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
Epispadias
- is an opening of the urinary meatus on the
dorsal or superior surface of the penis.
Glomerulonephritis, Acute Poststreptococcal (APSG)
- An inflammation of the glomeruli of the kidney
secondary to beta-hemolytic group A
streptococci.
- APSG, the most common form of
glomerulonephritis in children.
- An autoimmune disorder arising after an
infection with untreated streptococcal
pharyngitis.
- Tissue damage occurs from a complement
fixation reaction in the glomeruli (complement
is a cascade of proteins activated by antigen
antibody reactions & actually plugs or
obstructs glomeruli).
- IgG antibodies against Streptococcus may be
detected in the blood stream of children with
acute glomerulonephritis.
- Intravascular coagulation in minute renal
vessels occurs.
- Ischemic damage leads to scarring &
decreased glomeruli formation. This results in a
reduction in the glomerular filtration rate
leading to an accumulation of sodium & water
in the blood stream .
- Inflammation of the glomeruli increases
permeability, allowing protein molecules to
escape into the filtrate leading to protein loss
- .APSG is generally self- limiting & resolves
spontaneously within a few weeks.
- 2% of children do not completely recover from
APSG but develop chronic nephritis.
Types:
 Acute
 Chronic
Acute Post-streptococcal Glomerulonephritis
Assessment Findings:
*(Signs and symptoms APSG occur 1 to 2 weeks after
streptococal infection)
- Sudden onset of hematuria
- Proteinuria
- Urine sediment with white blood cells; epithelial cells;
& hyaline, granular, & red blood cell casts
- Oliguria
- Elevated urine specific gravity
- General malaise
- Anorexia
- Abdominal pain
- Weight gain
- Hypertension
- Headache
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Murillo 2018-2019
- Peri-orbital & peripheral edema
- Vomiting
- Low-grade fever
- If cardiac involvement occurs the child will have
- Orthopnea
- Cardiac enlargement
- Enlarged liver
- Pulmonary edema
- T wave inversion
- PR interval prolongation
- Heart failure (occur with extreme circulatory overload)
- Encephalopathy
- Cerebral symptoms
- Hypoalbuminemia secondary to massive proteinuria
- Low serum complement
- Mild anemia
- Elevated erythrocyte sedimentation rate
- Elevated blood urea nitrogen & creatinine levels
- Elevated antistreptolysin O (anti- DNase B)
Nursing Implication:
1. Teach the parents & child about the disease & its
progression, treatments & procedures to be
performed, & their rationale.
2. Offer support & guidance to parents, & explain that
this is generally self-limiting disease.
3. With uncomplicated APSG, allow the child to engage in
quite play activities with gradual increase of level of
activity.
4. Monitor the child’s cardiovascular & pulmonary status.
5. Assess heart rate & respiratory rate & lung sounds
every 4 hours.
6. Evaluate the child’s neurological status & watch for
increasing lethargy..
7. To detect changes in fluid status, weigh the child
everyday.
8. Measure fluid intake & output.
9. Monitor all signs of fluid status, such as edema.
10. Prevent fluid retention by restricting dietary
sodium.
11. Maintain fluid restrictions secondary to oliguria.
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
child losing large quantities of protein may need high-
protein diet.
16. Most children do well on a normal diet.
17. Administer antibiotics for active streptococcal
infection.
18. Position the child in a semi-fowler’s
19. Position if congestive heart failure occurs.
20. Administer oxygen as prescribed.
21. Limit competitive activity until kidney function has
returned to normal.
22. Be aware that proteinuria & impaired clearance of
urea & creatinine may remain for as long as 2 months.
23. Teach parents to be aware that increases in urine
protein for 2 months do not indicate reinfection or the
recurrence of the disease.
PEDIA FINALS NOTES #3
24. Prepare parents for the small chance of APSG
leading to a more chronic disease, & allow them to
verbalize their fears & concerns.
Nursing Diagnosis:
- Situational low-self-esteem, related to feelings
of responsibility for onset of serious illness.
Outcome identification:
- Child will verbalized appropriate positive
aspects about self & intact appropriately with
others in 1 month.
Outcome evaluation:
- Child states feelings about becoming ill;
discusses future plans & ways to maintain
health; participates in care.
Glomerulonephritis, Chronic
- is an irreversible disorder characterized by
slow, progressive loss of renal function with
nephron damage.
- This disorder is caused by anatomic
abnormality, heredity nephritis, or polycystic
disease or may be idiopathic.
- It occasionally may follow acute
glomerulonephritis or nephrotic syndrome, but
it also occurs as a primary disease.
- Progression of the disease varies with the
cause.
- Eventually, compensatory mechanisms fail, &
chronic renal insufficiency or end- stage renal
disease occurs.
- Treatment is aimed at symptomatic relief, with
drugs such as hydralazine or diuretics to treat
hypertension & corticosteroids to reduce
inflammation.
- These patients have an increased susceptibility
to infection, which is further aggravated when 19.
on corticosteriods.
Assessment Findings:
- Proteinuria
- Elevated BUN & serum creatinine
- Hyperphosphatemia
- Hypocalcemia
- Hyperkalemia
- Metabolic acidosis
- Edema with fluid & sodium retention
- Anemia
- Azotemia-an excess of urea & other nitrogenous
wastes in the blood stream.
- Hypertension
- Hematuria or oliguria
Nursing Implication:
1. Refer any child found to have proteinuria on routine 27.
examination for further investigative workup.
2. Educate the parents & the child regarding chronic
glomerulonephritis, & support them in accepting
this disease.
3. Encourage the family to find alternative Sports for
the child who cannot engage in those activities.
4. Promote the child’s renal function by maintaining
fluid & electrolyte balance.
Murillo 2018-2019
5. Encourage the family to find alternative noncompetitive
sports for the child who cannot engage in those
activities.
6. Promote the child’s renal function by maintaining fluid &
electrolyte balance.
7. Monitor the child’s weight daily & have the family notify
the physician if greater than 2 kg weight gain in 1 day.
8. Instruct the parents to keep track of urine output.
9. Advise the family & child on dietary Modifications that
will be necessary; this may include a high- CHO,
moderate –fat, low CHON diet.
10. Ensure adequate caloric intake.
11. Teach the parents & child about vitamins & drugs
necessary to limit effects of phosphorus & calcium
disturbance, such as vitamin D analogs & calcium
supplements .
12. Ensure that the family understands about all of the
actions & potential side effects of the drugs
administered.
13. Restrict sodium & fluid for a child with
hypertension.
14. Administer antihypertensives as prescribed &
evaluate family & child’s understanding of the
medications
15. Administer folic acid & iron supplements as
prescribed for the anemic child.
16. Explain the purpose & side effects of corticosteroid
use, & help the child to accept the long-term side effects
of this therapy.
17. Monitor for & help the family to understand subtle
signs of infection.
18. Administer antibiotics as necessary & adjust dose
as prescribed according to renal function.
Explain the purpose & side effects of corticosteroid
use & help the child to accept the long-term side effects
of this therapy.
20. Monitor for & help the family to understand Subtle
signs of infection.
21. Emphasize to the parents the importance of
reporting the earliest signs of infection.
22. Administer antibiotics as necessary. & adjust dose
as prescribed according to renal function..
23. Explain to the parents & child about different types
of dialysis that may be required.
24. Detect & manage complications of dialysis therapy.
25. Support the family & child throughout this chronic
disease.
26. Honestly respond to questions regarding prognosis
without renal transplantation.
Help the family & child find ways to adapt to living
with a chronic illness.
Complications:
1. Heart Failure
2. Hypertensive Encephalopathy
3. Pulmonary Edema
4. Renal Failure
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
name implies, little scarring of glomeruli
occurs.
- Age of peak incidence of the idiopathic
nephrotic syndrome is 2 to 3 years; the
syndrome occurs more often in males than in
females.
Assessment Findings( Signs & Symptoms):
- Proteinuria ( single dipstick of 1 to 4 & 24 hour
up to 15 g of protein
- Peri-orbital edema
- Ascites( parents child’s clothes do not fit
around middle)
- Anorexia and vomiting
- Pale, stretched, taut skin
- Elevated sedimentation rate
- Marked scrotal or labial edema
- Diarrhea
- Irritability
- Low serum albumin -hypoalbuminemia)
- Hyperlipidemia(increased blood lipid level)
Diet:
- Provide a low to moderate protein and sodium
diet that is adequate in carbohydrates and
calories
Nursing implication:
1. Perform a thorough history & physical assessment to
establish baseline.
2. Obtain necessary blood & urine samples, as prescribed.
3. Obtain vital signs.
4. Administer oral prednisone, as prescribed, to reduce
proteinuria rapidly & consequently edema.
5. Teach the parents first to test the child’s urine for
protein with a dipstick method & to keep an accurate
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
twice the calculated dose by adding extra tablets on
alternate days.
8. Help the parents design a reminder chart for the
refrigerator or the bathroom door
9. To help them remember when to administer the
medication.
10. Be certain that the parents & child know that the
prednisone causes a cushingoid appearance ( moon
face, extra fat at the base of the neck, & increased
body hair).
11. Caution the parents to plan ahead when getting
refills of the prescriptions so that
12. The prednisone therapy is not stopped abruptly
because they ran out of the medication, causing
adrenal insufficiency.
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Murillo 2018-2019
13. Obtain frequent blood studies on children receiving
long-term diuretic therapy, as prescribed.
14. Be sure to administer a rapidly acting diuretic, as
prescribed, after an albumin
15. Infusion to prevent fluid overload & congestive
heart failure.
16. Caution the parents of a child receiving
cyclophosphamide (Cytoxan) not to be misled into
believing that their child has cancer because he or she
is receiving a chemotherapeutic drug.
17. Perform frequent changes to prevent skin
breakdown of edematous skin.
18. Check the child’s clothing to make sure that the
elastic band around the waist is not too tight.
19. Check boy’s scrotum & apply oft gauze between
skin surfaces to prevent skin irritation & breakdown.
20. Position the child with the head elevated in a semi-
fowler’s position to reduce peri-orbital edema.
21. Be aware that the medication should be
administered orally if possible, & IM injections should
be kept at a minimum because medications are poorly
absorbed from edematous skin.
Nursing diagnosis
- Imbalanced nutrition, less than body
requirements, related to poor appetite,
restricted diet, & protein loss.
Outcome identification
- Child will demonstrate adequate intake of
nutrients for growth needs throughout course
of illness.
Outcome evaluation
- Child follows normal growth curve on standard
assessment scale.
Wilm’s tumor
Wilm’s Tumor (nephroblastoma)
- is a malignant tumor that rises from the
metanephric mesoderm cells of the upper pole
of the kidney or a tumor involving the kidneys.
It accounts for 20% of solid tumors in childhood
with no increased incidence for sex or race.
 Discovery usually occurs
between 6 months & 5 years
of age (peak at 3 to 4 years).
- Wilm’s tumor occurs in
association with
congenital anomalies,
such as aniridia (lack of
color of the iris), cryptorchidism, hypospadias,
pseudohermaphroditism, cystic kidneys,
hemangioma, & talipes deformity.
PEDIA FINALS NOTES #3
- Prognosis is best if cells are mostly differentiated
epithelial cells are undifferentiated stromal cells.
- Metastasis is most often to the lungs, regional
lymphnodes, liver bone & eventually brain.
Assessment Findings or S/S:
1.Discovered early in life (6 months to 5 years; peak at 3
to 4 years)
2.Distort the kidney anteriorly so that the tumor is felt as
a firm non-tender, abdominal mass.
3.Parents sometimes are aware that their infant has a
mass in the abdomen w/ abdominal pain.
4.Hematuria – means poor prognosis(may be present)
5.Low grade fever- a sign of tissue necrosis
6.Hypertension from excessive renin production
7.Weight loss & Anemia- lack of erythropoietin formation
by the diseased kidney
8.CT scan or sonogram will reveal the primary tumor any
points of metastasis
9. Kidney function studies, such as glomerular filtration
rate or blood urea nitrogen will be done to assess
function of the kidneys before surgery.
10. Mass displacing normal kidney structure on
intravenous pyelogram
11. Child’s abdomen can not be palpated anymore
because handling appears to aid metastasis. Place a
sign reading “ No abdominal palpation” over the
child’s crib.
Murillo 2018-2019
-Tumor extending beyond the kidney but completely
removed or resected surgically
-Regional spread of disease beyond the kidney with
residual abdominal disease postoperatively.
-Metastases to the lung, liver, bone, distant lymph nodes
or other distant sites or hematogenous metastases;
deposits are beyond stage III, namely to lung, liver, bone,
& brain
-Bilateral disease or bilateral renal involvement is present
at diagnosis.
Nursing implications:
1.Place a sign reading” no abdominal palpation” over
the child’s bed because handling appears to aid
metastasis.
2.Prepare the child & parents for staging procedures to
predict therapy & prognosis.
3.Support the family emotionally during staging &
throughout the course of therapy.
4.Anticipate the need for surgery (usually
nephrectomy) , radiation therapy, & chemotherapy,
& begin parent & child preparation.
5.Explain the need for follow-up to monitor for tumor
recurrence & complications of therapy, which may
include small bowel

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

1. If w/out metastasis – Surgery - Nephrectomy-
excision of the affected kidney.
2. Followed by ionizing radiation therapy- omitted
in stage I tumors – cobalt/ deep X-ray for 24
days exposure
3. chemotherapy- dactinomycin, doxorubicin,
vincristine. Given at varying intervals for as
long as 15 months; second surgical procedure
after 2 or 3 months to remove any remaining
tumor.
4. If w/ metastasis:
a) Radiation to both lung fields
b) b. Chemotherapy
c) c. Surgery – thoracotomy
Prognosis:
1.The younger the child. The better the
prognosis
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.
pneumonia, scoliosis, hypoplasia of the ileum & lower
rib cage, different growth rates in the two femurs,
sterility in girls, & development of a secondary
tumor.
7. Inform parents that in most protocols, if there is no
recurrence in 2 years, the child is considered cured.
Nursing diagnosis
- Decisional conflict related to approval of eye
removal to save child’s life.
Outcome identification
- Parents & child will feel comfortable about
decision regarding surgery postoperatively.
Outcome evaluation
- Parents & child state that they can accept
removal of eye to save child’s life.

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.