Nursing Care of the Child with GU disorders

External Defects in the Urinary System Extrophy of the bladder Hypospadias vs epispadius Cryptorchidism

Extrophy of the bladder Posterior bladder wall extrudes through the lower abd wall. Failure of the abd to close Pre-op focus of nsg care Prevent trauma Prevent infection of exposed bladder

Post-operative care with surgical care of extrophy of bladder Care of the surgical site with meticulous wound care Positioning: immobilization and avoidance of abduction of legs Neurovascular assessment of lower extremities Monitoring renal function and obstruction of tubes Promoting comfort Discharge teaching

Hypospadias vs Epispadias Congenital urethral defect Uretheral opening on VENTRAL (lower) aspect of the penis Epispadias Congenital urethral defect Urethral opening is on the DORSAL aspect of the penis

Treatment for hypospadias DO NOT circumcise infant; may need the foreskin for reconstruction Surgery: reconstructive to re-position the meatus at the tip Usually done before one year of age Post-op care:

Post-op management Care of the catheter (may be foley, suprapubic or urethral stent. Use double diapering Management of bladder spasms Prophylactic abx No bath until stent removed Increase fluid intake No play on straddle toys Call physician for temp > 101º

Cryptorchidism

Therapeutic interventions for cryptorchidism Orchiopexy done via laproscopy Nursing care post-op: Minimal activity for few days Allow opportunity to express fears about mutilation or castration

Critical thinking for client undergoing urinary tract surgery David is 5 years old and scheduled for ureter reimplantation surgery. In addition to discussion of post-op pain, tubes and dressings, the most significant other topic would be which of the following? A. Need to reassure David his genitals are intact and will function normally when the catheters are removed B. Importance of monitoring the urine drainage from stents and urethral catheter C. The need to assess the surgical site for bleeding or excessive drainage D. The home care regimen that can be anticipated when David is discharged

Obstructive Uropathy Stenosis of uteropelvic valve Stenosis of posterior urethral valve Stenosis of the uterovesicular junction otherwise known as “vesicoureteral reflux” Hydronephrosis the main problem with reflux of urine

What is vesicoureteral reflux?

Therapeutic management Corticosteroids (prednisone) Dietary management Restriction of fluid intake Prevention of infections Monitoring for complications: infections, severe GI upset, ascites, or respiratory distress

Physiologic changes r/t hydronephrosis Cessation of glomerular filtration and cell death Metabolic acidosis result Impairment of kidney’s ability to concentrate urine Obstruction results in stasis and infection Can lead to chronic renal failure

Diagnostic tests for renal/bladder function Urine culture and sensitivity: done every 2-3 months VCG: voiding cystourethrogram Renal/bladder ultrasound IVP Renal biopsy Cystoscopy

Nursing responsibilities with testing Responsible for preparation and collection of urine or blood Maintains careful intake and output Recognizes that renal disease can diminish the glomerular filtration rate(the amt of plasma from which a given substance is totally clear in one minute)

Treatment for vesicoureteral reflux Directed toward preventing UTIs Managed by time or surgery if a lower grade Single doses each day of abx as long as reflux lasts Urine cultures done q 6 wks up to 3 months to make sure no “silent infection”

Treatment and nsg care for obstructive uropathy Drug therapy Penicillin Cephalosporins Urinary antiseptics (Furadantin) Follow up VCG after few months post op Nsg care: Teach prevention of UTI Teach imp of taking all abx Monitor urinary drainage from catheters Assess for pain Teach parents how to change dressings, double-diaper s/s obstruction or infection Surgery: Repair of anatomical anomalies/pyeloplasty

Differences between adult s/s UTI and pediatric patient In children: Unexplained fever Failure to thrive Vomiting Diarrhea

Urinary tract infections Most common type of bacterial infections occurring in children Bacteria passes up the urethra into the bladder Most common types of bacteria are those near the meatus…staph as well as e.coli

Contributing factors Those with lower resistance, particularly those with recurrent infections Unusual voiding and bowel habits may contribute to UTI in children “forget to go to bathroom” Symptoms:

Therapeutic management Eliminate the current infections Identify contributing factors to reduce the risk of re-infection Prevent systemic spread of the infection Preserve renal function

FYI The single most important host factor influencing the occurrence of UTI is urinary stasis What is the chief cause of urinary stasis?

Nephrotic syndrome

Nephrotic syndrome, cont

Child with nephrotic syndrome

Treatment of nephrotic syndrome Varies with degree of severity Treatment of the underlying cause Prognosis depends on the cause Children usually have the “minimal change syndrome” which responds well to treatment

Nursing interventions to manage nephrotic syndrome Administer corticosteroids (prednisone) as ordered Dietary management Restriction of fluid intake Prevention of infections Monitoring for complications: infections, severe GI upset, ascites, or respiratory distress

Glomerular diseases Acute glomerulonephritis (AGN) Nephrotic syndrome (MCNS) or minimal-change nephrotic syndrome

AGN Immune-complex disease causing inflammation of glomeruli of kidney Usual organism is group A beta-hemolytic strep Decreased glomerular filtration Common in children (boys > girls) Assessment/diagnostic tests:

AGN Treatment and nursing care:                                                               Treatment and nursing care: Bed rest may be recommended during acute phase Record of daily weight is the most useful means for assessing fluid balance

Nursing diagnosis for the child with glomerulonephritis Fluid volume excess r/t to… Activity intolerance r/t…. Altered patterns of urinary elimination r/t … Altered family process r/t…

Nursing care specific to the child with AGN Allow activities that do not expend energy Diet should not have any added salt Fluid restriction, if prescribed Monitor weights Education of the parents