Nursing Care of the Child Nursing Care of the Child with GU disorderswith GU disorders
Summer 2009Summer 2009Lea Melvin, MSN, RN, CRRN, CWOCNLea Melvin, MSN, RN, CRRN, CWOCN
Austin Community CollegeAustin Community College
Radiography and other Radiography and other tests of urinary system tests of urinary system
functionfunctionUrine Urine culture & culture & sensitivitysensitivity
Renal/Renal/
bladder USbladder US
VCUGVCUG Imaging Imaging studiesstudies
Testicular Testicular USUS
Scout filmScout film
IVPIVP Renal bx, Renal bx, cystocysto
Whitaker perfusion testWhitaker perfusion test
Physical tests for Gu Physical tests for Gu functionfunction
• Volume for polyuria, oliguriaVolume for polyuria, oliguria• Specific gravitySpecific gravity• OsmolalityOsmolality• AppearanceAppearance• Chemistries on urine (Chemistries on urine (√ for blood, √ for blood,
WBCs, bacteria, casts)WBCs, bacteria, casts)
Blood tests of renal Blood tests of renal functionfunction
• BUN (blood urea nitrogen)BUN (blood urea nitrogen)• Uric acidUric acid• CreatinineCreatinine
Nursing responsibilities Nursing responsibilities with testingwith testing
• Responsible for preparation and Responsible for preparation and collection of urine or bloodcollection of urine or blood
• Maintains careful intake and Maintains careful intake and outputoutput
• Recognizes that renal disease can Recognizes that renal disease can diminish the glomerular filtration diminish the glomerular filtration raterate
External Defects
Extrophy of the BladderHypospadius / Epispadius
Cryptochidism
• Epispadias– Congenital urethral defect in which
the uretheral opening is on the upper aspect of the penis and not on the end
• Hypospadias– Congenital urethral defect in which the uretheral opening is on the lower aspect of the penis and not on the tip. May have associated
chordee.
Hypospadius
• Occurs from incomplete development of urethra in utero.
• Occurs in 1 of 100 male children. Increased risk if father or siblings have defect.
• Ranges from mild to severe. • Cyrptorchidism/Undescended testes may be found in
conjunction with hypospadias.
Assessment
Usually discovered during Newborn Physical Assessment
Interventions
• Medical Treatment:– Do NOT circumcise infant. May need to
use foreskin in reconstruction.
• Surgery– Reconstructive – repositions uretheral
opening at tip of penis– Chordee – released and urethra
lengthened.
• The reason for surgery at about 1 year of age is because:a. children will experience less pain.b. chordee may be reabsorbed.c. the child has not developed body
image and castration anxiety.d. the repair is easier before toilet
training.
Post –op Nursing Care 1. Assess pressure dressing (use to control
bleeding. 2. Maintain urinary drainage. 3. Control bladder spasms.
Antispasmotics (relax the bladder muscle)Pro-Banthine (probantheline)Ditropan (oxybutinin)Levsin (hyoscyamine)
A double diapering technique protects the urinary stent after surgery. The inner diaper collects stool and the
outer diaper collects urine.
4. Control Pain.5. Increase fluids intake. 6. Do not allow to play on any straddle toys.7. Prevent infection. – no bathing or swimming
until stents removed.8. Discharge teaching:
When to call doctor.No bathing or swimming until stents
removed.
Cryptorchidism
Failure of one or both of the testes to descend from abdominal cavity
to the scrotum
Etiology and Pathophysiology
• Testes usually descend into the scrotal sac during the 7-9 gestation
• They may descend anytime up to 6 weeks after birth. Rarely descend after that time.
• Cause unknown• Theories
– Inadequate length of spermatic vessels – Lowered testosterone levels
Assessment
Therapeutic Interventions
• Surgery – Orchiopexy done via laproscopy– Done around 1 year of age
• Nursing Care – Post-op– Minimal activity for few day to ensure that the
internal sutures remain intact– Allow opportunity to express fears about
mutilation or castration by playing with puppets or dolls.
Why is early surgery important?
• Morphologic changes to testis from higher temperature in abd cavity
• Decreased sperm count=infertility?
• Testicular cancer
Obstructive Uropathy
Vesicoureteral refluxPosterior urethral valves
Ureteropelvic junction defect
Vesicoureteral Reflux
Abnormal backflow (retrograde) of urine from the bladder into the ureters and possibly kidneys when the bladder contracts during emptying/voiding.
What is vesicoureteral What is vesicoureteral reflux?reflux?
Pathophysiology• Reflux occurs because the valve that guards
the entrance from the bladder to the ureter is defective from:– Primary reflux – congenital abnormal
insertion of ureters into the bladder– Secondary reflux – repeated UTI’s cause
scarring of valve– Bladder pressure that is stronger than usual,
neurogenic bladder• Backflow happens at voiding when bladder
contracts, urine is swept up the ureters• Results in stasis of urine in ureters or kidneys
which in turn leads to infection or hydronephrosis.
Vesicoureteral RefluxVesicoureteral RefluxGrades I through VGrades I through V
Assessment
1. Fever, chills2. Vomiting3. Straining/crying on urination, poor urine
stream4. Enuresis (bedwetting), incontinence in a
toilet trained child, frequent urination.5. Strong smelling urine6. Abdominal or back/flank pain
Vesicoureteral RefluxVesicoureteral Reflux• Approximately 20% of children that Approximately 20% of children that
have UTIs will be found to have have UTIs will be found to have vesicoureteral reflux on xrayvesicoureteral reflux on xray
Diagnostic Tests1. Urine culture
2. Cystourethrogram
(VCUG)3. Renal ultrasound
(RUS)
Therapeutic Interventions
• Drug Therapy– Antibiotics
• Penicillin• Cephalosporins
– Urinary Antiseptics• Nitrofurantoin
• Surgery– Repair of significant anatomical
anomalies, uretheral implantation
Goals of treatment Goals of treatment
• Directed toward preventing UTIsDirected toward preventing UTIs• Managed by time or surgery if grade Managed by time or surgery if grade
4 or 54 or 5• Single doses each day of abx as long Single doses each day of abx as long
as reflux lastsas reflux lasts• Urine cultures done q 6 wks –3 mos Urine cultures done q 6 wks –3 mos
Nursing Care• I&O - Keep records from stents and catheter
separate. • Secure stents and catheter to prevent
displacement.• Vital signs for signs of infection.• Control pain. • Discharge Teaching - prevention of UTI - importance of taking all antibiotics
- continue taking antiseptics even when have no symptoms.
Evaluation
• Follow-up = VCUG in 3-4 months• Renal SPECTRenal SPECT• RCG (radionucleaotide cystogram)RCG (radionucleaotide cystogram)
Test Yourself
• Which of the following organisms is the most common cause of UTI in children?a. staphylococcusb. klebsiellac. pseudomonasd. escherichia coli
Urinary Tract Infections
Urinary tract infectionsUrinary tract infections• Most common type of bacterial Most common type of bacterial
infections occurring in childreninfections occurring in children• Bacteria passes up the urethra Bacteria passes up the urethra
into the bladderinto the bladder• Most common types of bacteria Most common types of bacteria
are those near the meatus…staph are those near the meatus…staph as well as e.colias well as e.coli
Contributing factorsContributing factors
• Those with lower resistance, Those with lower resistance, particularly those with recurrent particularly those with recurrent infectionsinfections
• Unusual voiding and bowel habits may Unusual voiding and bowel habits may contribute to UTI in childrencontribute to UTI in children
• ““forget to go to bathroom”forget to go to bathroom”• Symptoms vary by age of childSymptoms vary by age of child
Therapeutic Therapeutic managementmanagement
• Eliminate the current infectionsEliminate the current infections• Identify contributing factors to Identify contributing factors to
reduce the risk of re-infectionreduce the risk of re-infection• Prevent systemic spread of the Prevent systemic spread of the
infectioninfection• Preserve renal functionPreserve renal function
Therapeutic Interventions
• Drug Therapy– Antibiotics – specific to causative
organism– Analgesics – Tylenol
• Nursing Care– Force fluids – childs choice– Dysuria – sit in warm water in bathtub
and void into the water
Parent Teaching
Change diaper frequentlyTeach girls to wipe front to backDiscourage bubble bathsEncourage fluids frequently throughout dayBathe dailyAdolescent girls when menstruating are to
change of pad every 4 hoursTeach to void immediately after intercourse
FYIFYI• The single most important host The single most important host
factor influencing the occurrence factor influencing the occurrence of UTI is urinary stasisof UTI is urinary stasis
• What is the chief cause of urinary What is the chief cause of urinary stasis?stasis?
Glomerular diseasesGlomerular diseases
• Acute glomerulonephritis (AGN)Acute glomerulonephritis (AGN)• Nephrotic syndrome (MCNS) or Nephrotic syndrome (MCNS) or
minimal-change nephrotic syndromeminimal-change nephrotic syndrome
Nephrotic SyndromeNephrotic Syndrome
Chronic renal disorder in which the basement membrane surfaces
of the glomeruli are affected, cause loss of protein in the urine.
Nephrotic syndromeNephrotic syndrome
Nephrotic syndrome, Nephrotic syndrome, contcont
Contrast of normal gloumerular activity with changes seen in Nephrotic Syndrome
Etiology
• Insidious onset with periods of remission / exacerbations throughout life- No cure
• 95% idiopathic, possibly a hypersensitivity reaction.
• Other causes: post acute glomerulonephritis, sickle cell disease, Diabetes Mellitus, or drug toxicity.
• Usually seen in preschool yrs (2-4). M>F
AssessmentFour most common characteristics:
1. Massive proteinuria
2. Hypoalbuminemia (K+ normal, BP normal)
3. Edema – usually starts in periorbital area and dependent areas of the body and progresses to generalized, massive edema. Pitting edema of 4+. Caused by hypo albumin which causes shift of fluids to extracellular space. *There is an insidious weight gain- shoes don't fit, etc
4. Hyperlipidemia
* Of note is that there is no
hematuria or hypertension
Other signs and symptoms
Fatigue
Anorexia
Weight gain
Abdominal pain – from large amount of fluid in abdominal
Treatment of nephrotic Treatment of nephrotic syndromesyndrome
• Varies with degree of severityVaries with degree of severity• Treatment of the underlying causeTreatment of the underlying cause• Prognosis depends on the causePrognosis depends on the cause• Children usually have the “minimal Children usually have the “minimal
change syndrome” which responds change syndrome” which responds well to treatmentwell to treatment
Ask Yourself?
• Which of the following signs and symptoms are characteristic of minimal change nephrotic syndrome?a. gross hematuria, proteinuria, feverb. hypertension, edema, fatiguec. poor appetite, proteinuria, edemad. body image change, hypotension
Acute Glomerulonephritis
Immune-complex disease which causes inflammation
of the glomeruli of the kidney as a result of an
infection elsewhere in the body.
Acute Glomerulonephritis
Etiology/Pathophysiology
• Usual organism is Group A beta-hemolytic streptococcus
• Organism not found in kidney, but the antigen-antibody complexes become trapped in the membrane of the glomeruli causing inflammation, obstruction and edema in kidney
• The glomeruli become inflamed and scarred, and slowly lose their ability to remove wastes and excess water from the blood to make urine.
AGNAGN• Treatment and nursing care:Treatment and nursing care:• Bed rest may be recommended Bed rest may be recommended
during the acute phase of the during the acute phase of the diseasedisease
• A record of daily weight is the A record of daily weight is the most useful means for assessing most useful means for assessing fluid balancefluid balance
Nursing care specific to Nursing care specific to the child with AGNthe child with AGN
• Allow activities that do not expend Allow activities that do not expend energyenergy
• Diet should not have any added saltDiet should not have any added salt• Fluid restriction, if prescribedFluid restriction, if prescribed• Monitor weightsMonitor weights• Education of the parentsEducation of the parents
Therapeutic Therapeutic managementmanagement
• Corticosteroids (prednisone)Corticosteroids (prednisone)• Dietary managementDietary management• Restriction of fluid intakeRestriction of fluid intake• Prevention of infectionsPrevention of infections• Monitoring for complications: Monitoring for complications:
infections, severe GI upset, ascites, infections, severe GI upset, ascites, or respiratory distressor respiratory distress
Nursing diagnosis for the Nursing diagnosis for the child with child with
glomerulonephritisglomerulonephritis• Fluid volume excess r/t to decreased Fluid volume excess r/t to decreased
plasma filtrationplasma filtration• Activity intolerance r/t fatigueActivity intolerance r/t fatigue• Altered patterns of urinary elimination Altered patterns of urinary elimination
r/t fluid retention and impaired filtrationr/t fluid retention and impaired filtration• Altered family process r/t child with Altered family process r/t child with
chronic disease, hospitalizationschronic disease, hospitalizations
Take a Break
Surgical procedures• Vesicostomy• Ureterostomy• Mitrafanoff catheterizable stoma• Malone Antegrade Colonic Enema
stoma (MACE or ACE)
Post-op nursing care• Care of stoma• Skin protection• Care of stents, tubes, drains• Signs and symptoms of problems
Mitrafanoffappendiceal stoma
• Creation of catheterizable channel from skin to bladder
• Channel is created from reversed appendix that is attached to bladder that has usually been augmented (made bigger). End of appendix brought to skin has nipple valve created and is usually place in the umbilicus.
Post-op care for Mitrofanoff
• Stoma with stents and catheter protruding from it.
• Keep skin clean, dry and protected.• Discharged home with stents and
catheter in place.• Teach care, prevention of infection,
when to call, return visit.
Teaching for Mitranoffusually done as
outpatient• Clean intermittent catheterization
using long vinyl coude tipped catheter, usually a size 12
• Must catheterize or will go into renal failure
• Bladder neck is either closed or suspended to prevent leakage
Malone Antegrade Colonic Enema
• Creation of catheterizable channel from ascending colon to skin of abdomen for purpose of giving colonic irrigation every other day
• Renders the child bowel continent• Channel is fashioned from piece of
small intestine and brought to skin in nipple valve
Post-op care for MACE• Stoma with catheter protruding
from it.• Keep skin clean, dry and protected.• Discharged home with catheter in
place.• Teach care, prevention of infection,
when to call, return visit.
Teaching for MACE• Must irrigate every other day to
maintain continence• Use mild enema solution• Maintain schedule for frequency• Allow time for evacuation
Nursing assessment• Ask child where stomas are and
which one is which• Allow child to do procedure as at
home with usual ritual• Must be done even if child is ill
with unrelated disorder
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