases;
1.Discovered early in life (6 months to 5 years; peak at 3 deposits are beyond stage III, namely to lung, liver, bone,
to 4 years)
& brain
2.Distort the kidney anteriorly so that the tumor is felt as
a firm non-tender, abdominal mass. -Bilateral disease or bilateral renal involvement is present
3.Parents sometimes are aware that their infant has a at diagnosis.
mass in the abdomen w/ abdominal pain.
4.Hematuria – means poor prognosis(may be present) Nursing implications:
5.Low grade fever- a sign of tissue necrosis 1.Place a sign reading” no abdominal palpation” over
6.Hypertension from excessive renin production the child’s bed because handling appears to aid
7.Weight loss & Anemia- lack of erythropoietin formation metastasis.
by the diseased kidney 2.Prepare the child & parents for staging procedures to
8.CT scan or sonogram will reveal the primary tumor any
predict therapy & prognosis.
points of metastasis
9. Kidney function studies, such as glomerular filtration 3.Support the family emotionally during staging &
rate or blood urea nitrogen will be done to assess throughout the course of therapy.
function of the kidneys before surgery. 4.Anticipate the need for surgery (usually
10. Mass displacing normal kidney structure on nephrectomy) , radiation therapy, & chemotherapy,
intravenous pyelogram & begin parent & child preparation.
11. Child’s abdomen can not be palpated anymore 5.Explain the need for follow-up to monitor for tumor
because handling appears to aid metastasis. Place a
recurrence & complications of therapy, which may
sign reading “ No abdominal palpation” over the
child’s crib. include small bowel

Therapeutic Regimen / Management: 6. Obstruction, liver damage, nephritis, interstitial

1. If w/out metastasis – Surgery - Nephrectomy- pneumonia, scoliosis, hypoplasia of the ileum & lower
excision of the affected kidney. rib cage, different growth rates in the two femurs,
2. Followed by ionizing radiation therapy- omitted sterility in girls, & development of a secondary
in stage I tumors – cobalt/ deep X-ray for 24 tumor.
days exposure
7. Inform parents that in most protocols, if there is no
3. chemotherapy- dactinomycin, doxorubicin,
vincristine. Given at varying intervals for as recurrence in 2 years, the child is considered cured.
long as 15 months; second surgical procedure
after 2 or 3 months to remove any remaining Nursing diagnosis
tumor. - Decisional conflict related to approval of eye
4. If w/ metastasis: removal to save child’s life.
a) Radiation to both lung fields Outcome identification
b) b. Chemotherapy - Parents & child will feel comfortable about
c) c. Surgery – thoracotomy decision regarding surgery postoperatively.
Prognosis: Outcome evaluation
1.The younger the child. The better the - Parents & child state that they can accept
prognosis removal of eye to save child’s life.
2.Depends on absence/ presence of metastasis.
3.But even with metastasis, as long as it is not
in the bones or bone marrow, prognosis is still
fair.
4.A 2 year period free of the disease is
considered a cure.

Complications:
-Bowel obstruction from fibrotic scarring and hepatic
damage from radiation to the lesion can occur.
-Nephritis in the kidney
-Girls- radiation to ovaries cause sterility
-Radiation to lungs result in interstitial pneumonia
-Spine radiation can result in scoliosis
-Survival 5 years for those without metastasis ninety
percent effective.
-Stages of Wilm’s Tumor
-Tumor confined to the kidney and completely removed
surgically.