Care of the Pediatric Patient with Elimination Problems Elizabeth Allen RN, MSN

Identify anatomic and physiologic differences between the adult & pediatric renal system Describe pathologic conditions of the renal system in the pediatric patient Discuss treatment, testing and specimen collection for a UTI in a pediatric patient Learning Objectives

Anatomic and Physiologic Differences Kidneys less efficient until 2 years Kidney grow most in first 5 years Bladder capacity increases with age Bladder capacity age + 2 in oz. Bladder control >2 years due to nerve development Low set ears associated with urinary tract abnormalities Anatomic and Physiologic Differences

Renal Gomerulonephritis Acute Post-infectious Gomerulonephritis Most often results from Strep infection on skin (impetigo) or throat Also from staphylococcus, Pneumococcus and Coxsackie Develops 10-21 days post infection Most common 2-6 years Renal

Renal Gomerulonephritis Immune complex Reaction Antigen-Antibody complexes lodge in glomeruli Inflammation and Obstruction Increased permeability to RBCs & Protein Decreased ability to filter wastes, regulate fluid balance Renal

Renal Glomerulonephritis Symptoms Hematuria Mild to Moderate Proteinuria Elevated BUN, Creatinine Fever Flank or midabdominal Pain Edema- periorbital and dependent Acute HTN- possible encephalopathy and headache from HTN Hypertension is defined by a reading that is >95th percentile for children of the same gender, age and height. There isn't a simple target blood pressure reading that indicates high blood pressure in all ages for children, because what's considered normal blood pressure changes as children grow. In children 12-17 years reading >90th percentile or greater than 120/80 indicate prehypertension Renal

Renal- Definition of HTN Hypertension: defined by percentiles for Age & Height per National Heart Lung and Blood Institute Hypertension is defined as a reading >95th percentile for children of similar gender, age and height http://www.nhlbi.nih.gov/files/docs/guidelines/child_tbl.pdf Renal- Definition of HTN

Renal Glomerulonephritis Treatment Acute Phase Risk for infection Risk for skin breakdown Fluid and electrolyte correction Monitor urine output Fluid restriction Low protein, low sodium diet Treat HTN, pain Antibiotic for infection Dialysis as needed Resolves 3 weeks or longer Renal

Renal Nephrotic Syndrome Clinical State: Increased protein permeability in glomeruli 85% have Minimal Change Nephrotic Syndrome (MCNS) Congenital Primary (i.e. glomerulonephritis) Secondary (disease, drugs, toxins) Increased protein permeability in the glomeruli- allows proteins from blood to leak into urine Not a specific disease but a syndrome: a clinical state characterized by edema, massive proteinuria, hypoalbuminemia, hypoproteinemia, hyperlipidemia and altered immunity Congenital, primary- results from a disease that affects only the kidney (ex glomerulonephritis), secondary- things that alter kidney function Renal

Renal Nephrotic Syndrome Signs Edema Massive Proteinuria- frothy urine! Altered immunity Hyperlipidemia Hypoalbuminemia, hypoproteinemia Hypercoagulability Altered immunity because of lost immunoglobulins & steroid treatment Hyperlipidemia- liver secretes more lipoprotein Hypercoagulability bc of alterations in coagulation factors Renal

Renal Nephrotic Syndrome Treatment Corticosteroid Risk for Skin Breakdown Risk for Infection Treat Pain IV Albumin and Furosemide to reduce edema Corticosteroid like prednisone to decrease protein loss in urine. Usu responds in 2-3 weeks Renal

National Kidney and Urologic Diseases Information Clearinghouse (NKUDIC) Resource for Nephrotic Syndrome http://kidney.niddk.nih.gov/KUDiseases/pubs/childkidneydiseases/nephrotic_syndrom/#sec8 Renal

Renal Polycystic Kidney Disease Genetic Disorder Autosomal dominant and recessive Cysts form in collecting ducts- become larger as child grows Cysts replace kidney mass and reduce function Cysts also develop in liver Renal

Autosomal Dominant Autosomal Recessive 90% of PKD Symptoms usually develop age 30-40, can begin in childhood Symptoms of Renal Failure Rare Symptoms start perinatally to 1 year Low set ears, small jaw, flat nose Symptoms HTN UTIs Oliguria Respiratory Distress Developmental Delay Liver problems Treatment is supportive Treatment with diuretics, nutrition support, dialysis and kidney transplant Renal

Renal Wilm’s Tumor (Nephroblastoma) Most often 2-3 years Palpable mass on 1 side or other abdomen Fast growing- doubles in size in 11-13 days Staging of tumor Preoperatively, do not palpate after diagnosis Do not know what stage/lymph involvement Staging similar to other cancers- 1 is contained to kidney and removed completely, 2 abdomen and removed completely, 3 confined to abdomen, 4 bilateral renal involvement at diagnosis Renal

Renal Wilm’s Tumor Treatment Nephrectomy- involved kidney only Post op care of patient Chemotherapy or Radiation as needed for Staging Single Kidney http://www.healthychildren.org/English/health-issues/conditions/genitourinary-tract/Pages/Children-with-a-Single-Kidney.aspx Link to AAP recommendations for children with a single kidney Renal

Urinary Urinary Tract Infections 0-6 months more common in boys Especially uncircumcised males >2 years more common in girls Cystitis and pyelonephritis Urinary

Urinary UTI Specimen collection Sterile: straight cath in non toilet trained Clean catch: hat for toilet trained VCUG (Voiding cystourethrogram) for repeated UTIs Renal Ultrasound Treatment with Antibiotics Education for parents or patient http://www.healthychildren.org/English/ages-stages/baby/bathing-skin-care/Pages/Care-for-an-Uncircumcised-Penis.aspx Specimen collection- sterile for culture if possible. VCUG for urine reflux into ureters Education- front to back wiping in females, IF foreskin retracted, cleaning beneath the foreskin in males. See link from AAP regarding foreskin care Urinary

Urinary Congenital Urinary Tract Disorders Increased risk for Latex Allergy Usually require surgical correction Neurogenic bladder: may result from congenital defect affecting spinal cord or acquired condition Urinary

Urinary Hypospadias Congenital Hypospadias may be anywhere on ventral shaft of penis Associated with Chordee Surgical repair < 1 year Delay circumcision Chordee fibrous tissue causing a curvature of the penis- causes decreased reproductive function. Delay circumcision in case tissue needed for repair Urinary

Urinary Hypospadias Post Op Care Urinary catheter or stent stitched in place Double diapering or dressing to protect stent Pain management Restricted activity Monitor urine output Double diapering to remove stool without needing to change diaper protecting catheter or stent Urinary

Urinary Enuresis Nocturnal or diurnal Primary or Secondary Thorough assessment including family hx Strategies to promote dryness Evening fluid restriction Positive rewards Waking to void Alarms Pharmacological approach Repeated involuntary voiding by a child old enough that bladder control is expected- usu 5-6 years old Primary- wet at night, maturational delay or small functional bladder Secondary- after 6 months of dryness. Associated with stress, infection or sleep disorder Pharm: DDAVP or oxybutinin Urinary

Bowel Encopresis Stool holding or soiling at inappropriate times Primary or secondary Retention of stool in rectum- becomes hard and painful Leads to irregular/unpredictable elimination pattern Liquid stool may ooze around it Often present as constipation or diarrhea Encopresis, also called stool holding or soiling, occurs when your child resists having bowel movements, causing impacted stool to collect in the colon and rectum. When your child's colon is full of impacted stool, liquid stool can leak around the impacted stool and out of the anus, staining your child's underwear Can lead to incompetence of the inner sphincter Bowel

Bowel Encopresis Studies to rule out disorder Evacuate bowel- enema Dietary management of constipation Positive reinforcement Toileting schedule Studies may include lower GI series, KUB x ray Toileting schedule to retrain bowel. May take several months if inner sphincter is incompetent Bowel