Repeated involuntary voiding or incontinence by a

child past the age of toilet training.

about 5-6 years of age

EnuresisMultitreatment Approach

Fluid Restriction Bladder exercises Timed voiding Enuresis alarms Reward system Medications

Test Yourself

• Which of the following organisms is the most common cause of UTI in children?

a. staphylococcusb. klebsiellac. pseudomonasd. escherichia coli

All are causative agents, Escherichia coli is the more common cause of first time UTI’s.

Urinary Tract Infections

• Etiology and Pathophysiology– Tend to occur more in girls than in boys

because the urethra is shorter in girls and is located close to the vagina and anus.

– Pathogens enter as an ascending infection

– Most common causative organism is Escherichia coli

Assessment

• Typical symptoms of older children and adults – dysuria, frequency, urgency, burning,hematuria – may not be present.

• Symptoms not always clear– Fever– Mild abdominal pain– Bedwetting (enuresis)– If gets worse – high fever, flank pain,

vomiting, malaise

Diagnostic Tests

• Urine for culture and sensitivity– Clean catch– Suprapubic aspiration– Catheterization

• A Positive Test– Bacteria colony count is more than

100.000/ml.– Proteinuria may also be present indicating

presence of bacteria.

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

Therapeutic Interventions

• Parent Teaching– Change diaper frequently– Teach girls to wipe front to back– Discourage bubble baths– Encourage children to drink periodically

during the day– Bathe daily– Adolescent start menstruating – encourage

change of pad every 4 hours– When girls become sexually active – teach

to urinate immediately after intercourse

Evaluation

• Follow up– Return for repeat urinalysis – usually after

72 hours of treatment to be sure treatment is working

– Girls who have more than three UTI’s, and boys with first UTI should be referred to urologist for further evaluation.

Common Sites for Obstruction

• Stenosis of ureteropelvic valve

• Stenosis of ureterovescicular junction

• Stenosis of the posterior urethral valve

Vesicoureteral 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.

Clinical Manifestations

1. Fever

2. Vomiting

3. Chills

4. Straining or crying on urination, poor urine stream,

5. Enuresis (bedwetting), incontinence in a toilet trained child, frequent urination.

6. Strong smelling urine

7. Abdominal or back/flank pain

Diagnostic Tests

1. Urine culture – done every 2-3 months

2. cystourethrogram

3. renal ultrasound - a non-invasive test in which a transducer is passed over the kidney producing sound waves which bounce off the kidney, transmitting a picture of the organ on a video screen. The test is used to determine the size and shape of the kidney, and to detect a mass, kidney stone, cyst, or other obstruction or abnormalities.

Therapeutic Interventions

• Drug Therapy– Antibiotics

• Penicillin• Cephalosporins

– Urinary Antiseptics• Nitrofurantoin

• Surgery– Repair of significant anatomical

anomalies, uretheral implantation

Nursing Care following surgery• Keep accurate record of intake and output. Keep

records from stents and catheter separate. Decreased output from stent could indicate obstruction.

• Secure stents and catheter to prevent displacement.• Assess vital signs for signs of infection.• Assess pain. Handle child gently Administer pain

medications• Patient Teaching - regarding prevention of UTI, - importance of taking all antibiotics, continue

taking antiseptics even when have no symptoms.

Evaluation

• Follow-up

– Go in for a VCUG (voiding cystourethrogram) after a few months

CryptorchidismHypospadius / Epispadius

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 month 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

Answer:

• The higher temperatures in the abdomen than in the scrotum results in morphologic changes to the testis – mainly concerned with lower sperm counts at sexual maturity.

Assessment

Palpate the testes separately between thumb and forefinger, with thumb and forefinger of other

hand over the inguinal canal.

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.

• Hypospadias– Congenital urethral defect in which the uretheral opening is on the lower aspect of the penis and not on the tip.

• Epispadias– Congenital urethral defect in which

the uretheral opening is on the upper aspect of the penis and not on the end

Etiology and Pathophysiology• Epispadias – rare and often associated with

extrophy of bladder.• Hypospadias

– Occurs from incomplete development of urethra in utero.– Occurs in 1 of 100 male children. Increased risk if father

or siblings have defect. – Defect ranges from mild (meatus is just below tip); to

meatus on the perineum between scrotum, ventral foreskin lacking

– May have accompanying chordee (a fibrous band that causes the penis to curve downward),

– Undescended testes – found in conjunction with hypospadias

– Might interfere with fertility in the mature male if not corrected.

Assessment

Usually discovered during Newborn Physical Assessment

• Why would the nurse question an order to prepare the infant for a circumcision?

Ask Yourself?

Answer:

• The nurse would question the order for a circumcision because the foreskin is used in reconstruction and repair of the defect.

• What is the relation of epispadius or hypospadius to

infertility?

Answer:

• If the urethral opening is not at the end of the penis, then the male will not be able to deposit his sperm at the opening of the os of the cervix.

Interventions

• Medical Treatment:– Surgery

•Reconstructive – repositions uretheral opening at tip of penis

•Stent placed in urethra to maintain patency

•Chordee – released and urethra lengthened.

• The reason for surgery at about 1 year of age is because:

a. children will experience less painb. chordee may be reabsorbedc. the child has not developed body image and castration anxietyd. the repair is easier before toilet training

C= answer

Post –op Nursing Care 1. Assess bleeding - Bleeding is controlled post-

operatively by the use of pressure dressings. However, a small amount of bleeding for the first several days post-operatively is normal. A few drops of blood or a spot no larger than a quarter on the diaper is acceptable.

2. Maintain urinary drainage – care for catheter – foley / suprapubic, or urethral stent. Use double diapering.

A double diapering technique protects the urinary stent after surgery. The inner diaper collects stool and the

outer diaper collects urine.

3. Control Bladder Spasms - usually due to the presence of the in-dwelling catheters are common post-operatively and are controlled by medications that relax the bladder (ie. Antispasmotics- Pro-Banthine and Ditropan)

4. Control Pain – may be given Tylenol5. Increase fluids intake – assists in maintaining hydration and free flow of urine.6. Do not allow to play on any straddle toys.7. Prevent infection – no bathing or swimming until stents removed.8. Call Dr if:

– temp is over 101– loss of appetite– pus or increased bleeding from stent– cloudy or foul smelling urine

Acute PostinfectiousGlomerulonephritis

Immune-complex disease which causes inflammation

of the glomeruli of the kidney as a result of an

infection elsewhere in the body.

Etiology and 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.

Acute Glomerulonephritis

• Decreased glomerular filtration leads to accumulation of sodium and water in bloodstream causing increased intravascular and interstitial fluid volume, or edema

• Protein molecules filter through the damaged glomeruli – proteinuria

• Damage to glomeruli leads to hematuria.• High B/P, Heart failure may result• Common in boy 5-10 years old. Occurs 1-2

weeks after a Strep respiratory infection or after impetigo.

• Has 2 phases – Edematous phase – 4-10 days– Diuresis phase

Assessment1. Renal:

a. Moderate Proteinuria

b. Sudden onset of hematuria (tea-colored, reddish-brown, or smoky) and next develops oliguria

c. Excessive foaming of urine

2. Cardiovascular:• a.  Edema-usually eyes, hands, feet, not generalized• b.  Hypertension from hypervolemia which can lead to• c.  Cardiac involvement CHF- orthopnea / dyspnea, • cardiac enlargement, pulmonary edema

3.Neuro

a. Encephalopathy (headache, irritability,

convulsions, coma-from cerebral edema)

Test Yourself

• A 6 year old is admitted with R/O AGN. Which of the following symptoms would the child most likely have?a. normal blood pressure, diarrheab. periorbital edema, grossly bloody

urinec. severe, generalized edema, ascitesd. severe flank pain, vomiting

Diagnostic Tests

Urinalysis- protein (moderate), RBC's, WBC's, Specific Gravity elevated.

*All children should have a urinalysis 2 wks after strep infection.

Blood- • 1)     ASO titer (antistreptolysin O) (antibody formation

against Streptococcus) is elevated, indicating a recent hemolytic streptococcal infection Normal titer is 170-330 Todd units; IgG antibodies against Streptococcus may be found

• 2)     ESR (erythrocyte sedimentation rate) elevated showing inflammatory process

• 3)     BUN(urea nitrogen)& creatinine elevated indicating glomeruli damage

Therapeutic Interventions

1. Depends on the severity of the disease. No

specific treatment. Bedrest encouraged. Disease

is self-limiting!

2. Treat at home if normal BP & adequate output.

3. Must be hospitalized if: – BP increases– gross hematuria– oliguria present.

• This way the child can be monitored closely and prevent complications. Rarely develops into acute renal failure

Main Goals: Relieve Hypertension

Reestablish fluid and electrolyte balance by:

• Keep accurate record of I&O. Be sure that child does not exceed maximum intake ordered. • Record characteristics of urine output including presence of proteinuria and hematuria.• Check and record specific gravity with each

voiding• Monitor vital signs and neuro vital signs• Monitor and record amount of edema at least

once a shift.

• Daily weights• Bedrest for 4-10 days during acute phase.

Semi-fowlers position to assist with breathing. Quiet play.

• Oxygen therpay• Diet therapy

• Limit salt intake with hypertension or edema

• Limit protein if BUN elevated• Decrease intake of Potassium if output

decreased• Drug therapy

• Antibiotics• Digitalization• Antihypertensives- vasodilators

Critical Thinking

• With a diagnosis of AGN, which of these nursing diagnoses should receive priority?a. fluid volume excessb. risk for impaired skin integrityc. risk for injuryd. activity intolerance

Critical Thinking

When teaching parents about knownantecedent infections in acuteglomerulonephritis, which of the

followingshould the nurse cover?

A. Herpes simplexB. ScabiesC. VaricellaD. Impetigo

Nephrotic Syndrome Nephrotic Syndrome

Chronic renal disorder in which the basement membrane surfaces of the glomeruli are affected, causing loss of protein in the urine.

The glomeruli membrane has increased permeability permitting albumin and protein to pass through the membrane and excreted in the urine.

Note the contrast between the normal glomerular anatomy and the changes that exist in nephrotic syndrome permitting protein to be excreted in the urine.

Clinical ManifestationsFour most common characteristics:

1. Edema - May have periorbital edema upon rising in morning and shifts

during the day. 2. Massive proteinuria and hypoproteinemia

3. Hypoalbuminemia

4. Hyperlipidemia

Other signs and symptoms

• Fatigue

• Anorexia

• weight gain

• Abdominal pain – from large amount of fluid in abdominal

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 appetitie, proteinuria, edemad. body image change, hypotension

Answer = C

Diagnostic Tests

• 1. Urinalysis – protein-to-creatitine (PR/CR) ratio of

first morning void to assess for proteinuria. Urine

appears dark and frothy.

• 2. Blood tests – hypoalbuminemia, elevated

cholesterol and triglycerides, elevated hgb, hct,

platelets

Try this

• Prednisone is the primary drug used in treating NS. What are the side effects and nursing implications?

• What teaching should the nurse include with respect to this medication?

Answers:

• Nursing Implications related to Prednisone therapy

• See Drug Guide on p. 1057.

Complications

• Children with Nephrotic Syndrome are prone to infection related to:– Loss of immunoglobins in the urine

– Corticosteroid Therapy

Therapeutic Interventions1. Administer medications – assess for side effects

– Prednisone, Albumin, Diuretics

2. Prevention of infection – avoid people with infections. May be placed on protective isolation. 3. Keep accurate record of I&O. Measure abdominal

girth, weigh daily.4.  Test urine for protein and specific gravity to see if

treatment is effective5.  Diet:

– Normal diet for child’s age– A “no added salt” diet is recommended during

steroid treatment. 6. Promote rest7. Discharge teaching