4. Acute renal failure
1. Definition: sudden, severe loss of function of kidneys, usually reversible
2. Etiologies:
1. dehydration
2. underlying conditions
3. burns
4. obstruction
5. infection
3. Pathophysiology
1. severe reduction in glomerular rate
2. an elevated BUN
3. decreased tubular reabsorption of sodium from the proximal tubule
4. increase in sodium in distal tubules stimulated renin mechanism
5. decrease renal blood flow
6. cortical and tubular necrosis
4. Findings
1. usually related to imbalances in fluids and electrolytes
2. often nonspecific (edema, hypertension, decreased feeding, anorexia, lethargy, pallor, seizures)
3. oliguria
5. Diagnostics
1. history
2. I & O
3. laboratory testing
4. radiographic (ultrasound, renal scan)
6. Management
1. treatment directed at:
1. correcting underlying cause
2. managing complications
3. supportive therapy
2. acute: fluids, electrolytes, dialysis (peritoneal, hemodialysis), antihypertensives, diuretics
7. Concerns: fluid status, acute and chronic renal damage, infection, cardiac failure
   
5. Chronic renal failure (CRF)
1. Definition: progressive deterioration of kidneys so that they can no longer maintain normal chemical structure of body fluids under normal conditions
2. Etiology: immunological injury, congenital anomalies, underlying disease/condition
3. Pathophysiology: irreversible and permanent
1. progressive nephron destruction
2. distribution throughout nephron - uremia (urea in blood)
3. final stage: end-stage renal disease (ESRD) is irreversible
4. Findings
1. failure to thrive, anorexia, nausea and vomiting
2. fluid and electrolyte imbalances
3. hypertension, uremia, anemia, bleeding tendencies
4. increased fatigue on exertion
5. skin: sallow, muddy appearance
5. Diagnostics: history, physical exam, laboratory testing, radiographic studies
6. Management
1. dialysis
2. kidney transplant
3. diet: modified (decreased sodium, potassium, phosphorus, protein; fluid restriction, high calcium)
4. medications: antihypertensives, diuretics, erythropoietin, growth hormone, immunosuppressants (post transplant)
5. monitor status (for example, laboratory reports)
6. give psychological support
7. Concerns: bone demineralization, anemia, failure to thrive, retention of wastes; transplant concerns: kidney rejection and immunosuppression
   

Genitalia Problems

10. Cryptorchidism
1. Definition: failure of one or both testes to descend normally through inguinal canal into scrotum
2. Etiology/pathophysiology
1. abnormal testes, or
2. decrease in the hormonal stimulation necessary for descent
3. Management: wait up to one year for descent, medications (HCG) to assist in descent, or surgery (orchiopexy).
   
11. Hypospadius
1. Definition: urethral meatus below normal placement on glans penis or anywhere along ventral (underside) surface of penile shaft
2. Etiology: idiopathic - related to genetics, environment, hormonal
3. Pathophysiology: incomplete development in utero
4. Management: surgical correction (with urinary catheter and stents post-op), post-op pressure dressing must not be removed by anyone other than the health care provider
5. Concerns: stenosis, chordee, body image/self esteem
   
12. Bladder exstrophy
1. Definition: externalization of bladder, splaying at the urethra with failure of tubular formation and diastasis of pelvic bone
2. Etiology: congenital - associated with genital abnormalities
3. Pathophysiology
1. failure of abdominal wall and underlying structures, including the ventral wall of the bladder, to fuse in utero
2. bladder develops outside
3. the earlier in gestation, the more severe the defect.
4. defect almost always associated with epispadias
4. Management:
1. treament objectives:
1. preservation of renal function
2. attainment of urinary control
3. adequate reconstructive repair
4. preservation of optimum sexual function
2. pre-op:
1. prevent organs from drying out, fluids, infection control
2. surgery: staged procedure
3. post-op (antibiotics, compression bandage, bed rest)
5. Concerns: urinary incontinence, VUR, infection
   
13. Ambiguous genitalia
1. Etiology: abnormalities in chromosomal complement, embryogenesis, or hormones
2. Pathophysiology: interruption in normal development around seven to eight weeks gestation, when normally male begins differentiating from female
3. Diagnostics: history, physical exam, tests to determine gender (endoscopy, ultrasound, radiographic contract), genetics lab test, laparotomy, biopsy
4. Concerns: body image/self esteem, family support
   
1. Pediatric Musculoskeletal System (illustration 1  illustration2)

Differences

1. Children's musculoskeletal differences
1. Bones are more pliable and porous; bend, buckle, absorb shock
2. Tendons and ligaments are more flexible
3. Bones produce callus that speeds healing
4. Thicker periosteum, so stronger and more active osteogenesis.
5. Skull is pliable during infancy; anterior fontanel fuses at 18 months; posterior fontanel fuses at two months
6. Skeletal maturation completes when epiphysisfuses with diaphysis, which is usually 18 to 21 years of age
   
2. Immobilization in children
1. Affects multiple systems
1. muscular, GI, GU, pulmonary, cardiovascular, integumentary
2. psychologic, behavioral, economic
2. Affects normal growth and development
3. Pathologic changes most occur due to
1. decreased muscle strength and mass, decreased metabolism
2. possible bone demineralization
3. decreased range of motion and decreased joint movement
4. Concerns:
1. hydration
2. dietary modification
3. activity as condition permits
4. self care as condition permits