Chapter 34: Renal and Urinary Disorders

Welcome to Last Minute Lecture.

This free chapter overview is designed to help students review and understand key concepts.

These summaries supplement not replaced the original textbook and may not be redistributed or resold.

For complete coverage, always consult the official text.

Welcome to the Deep Dive.

Today we're tackling a really crucial area of pediatric health,

renal and urinary disorders in children.

That's right.

We've got a chapter here that's, well, packed with information, our goal, to pull out the vital knowledge you need to understand these conditions.

Yeah, covering the spectrum from maybe more common things like dead wedding all the way to more complex issues.

Exactly.

Things like glomerulonephritis, nephrotic syndrome, even some congenital anomalies.

And the mission for you listening is to get a clear kind of concise but insightful grasp of these disorders.

What makes them tick?

The key characteristics, nursing interventions, and importantly, parent education points.

Right.

We're aiming for those practical aha moments, you know, without getting totally bogged down in every single detail.

Okay, sounds good.

Let's dive right in then.

First up, glomerulonephritis.

What exactly is happening in the body here?

So glomerulonephritis, it's basically a group of disorders where the glomerulose, those are the tiny filters inside the kidneys, they get inflamed.

Inflamed.

And that's usually the immune system.

Primarily, yes.

It's usually triggered by the immune system reacting, sometimes a bit too strongly.

Okay, so when that immune reaction happens, what are the direct effects on the kidneys' function?

Well, this immune response causes these proliferative and inflammatory changes right within the glomeruli.

So the filters themselves get damaged.

Exactly.

Think of it like the kidneys' delicate filtering units becoming swollen, damaged.

It can lead to destruction, inflammation, even scarring sclerosis of these glomeruli.

In both kidneys.

In both kidneys, yeah.

And what's pretty interesting is that this often stems from an earlier infection somewhere else in the body setting off an antibody reaction.

So the kidney problems start somewhere else entirely.

Often, yes.

And this damage ultimately messes up the kidney's ability to filter waste like it should.

So something that seems like just a sore throat could actually kick off a reaction that leads to kidney issues weeks later.

Wow.

That really highlights why treating infections properly is so key.

Absolutely.

Even seemingly minor ones.

And what are the usual suspects for that initial infection?

What kicks this off?

The big one, the most common link we see, is a prior group, a hemolytic streptococcal infection.

That's strep throat, right, or skin infection.

Exactly.

Strep throat, certain skin infections, and the timing is interesting too.

There's usually a delay, maybe two to three weeks, between that initial infection, like pharyngitis or tonsillitis, and when the glomerulonephritis symptoms actually show up.

So a history of a recent sore throat is a big clue.

It definitely is.

We also see it linked with other immunological diseases, autoimmune conditions too.

Okay.

And does glomerulonephritis always look the same or does it present differently over time?

Good question.

We generally classify it as either acute or chronic.

Acute being sudden onset.

Right.

Acute tends to pop up relatively quickly, like those two to three weeks after the strep infection we mentioned.

And chronic.

Chronic glomerulonephritis, well that can develop more slowly over time, or it might follow an episode of the acute form.

What kind of serious problems can this lead to if it's not managed well?

Unfortunately, it can lead to some pretty serious stuff.

Kidney failure is a major concern.

Also, hypertensive encephalopathy.

That's high blood pressure affecting the brain.

Exactly.

Which can lead to seizures.

Then there's pulmonary edema fluid in the lungs and even heart failure.

So really significant potential complications.

Yeah.

Now if a child comes in and you suspect glomerulonephritis, what are the key assessment findings, the telltale signs?

There are several key things you'd look for.

Often you'll see periorbital and facial edema that's swelling around the eyes and face.

More noticeable in the morning, you said?

Yeah, usually more pronounced when they wake up.

The child might have anorexia, loss of appetite, and their urine output will probably decrease.

And the urine itself?

It can look cloudy, maybe smoky, sometimes even brownish.

That's hematuria blood in the urine.

You might also notice they look pale.

Irritability, lethargy.

In older kids, they might complain of headaches, maybe some abdominal or flank pain, and dysuria, which is pain when they urinate.

And blood pressure.

Hypertension, high blood pressure is common.

And also proteinuria, too much protein in the urine.

Sometimes you can even see excessive foam because of it.

What about lab tests?

Labs are key.

They'll likely show azotemia that's a buildup of waste products like urea in the blood.

Which can make them feel tired and unwell.

Right, exactly.

Indicated by increased BUN and creatinine levels.

And a really important diagnostic marker, especially for the post -strep type, is an increased antistreptilicin O -titer.

That confirms a recent strep infection.

Got it.

So let's say you have a child with glomerulonephritis, and they're showing signs of fluid volume overload.

What are the absolute priority nursing actions right then and there?

Okay, priority number one is airway.

Make sure it's clear they're breathing okay.

Then you're closely monitoring vital signs and their weight.

Looking for fluid signs.

Yes.

Things like a bounding pulse, maybe distended neck veins or hand veins.

The nurse assists the RN with checking central venous pressure, looking for any heart rhythm issues.

And communication.

Crucial.

Notify the primary healthcare provider, the PHCP, as the RN directs, and help implement treatments.

That often means restricting water and sodium, maybe giving diuretics.

Because the big risk is fluid overload getting worse.

Exactly.

The risk is cardiovascular issues, pulmonary edema.

So really careful monitoring is essential.

Beyond those immediate priorities, what are the general nursing interventions for a child with this condition?

Well, ongoing monitoring is key.

Vitals, daily weight, tracking intake and output, INO, looking at the urine characteristics.

That daily weight needs to be consistent, right?

Super important.

Same time, same scale, similar clothes.

It gives you the best picture of their fluid balance.

Also, limiting their activity, providing safety measures.

What about diet?

Dietary restrictions usually involve sodium, maybe potassium too.

If their urine output is very low, that's oliguria.

And always monitoring for those complications we talked about.

Kidney failure, seizures, etc.

And medications.

Nurses assist with meds, diuretics for the edema, antihypertensives for the high blood pressure, antibiotics if they're still strap lingering.

And seizure risk.

If hypertensive encephalopathy is a concern,

definitely initiate seizure precautions and assist with any anticonvulsants ordered.

And parent education is huge here too, I imagine.

Absolutely.

Teaching parents what to watch for at home, reporting bloody urine, headaches, more swelling.

Emphasizing how important it is to treat infections promptly, especially sore throats, URIs, skin infections.

And reinforcing that daily weight check at home.

It's a key tool for them.

Okay, great.

Let's shift gears now to nephrotic syndrome.

How is this one defined?

Nephrotic syndrome is another kidney disorder, but its signature features are a bit different.

You see massive proteinuria, huge amounts of protein in the urine.

Way more than in glomerulonephritis.

Generally, yes, it's a hallmark.

This leads to hypoalbuminemia, low levels of albumin, a key protein in the blood and significant edema or swelling.

So the goals of treatment are focused on that protein loss and swelling.

Exactly.

The goals are to cut down the protein loss in the urine, get the urine back to being protein -free ideally, reduce that edema, prevent infections, which they're prone to, and minimize other complications.

Why does losing all that protein cause so much swelling?

It's about oncotic pressure.

Albumin in the blood helps keep fluid inside the blood vessels.

When you lose massive amounts of it in the urine, the oncotic pressure drops and fluid shifts out into the tissues, causing that edema.

So what specific signs would make you suspect nephrotic syndrome in a child?

Well, often there's noticeable waking from the fluid, again, cariorbital and facial edema, especially in the morning.

Similar to glomerulonephritis there.

Similar, yes, but often more pronounced in nephrotic syndrome.

They can also get edema in their legs, ankles, sometimes the labial or scrotal area.

Urine output tends to go down and the urine itself looks dark and frothy.

That's the protein again.

Frothy urine, you know.

A sedious fluid in the abdomen can happen too.

Interestingly, their blood pressure is usually normal or maybe even a little low.

That's different from glomerulonephritis.

It is.

Other signs can be lethargy, anorexia, pallor,

and the labs confirm it.

Massive protein area, low serum protein,

hypoalbuminemia, and often high serum lipids, high cholesterol, and triglycerides.

Okay.

So what are the important nursing interventions for a child dealing with nephrotic syndrome?

Again, monitoring is foundational.

Vitals, INO, daily weights.

We also monitor the urine closely for specific gravity and protein levels.

Tracking the protein specifically.

Right, because reducing it is a key goal.

Assessing the edema regularly.

Where is it?

How bad is it?

Nutrition -wise, if they're in remission, usually a regular diet, just no added salt.

But if the edema is bad.

Then definitely sodium restriction and maybe fluid restriction too.

Corticosteroids are a mainstay of treatment, often started right away.

And nurses monitor for side effects.

Yes, especially infection risk because steroids suppress the immune system.

Sometimes immunosuppressants are used too, maybe if they relapse often or don't respond well to steroids alone.

To help get them into remission.

Exactly, or maintain remission.

Diuretics might be used for the edema.

And in really severe cases, plasma expanders like salt -poor albumin might be given IV.

To pull fluid back into the vessels.

Correct.

And parent education is vital.

Teaching them how to do urine protein dipsticks at home, how to give meds, watch for side effects, general care.

And infection prevention.

Huge!

Teach them the signs of infection, stress, avoiding contact with sick people.

Their immune system might be suppressed by the disease itself or the treatment.

Got it.

Let's move to hemolytic uremic syndrome, HUS.

What's thought to cause this one?

HUS is usually associated with bacterial toxins.

E.

coli is a common one, but also certain chemicals or viruses.

These triggers lead to acute kidney injury.

And in effects, younger kids mostly.

Primarily, yes.

Usually infants and small children, say between six months and five years old.

What are the defining clinical features of HUS?

There's a classic triad, acquired hemolytic anemia, meaning red blood cells are being destroyed.

Anemia.

Thrombocytopenia, which is a low platelet count.

Low platelets.

And acute kidney injury.

You might also see some central nervous system symptoms.

So what would the assessment, the data collection show for HUS?

Well, that diagnostic triad, anemia, thrombocytopenia, renal failure.

You'll also probably see proteinuria and hematuria, blood and protein in the urine, maybe urinary casts too.

Indicating kidney damage.

Right.

Blood tests show elevated BUN and creatinine kidney function markers and decreased hemoglobin and hematocrit, reflecting that anemia.

Are there other signs?

Yes.

There can be others.

Vomiting, irritability, lethargy.

They might look really pale, marked pallor.

Hemorrhagic signs like bruising, little red spots called petechiae.

Maybe jaundice, bloody diarrhea even.

Wow.

Quite a range.

Yeah.

And their urine output might drop significantly oliguria or stop completely anuria.

And in severe cases, CNS involvement.

Seizures.

Stupor.

Coma.

What are the crucial interventions then for a child with HUS?

If they develop anuria, dialysis is often needed hemodialysis or peritoneal dialysis to take over the kidney's filtering job.

So managing fluids is critical.

Absolutely critical.

Strict fluid balance monitoring.

Fluid restrictions might be needed if they're anuric.

Infection prevention is paramount.

They're very vulnerable.

Nutrition.

Ensuring adequate nutrition is really important too.

Other treatments might include meds for specific symptoms.

And if the anemia is severe, maybe blood transfusions, but very cautiously to avoid fluid overload.

Let's shift now to something many families deal with.

Enuresis.

Basic definition.

Enuresis is just the inability to control bladder function at an age when you'd normally expect them to or after they've already been toilet trained for a while.

And usually by age five, most kids have control.

Generally, yes.

By around five, most kids are aware of a full bladder and can control voiding.

Okay.

What's the difference between primary nocturnal enuresis and secondary?

Good distinction.

Primary nocturnal enuresis is basically bedwetting in a child who has never really been consistently dry at night for a long stretch.

Is it common?

It's actually very common.

And the good news is most kids just outgrow it without needing any major intervention.

Why does that happen?

It's often thought they just don't fully sense the full bladder while asleep so they don't wake up.

Maybe a slight delay in nervous system maturation.

But it's crucial to rule out any underlying medical cause first.

Right.

And secondary enuresis?

That's when a child who has been dry for a good period, say six months or more, starts wetting again.

This could be at night, during the day, or both.

And you need to investigate that more.

Yes, definitely.

They might complain of things like painful urination, urgency, frequency.

Checking for a urinary tract infection, a UTI, is really important in secondary enuresis.

So for enuresis generally, what data are you collecting?

Primarily, it's the history.

A child over five who is wetting the bed and hasn't had long periods of being dry.

And what are the nursing interventions?

How do you help manage it?

Well, first step might be a urinalysis and culture just to rule out infection or other urinary issues.

Then it's really about working with the family.

Finding a plan that works for them.

Exactly.

Identifying a treatment plan often involves practical steps.

Limiting fluids in the evening, making sure they void right before bed.

What about the child's involvement?

Getting the child involved, maybe helping change wet sheets, can give them a sense of ownership.

Reward systems can be helpful.

Positive reinforcement.

Any other approaches?

Behavioral conditioning, like bed -wetting alarms, can work well for some.

Sometimes medications are considered things like tricyclic antidepressants, antidiuretics, or antispasmodics.

And follow -up is important to see if the plan is working.

Okay.

Let's move to a different kind of structural issue.

Cryptorchidism.

What is that?

Cryptorchidism means hidden testus.

It's when one or both tests haven't descended down from the abdomen through the inguinal canal into the scrotum where they belong.

And how do you detect that on exam?

Pretty straightforward, usually.

During the physical exam, one or both tests just aren't felt in the scrotum, or you can't easily guide them down there.

What's the approach to managing this?

Well, in the first year of life, we often just monitor.

Sometimes they descend on their own.

Watchful waiting.

Exactly.

But if a testus hasn't descended by age one, then treatment, either medical or surgical, is usually considered.

What kind of treatments?

For some older kids, they might try hormonal treatment with HCG human chorionic granatotropin to stimulate testosterone and hopefully encourage descent.

But more often, if it doesn't come down on its own, surgery is needed.

What's the surgery called?

It's called an orchiopexy.

The goal is to surgically bring the testes down into the scrotum and fix it there.

Ideally, this is done before age two, often between one and two years old.

And after surgery?

Post -op monitoring is for bleeding, signs of infection.

Parents need education on home care, preventing infection, managing pain, any activity restrictions.

What about long -term concerns?

It's important to offer counseling about future fertility.

Cryptorchidism can sometimes impact sperm production later on, so parents might have concerns about that.

Right, good point.

Now, epistatias and hypostatias, what are these?

These are congenital defects present at birth involving the penis.

The problem is where the urethral opening, the hole where urine comes out, is located.

It's not in the normal spot at the tip.

And that causes problems.

Yeah, this abnormal placement can make it easier for bacteria to get into the urinary tract and cause infections.

How are they different, epistatias versus hypostatias?

Location.

In epistatias, the opening is on the dorsal surface, the top side of the penis.

It's often seen along with bladder extrophy, which we'll get to.

Top side for epity and hypo.

In hypostatias, the opening is located somewhere below the glands, along the ventral surface, the underside of the penis.

And how are these corrected?

Surgery is the answer.

It's usually done before toilet training age, ideally around 16 to 18 months old.

And there's something important about circumcision, right?

Yes, crucial point.

Circumcision is not done on newborns who have epistatias or hypostatias.

Why not?

Because the surgeon might need to use the foreskin tissue as part of the reconstructive surgery to repair the urethra.

So you need to preserve it.

Makes sense.

What about post -operative care after the repair surgery?

After surgery, they'll likely have a pressure dressing.

Sometimes they need a urinary diversion, like a small catheter or stent, to keep the newly repaired urethra open while it heals.

So monitoring urine output is key.

Absolutely.

Monogravital signs encourage fluids to keep urine flowing and keep the stent, if there is one, patent.

Track INO, check the urine for cloudiness or bad odor signs of infection.

What if there's no urine output?

That's an urgent issue.

If there's no drainage for an hour, you need to notify the RN immediately.

It could be a kink in the stent or tubing or maybe an obstruction.

Okay.

What else for post -op care?

Assisting with pain management, maybe antispasmodic meds, like anticholinergics to prevent bladder spasms, which can be uncomfortable.

Antibiotics are usually given too.

And parent teaching?

Lots of parent teaching needed.

How to care for the diversion or stent, if there is one.

No tub baths until a stent is out, making sure the child drinks enough fluids, giving meds, watching for infection signs, and knowing when to follow up with the provider, usually for dressing removal after about four days.

Okay.

Here's that critical thinking point related to this.

What should the nurse do if an infant has no urinary output for one hour after a hypospadius repair?

Right.

Like we just said, the immediate action is to notify the registered nurse.

That lack of output is a red flag for a potential kink or obstruction, and it needs prompt assessment and intervention.

Got it.

Okay.

Last condition on our list.

Bladder extrophy.

What is this?

Bladder extrophy is another congenital anomaly present at birth.

It's where the urinary bladder is essentially turned inside out and protrudes through a defect in the lower abdominal wall.

So the bladder is visible on the outside?

Yes.

The inner lining, the mucosa is exposed.

We don't really know the exact cause.

It requires staged surgical repair.

Staged, meaning multiple surgeries.

Yes.

The first surgery is usually done very early within the first few days of life to close the bladder and the abdominal wall defect.

Later surgeries aim to reconstruct the bladder and genitals and hopefully achieve urinary continence down the road.

What would you actually see in a newborn with this condition?

The most striking thing is that exposed bladder mucosa.

You'll also often see a widened symphysis cubus, the front pelvic joint, and maybe defects in the external genitalia as well.

What are the key nursing interventions right after birth for a baby with bladder extrophy?

Monitoring urinary output is essential even though it's draining externally.

Watching closely for signs of UTI or wound infection.

And protecting that exposed bladder.

Top priority.

You need to keep the exposed bladder tissue moist and protected until surgery while still allowing urine to drain away.

Immediately after birth, it's typically covered with a sterile non -adherent dressing as prescribed.

Anything to avoid putting on it?

Yes.

Importantly, avoid petroleum jelly.

It seems like it would keep it moist, but it can actually cause drying and damage the delicate tissue.

Good to know.

Other interventions.

Monitoring lab values, urinalysis to check kidney function,

assisting with antibiotics, and a huge part is providing emotional support to the parents.

This is obviously very shocking and frightening for them, so encouraging them to verbalize their fears and concerns is really important.

Absolutely.

So just to recap, we've covered glomerulonephritis, nephrotic syndrome, HUS, enduresis, cryptorchidism, epispadias, hypospadias, and bladder extrophy.

That covers the main conditions in this chapter, right?

Yes, that's correct.

We've hit the descriptions, causes, types, complications, key assessment points, and the crucial nursing interventions for each one.

Okay, that wraps up our deep dive into pediatric, renal, and urinary disorders.

We covered a lot of ground today.

Really important information.

It definitely underscores how vital it is to understand these conditions for recognizing and managing them effectively in kids.

I think the key takeaway for you listening is hopefully gaining that foundational understanding of this diverse group of disorders, their unique features, and those essential nursing considerations needed to provide really good care.

And maybe a final thought to leave you with.

Consider how early recognition, that awareness by parents and caregivers of even subtle signs and symptoms, can make such a huge difference in managing these conditions and improving the outcomes for these children.

Yeah, absolutely.

Perhaps this chat sparked your interest in exploring one of these conditions further, or thinking about how they might present a bit differently, depending on the child's age.

Thanks for joining us for this deep dive.