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