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Nursing Assessment at Birth

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-Examine urethral opening (*is it present/or not?*) -Is there narrowing of the foreskin? -Where is the urethral opening? -Is the scrotal sac swollen/testes present? -Is the penis straight? -Is the abd intact? -Has the newborn voided?(*this is very important*)

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Congenital Anomalies

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-Phimosis -Hydrocele -Cryptochidism -Hypospadias -Inguinal Hernia -Exstrophy of the Bladder -Epispadias -Chordee -Vesicoureteral reflex (VUR) -Ambiguous Genitalia

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Phimosis is?

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*Narrowing of the preputial opening of the foreskin that prevent the retraction of the foreskin over the glans penis* Normal finding Problems

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A finding of Phimosis is?

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Normal. But problems associated with it are if Phimosis is too tight around the penis.

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What can happen if Phimosis is too tight around the penis?

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It can cause: -Decreased blood supply -Decreased urine flow -Painful sex -A decrease in fertility ability later in life

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Therapeutic Management of Phimosis (Mild Case)

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Manual retraction of foreskin & proper cleansing of area.

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Therapeutic Management of Phimosis (Severe Case)

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Circumcision or vertical division & transverse suturing of foreskin.

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Hydrocele is?

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Fluid in the scrotum.

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Therapeutic Management of Hydrocele

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Surgical repair indicated if spontaneous resolution does not get accomplished in 1 year. *If resolves spontaneously: the skin retracts back to normal size*

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What are some causes of Hydrocele?

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Too much fluid from mom can cause baby to have fluid issues.

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Cryptorchidism is?

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Undescended Testes-one or both testes fail to descend into the scrotum, remaining in the abdomen, in the inguinal canal or at the external ring *May descend on their own in a few weeks*

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Where are some places the testes can reside in if they fail to descend?

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-Abdomen -Inguinal canal -External ring

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A key thing to do when measuring the equality of the testes

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Put thumb in between the scrotum to keep from measuring the same spot twice.

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What can happen in the testes don't ever distend?

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Fertility issues result.

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How it happens (Cryptorchidism)

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-The testes descend from the abdomen into the scrotum during the *last 2 months of gestation*. -*Testosterone stimulates the formation of the gubernaculum* (This helps pull the testes into the scrotum by shortening as the fetus grows).

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What does Testosterone due in relation to Cryptorchidism?

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-Testosterone stimulates the formation of the gubernaculum. -This helps pull the testes into the scrotum by shortening as the fetus grows.

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What happens when there isn't enough Testosterone in relation to Cryptorchidism?

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Undescended testes may result if testosterone levels are inadequate or if there's a defect in the testes or gubernaculum.

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Complications of Cryptorchidism

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-Sterility -Trauma to testes -Testicular cancer

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What to look for with Cryptorchidism

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-*Testes on the affected side is not palpable in the scrotum* -Scrotum appears underdeveloped -Check kidney function -*Palpate 1 testicle at a time

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Therapeutic Management for Cryptorchidism

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1) Medical: administration of human chorionic gonadotropin (*in older child*). 2) Surgical: orchipexy

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Hypospadias is?

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-Congenital anomaly of the penis in which the urethral meatus opens on the *ventral surface of the penis.* -In severe cases, the opening is located on the *scrotal region* -Cause is unknown-*genetic factors most likely*

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What is common in relation to Hypospadias?

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It is more common where meatus doesn't go to the penis. (*don't circumsize penis until Hypospadias is fixed*)

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What to look for with Hypospadias

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-Altered angle of urination (*going down instead of up*). -Urethral opening is located on the underside of penis. -Common with chordee (coming soon). -Observation confirms abnormal placement of urethral opening.

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Therapeutic Management of Hypospadias

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-Avoid circumcision until seen by specialist -*No treatment is necessary in mild disorder* -Urology will be consulted for surgery if necessary -(repair of Hypospadias ; circ performed at the same time) -The first stage involves straightening of the penis by the surgical release of fibrous band causing the deformity -The second operation is performed 6 months later to construct the new urinary passage or urethra so that the new urinary opening is at the tip of the penis.

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Epispadias

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-Urinary meatus is not at the end of the penis but on the upper side of the penile shaft (less common). -The meatal opening can be anywhere along the upper shaft, most frequent anomalies are minor with openings off-center but still in glans.

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What is Epispadias associated with?

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Exstrophy of the bladder.

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Which type of meatal openings are the most frequent anomalies but are *minor*

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When the meatal opening is off-center but still in the glans.

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Therapeutic Management of Epispadias

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(*Surgery typically requires multiple procedures*) -2nd phase of surgery involves the lengthening ; straightening of the penis ; creation of a more distal urethral opening.

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What can occur with girls that have Epispadias?

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Frequent UTIs.

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Nursing Interventions for Epispadias

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-Keep the area clean -Surgery may involve implants or reconstruction -Emotional support -VS -I;O -Antibiotics -Follow up care

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Chordee is?

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Ventral curvature of the penis

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What is Chordee associated with?

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Hypospadias. (Curvature of penis may be released before hypospadias repair)

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What are problems associated with Chordee?

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Difficulty in penetration later in life during sexual intercourse indirectly affecting fertility and conception. (Surgery ideally must be done around 1½ years of age.)

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Repair of Chordee is a 2 phase treatment (*repair is with surgical intervention*)

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-The first stage involves straightening of the penis, correction of chordee. -The second operation is performed 6 months later to construct the new urinary passage or urethra so that the new urinary opening is at the tip of the penis.

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Exstrophy of the Bladder is when?

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The lower portion of the abdominal wall ; anterior bladder wall are missing, resulting in the bladder being open and exposed on the abdomen.

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What anomalies would you observe at the same time with newborns?

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Exstrophy of the bladder, Hypospadias, ; Epispadias.

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Pathophysiology of Exstrophy of the bladder

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-Occurs more frequently in boys ; is most frequently associated with epispadias. -Bladder appears as an angry red mass glistening with urine Continuous drainage of urine from the ureters may lead to excoriation of the skin surrounding the bladder -Can be life threatening and therefore needs to be corrected as soon after birth

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What is Exstrophy of the bladder most frequently associated with?

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Epispadias.

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In Exstrophy of the bladder, what does continuous drainage of urine lead to?

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Excoriation of the skin surrounding the bladder. (*needs to be corrected soon after birth/is life threatening if bladder ruptures*).

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Assessment of Exstrophy of the bladder

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Anomaly is identified ; is immediately obvious at birth, *evaluate infant for other anomalies like Epispadias ; Hypospadias*

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Therapeutic management of Exstrophy of the bladder

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*Nursing care:* (birthing nurse will asses the baby) -Cover the bladder with sterile plastic wrap ; maintain skin integrity of the surrounding area using skin sealant to protect it. -Closure is corrected during the first 48-72 hrs of life. -Staged surgical correction. (transfer the baby to tertiary medical center) -VS -Talk with the parents -*Protect the bladder, is of utmost importance*

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Post Operative Care for Exstrophy of the bladder

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-Bryant's traction (keeps legs from moving) -Change dressing -Monitor U/O -Signs of obstruction -Emotional support -VS

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Inguinal Hernia (usually happens around age 4-5yrs)

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-Protrusion of abdominal contents through inguinal canal into scrotum. -Detected as painless inguinal swelling of variable size. -Goes away when sitting but comes back when standing -Most common in pedi boys. -Is a same day procedure.

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How does an inguinal hernia form?

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Occurs when a portion of the small intestine enters the inguinal canal.

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Therapeutic management of Inguinal Hernia

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Surgical closure if inguinal defect.

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Ambiguous Genitalia is?

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-Abnormal sexual differentiation -Penis & labia from premature newborns -Happens via increased androgen production resulting in ambiguous genitalia in newborn girls.

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Therapeutic Management for ambiguous genitalia

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-*Gender assignment*- do not perform irreversible surgery because some children may change gender later in life-*family participation essential.* -A work-up is needed to determine gender and the underlying cause of the ambiguity should begin immediately. (These infants should be initially observed in the NICU so that any electrolyte abnormalities can be identified and treated rapidly, and appropriate specialists involved (e.g. endocrine, genetics, urology))

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Congenital Adrenal Hyperplasia (CAH) is?

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-Is generally recognized at birth or in early childhood because of ambiguous genitalia. -(CAH) is a collection of genetic conditions that limit your adrenal glands' ability to make certain vital hormones.

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Problems with CAH

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-Can cause problems with normal growth ; development in children (*including normal development of the genitals. It affects both males ; females. Such as: PKU deficiency ; Ambiguous Genitalia*).

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Treatment of CAH

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-It's best to get a referral to a pediatric endocrinologist. -*Medications.* In most cases, your child's doctor will prescribe replacement hormone medication to boost the levels of deficient hormones in your child and restore them to normal levels. (re-establish PKU?*)

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Surgical treatment for CAH

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-In some infant girls who have ambiguous external genitalia, doctors recommend reconstructive surgery to correct the appearance ; function of the genitals. -This procedure may involve reduction of the clitoris size ; reconstruction of the vaginal opening. (*The surgery is typically performed between 2-6 months of age.*)

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PKU is used to ID what?

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*Congenial hyperplasia* can be first detected with the PKU done before discharge from hospital.

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Vesicoureteral Reflux (VUR) is?

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-Abnormal retrograde flow of bladder urine into the ureters -Primary ; Secondary Reflux.

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Primary Reflux

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Congenital abnormal insertion of ureters into the bladder.

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Secondary Reflux

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Result of an acquired condition.

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S/S od VUR

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-Recurring kidney infections/UTIs -High fevers, vomiting ; chills -Renal Scarring

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What is the most common cause of renal scarring?

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VUR (reflux) associated with UTI.

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Management of VUR

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-Preventing bacteria from reaching kidneys. -*Management is conservative with low dose antibiotic therapy*. -Urine culture every 2-3 months ; anytime a child has a fever. -*Surgical:* significant anatomic abnormality, recurrent UTIs, sever forms of VUR, non compliance, intolerance to antibiotics or VUR after puberty in females

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Surgical intervention with VUR

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Performed when there is a significant anatomic abnormality, recurrent UTIs, severe forms of VUR, non-compliance, intolerance to antibiotics or VUR after puberty in females.

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Long term VUR

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-Should out grow the reflux over a period of years. -*Prognosis:* prompt ; adequate treatment of diagnosis should be good. -Hazard of progressive renal injury is greatest when infection occurs in young children ; is associated with congenital renal malformations ; reflux.

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What is the hazard of long term VUR?

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Progressive renal injury is greatest when infection occurs in young children ; is associated with congenital renal malformations ; reflux.

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Nursing Alert for VUR

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-Check diaper every ½ hr. -Check for discomfort with urination ; starting/stopping stream intermittently -Teach S/S UTIs to parents

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Teaching r/t VUR

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-Prevention! -Cleansing: front to back -Children should void as soon as they feel the urge -Sexually active females are advised to urinate asap after they have intercourse -*If on low dose antibiotics: give at bedtime to allow the medication to remain in the bladder overnight*

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Urinary Disorders

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-Acute post-streptococcal glomerulonephritis -Enuresis -Hemolytic Uremic Syndrome -Nephrotic syndrome -Wilms's tumor -Testicular Torsion

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Acute Poststreptococcal Glomerulonephritis is?

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*Definition:* an inflammation of the tubules of the kidneys (glomeruli), which filter waste products from the blood. -It's when theres an infection of strep bacteria in early pedi phase. -Most commonly-boys-3-7 -95% fully recover, the rest may progress to chronic renal failure.

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Acute Poststrep Glomerulonephritis can lead to?

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Chronic renal failure.

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What should you do upon the admit of a child with APG?

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Obtain a history of strep infection.

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What causes Acute Poststrep Glomerulonephritis?

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-Typically follows group A beta-hemolytic streptococcal infection of the respiratory tract. -Less commonly, it may follow a skin infection such as impetigo.

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When does Acute Poststrep Glomerulonephritis occur?

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The disease usually begins about 1-6 weeks after a streptococcal infection, although 2 weeks is the most common time of onset. *Inflammation doesn't allow fluid & waste to be expelled leading to edema*

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Acute Poststrep Glomerulonephritis co-morbid with Immunologic Disorder

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-Antigens from streptococci clump together with the antibodies that killed them & become trapped in the tubules of the kidneys. -Tubules become inflamed & edema of the capillary walls decreases the amount of glomerular perfusion. -The kidneys then become incapable of filtering & eliminating body wastes. (*waste*)

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What to look for with Acute Poststrep Glomerulonephritis

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-EDEMA-initially in the face, esp around the eyes, later in the legs -Oliguria -Hematuria -Proteinuria -Cola-colored (smoky) urine -Inc BP -Mild anemia, pallor

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Therapeutic Management of Acute Poststrep Glomerulonephritis

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-Antibiotics (*type of drug depends on child's age ; the child himself*) -Antihypertensives -Diuretics -Cortiosteroids

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Nursing Considerations for Acute Poststrep Glomerulonephritis (*for inpatient babies*)

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-Vital signs -Careful physical assessment -Assess renal function -Daily weights -Medication administration -Nutrition: no salt, fluid restriction, low protein -Activity monitoring: Lay Low -Discharge teaching/home monitoring/VNA

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Hemolytic Uremic Syndrome is?

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-*A complex of symptoms that includes: acute renal failure, hemolytic anemia, ; thrombocytopenia* -Acute renal disease that occurs mostly in infants ; children from age 6 mo to 3 yrs. -One of the main causes of acute renal failure in the young child

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Hemolytic Uremic Syndrome is one of the main cause of what?

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Acute renal failure in young children.

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What follows after hemolytic Uremic Syndrome?

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-Usually follows an attack of infectious bacterial diarrhea or viral infection -May follow an upper respiratory infection

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How does Hemolytic Uremic Syndrome occur?

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1) Bacterial infection causes endothelial cell injury in the lining of the small glomerular arterioles. 2) Cell damage triggers microvascular lesions with platelet-fibrin microthrombi, that occlude the arterioles ; capillaries. 3) This platelet aggregation results in thrombocytopenia ; the kidneys become swollen ; pale. 4) Other organs may be involved.

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What results from platelet aggregation in HUS?

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Thrombocytopenia along with the kidneys becoming swollen ; pale.

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What is HUS in a nutshell?

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It's a systemic degradation of kidney function.

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What to look for in HUS

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-History: recent episode of diarrhea, less common: URI or viral infection -Irritability, weakness, lethargy -Pallor -ecchymosis & ptechiae -Oliguria or anuria -Hypertension -GI bleeding with blood in stool -Seizures -Heart failure

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What are the s/s of late onset HUS?

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Seizures & HF.

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Therapeutic management of HUS

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-*Most consistent & effective treatment is hemodialysis or peritoneal dialysis.* -Daily plasma exchange. -Maintenance of adequate fluid & electrolyte balance. -HUS needs aggressive care.

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Nursing Interventions for HUS

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-I/O strict -child's weight -monitor BP ; pulse -Assess hydration ; nutritional status -Observe signs of complications (*edema, HF, increased BP*)

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What are s/s of complications r/t HUS?

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Edema, HF, increased BP.

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Enuresis is?

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-Repeated involuntary urination -Usually occurs at noc -Primary/secondary enuresis -Nocturnal enuresis

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What is secondary enuresis?

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The child was fine ; then wasn't. Could be anxiety related (Ex: going to school for the first time).

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What may cause Enuresis

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-Stress incomplete muscle maturation -Altered sleep pattern -Irritable bladder -Sound sleeper -Smaller bladder -Can be developmentally related (*not ready to be potty trained by the time the parents are*).

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What are some complications of Enuresis?

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-Low self-esteem -Social withdrawal -Anger, refection & punishment by caregivers

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Assessment findings for Enuresis

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-Acute urgency to void followed by discomfort & restlessness -Voiding during sleep

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What should be done with assessing Enuresis?

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-Routine physical exam & history -Functional bladder capacity -Urinalysis

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Therapeutic management for Enuresis (*management is dependent on parents & child's motivation*)

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-Enuresis alarm -Social motivation -Drug therapy: use of tricyclic antidepressants, anti-dieuretics ; antispasmodics. -Other drugs: Desmopressin nasal spray (*reduces nighttime urine output to a volume less than functional bladder capacity*).

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Desmopressin related to Enuresis

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Can be used during sleep overs ; when they don't want a pull-up.

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Nursing interventions for Enuresis

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-Treatment varies with the cause -Toilet every 2 hrs -Decrease fluids after 5 pm -Teach bladder-stretching exercises -Provide emotional support -Sleep diary -Practice consistent good sleep hygiene.

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Nephrotic Syndrome is?

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A condition in which the kidneys lose a significant amount of protein in the urine, *resulting in low blood levels of protein.*

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Preschool Predominance of Nephrotic Syndrome

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-*Primary Nephrotic Syndrome occurs predominantly in preschool children.* -Incidence peaks between 2-3years & is rare after age 8. -More common in boys. -Some forms may eventually progress to end-stage renal disease.

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How Nephrotic Syndrome occurs

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-The injured glomerular filtration membrane allows the loss of plasma proteins, especially albumin & immunoglobulin, *resulting in decreased levels of serum albumin (hypo-albuminemia).* -This results in decreased colloidal osmotic pressure & fluid accumulation in the interstitial spaces. -Edema subsequently results from sodium & water retention.

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What does Hypo-albuminemia cause?

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Decreased colloidal osmotic pressure & fluid accumulation in the interstitial spaces. (*causing edema*)

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The loss of plasma proteins (*albumin & immunoglobulin*) cause what?

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Hypo-albuminemia from Nephrotic Syndrome.

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What is assessed in Nephrotic Syndrome?

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-Oliguria with dark, concentrated urine. -Edema: starting peri-orbital & then more generalized. -Weight gain -Abdominal distention -Irritability -Lethargy, easy fatigued -Pallor -*Hypertension (in later stages)*

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Nursing interventions for Nephrotic Syndrome

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-Multiple hospital stays disrupt routine -Maintain fluid balance -Monitor for s/s of fluid volume excess (*hyper-volemia*) -Reducing excretion of urinary protein -Signs of electrolyte imbalance -Assess general nutritional status -Assess for adverse effects of medications -Signs of infection, pain, & emotional support

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Wilm's Tumor/Nephroblastoma is?

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-*Most common type of renal cancer in children* -Most frequent intra-abdominal tumor of childhood -Peaks in 3 yrs of age -*Favors left kidney* -Associated with congenital abnormalities -Can remain encapsulated for a long time, prognosis is excellent if metastasis hasn't occurred.

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What is Wilm's Tumor/Nephroblastoma associated with?

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Congenital abnormalities.

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How Nephroblastoma occurs

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-Embryonal cancer of the kidney *originating during fetal life* -In the early stages, the tumor is well encapsulated but it may later spread into the lymph nodes, renal vein, or vena cava, mets to the lungs or other sites may occur.

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Assessment for Nephroblastoma

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-Nontender abdominal mass (*noticed by parents in bath or dressing*). -Mass can be palpated in the region of the *lower abdomen ; is usually confined to one side*). -Other s/s may include an enlarged abdomen, HTN, V, hematuria, anemia ; constipation.

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Therapeutic Management of Nephroblastoma

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-Surgical removal of the entire affected kidney -Exploratory surgery -If bilateral, biopsy of the tumor is taken -Chemotherapy ; further surgery

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Nursing interventions for Nephroblastoma

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-*DON'T PALPATE* -Prep for treatments & surgery

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Stages of Nephroblastoma

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-Stage I: limited to one kidney -Stage II: extends to beyond the kidney but can be completely re-sected -Stage III: the tumor has spread but is confined to the abdomen -Stage IV: metastases, deposits are beyond stage III, namely to the lung, liver , bone, and brain -Stage V: involves both kidneys

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Testicular Torsion is?

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*The twisting of the spermatic cord, which cuts off the blood supply to the testicle & surrounding structures within the scrotum.* (Usually between 12-18 years of age.)

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S/S of Testicular Torsion

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-Sudden onset of severe pain in one testicle, with or without a previous predisposing event. -Swelling within one side of the scrotum -Nausea or vomiting

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Treatment for Testicular Torsion

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Surgery is usually required and should be performed as soon as possible after symptoms begin. If surgery is performed within 6 hours, most testicles can be saved.

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Complications of Testicular Torsion

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If the blood supply is cut off to the testicle for a prolonged period of time (*usually max 6 hrs*), it may atrophy (shrink) & need to be surgically removed.

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Nursing Diagnosis

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-Fluid volume excess r/t failure of renal regulatory mechanisms -Risk for injury r/t accumulated electrolytes and waste products -Altered nutrition: less than body requirements r/t restricted diet. -Body image/self esteem disturbance r/t altered appearance, chronic illness, frequent treatments.... -Impaired social interaction r/t hospitalizations -Altered family process r/t to child with chronic illness

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