Providing Patient Centered Care for the Child Experiencing a Genitourinary Disorder Marlene Meador RN, MSN, CNE

Pediatric Differences in the Urinary Tract: Kidney function Bladder capacity Bladder control Recovery

Enuresis Difficulty with urination control Nocturnal – Enuresis at night Diurnal – Enuresis during the day Primary – Never having experienced a period of dryness Secondary – Occurs when a 6-12 month of dryness has preceded the onset of enuresis

Possible Cause: Physical Bladder capacity Urinary tract abnormality Neurologic alterations Obstructive sleep apnea Constipation UTI Pinworm infestation Diabetes mellitus Voiding dysfunction

Treatment Limit fluids after supper and void before bed Imagery Let child keep record of progress Rewards can be used Behavioral use of alarm that detects moisture Imipramine HCL – Tricyclic Antidepressant Despropressin acetate – tablet or nasal spray which has antidiuretic effect Address the emotional side with all involved

Risk Factors: Emotional Family disruption Inappropriate pressure during training Inadequate attention to voiding cues Decreased self-esteem Sexual abuse

Diagnosis Diagnosis is based on history and symptoms Repeated involuntary voiding or incontinence past the age of toilet training. Urinalysis and culture are done Measurement of urine flow and bladder capacity with voiding cystourethrogram

Treatment Limit fluids after supper and void before bed Imagery Let child keep record of progress Rewards can be used Behavioral use of alarm that detects moisture Imipramine HCL – Tricyclic Antidepressant Despropressin acetate – tablet or nasal spray which has antidiuretic effect Address the emotional side with all involved

Nursing Diagnoses Situational low self-esteem related to bed- wetting or urinary incontinence Impaired social interaction related to bed- wetting or urinary incontinence Compromised family coping related to negative social stigma and increased laundry load Risk for impaired skin integrity related to prolonged contact with urine

Urinary Tract Infections Etiology and Pathophysiology Why are girls more likely to have a UTI than boys? What is the most common causative pathogen? May be bacterial, viral or fungal infection

Assessment Typical symptoms of older children & adults: Dysuria Frequency & urgency Burning Hematuria (usually older child) Symptoms for infants and young children can be vague and nonspecific: Fever Mild abdominal pain Enuresis If severe: High fever, flank pain, vomiting, malaise

Diagnostic Tests Urine for culture and sensitivity Clean catch Suprapubic aspiration Catheterization Positive Urinalysis Bacteria colony count of more than 100,000/ml. Presence of protein

Therapeutic Interventions Drug Therapy Antibiotics Analgesics – Tylenol Antipyretic Nursing Care Force fluids for rehydration Prescribed antibiotics Promote comfort

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.

Vesicoureteral Reflux

Pathophysiology Urinary Reflux – defective ureterovesicular valve that guards the entrance from the bladder to the ureter : Primary reflux – congenital abnormality Secondary reflux – repeated UTI’s Neurogenic bladder – stronger than usual bladder pressure. Backflow – while voiding when bladder contracts, urine is swept up the ureters Stasis of urine in ureters or kidneys which in turn leads to hydronephrosis

Assessment Fever Vomiting Chills Straining or crying on urination, poor urine stream Enuresis (bedwetting), incontinence in a toilet trained child, frequent urination Strong smelling urine Abdominal or back/flank pain

Diagnostic Tests Urine culture Voiding Cystourethrogram Renal ultrasound

Therapeutic Interventions Drug Therapy Antibiotics Penicillin Cephalosporins Urinary Antiseptics Nitrofurantoin Surgery Repair of significant anatomical anomalies, uretheral implantation

Nursing Care Keep accurate record of intake and output Secure stents and catheter Assess vital signs Assess comfort level Patient Teaching

Evaluation Follow-up: Repeat VCUG (voiding cystourethrogram) after a few months

Test Yourself Which of the following organisms is the most common cause of UTI in children? a. staphylococcus b. klebsiella c. pseudomonas d. escherichia coli

Bladder Exstrophy A rare defect in which the bladder wall extrudes through the lower abdominal wall Due to failure of abdominal wall to close in fetal development Upper urinary tract usually normal 1:400,000 live births Treatment is surgical reconstruction in stages

Goals of Surgical Reconstruction Bladder and abdominal wall closure Urinary continence, with preservation of renal function Creation of functional and normal – appearing gentitalia Improvement of sexual functioning

Nursing Care Pre-op focus-prevent infection Post-operative focus – Immobilize to promote healing of surgical site Monitor renal function – assess I&O and urine chemistries to detect renal damage Maintain patency of drainage tubes Analgesics Antibiotics as ordered Emotional support of parents

Epispadias Hypospadias

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.

Hypospadias

Assessment When is this anomaly typically diagnosed?

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.

Clinical Judgment: What is the rationale for the corrective surgery occurring prior to the child’s first birthday? a. the procedure is less painful for a child b. chordee may be reabsorbed c. the child has not developed body image and castration anxiety d. the repair increases the ease of toilet training

Post–operative Nursing Care Assess bleeding Maintain urinary drainage Control Bladder Spasms Prophylactic antibiotics Control Pain Increase fluid intake

Do not allow to play on any straddle toys. Prevent infection Call Dr if: temp is over 101 loss of appetite pus or increased bleeding from stent cloudy or foul smelling urine

Cryptorchidism Failure of one or both of the testes to descend from abdominal cavity to the scrotum

Therapeutic Interventions Surgery Orchiopexy done via laproscopy Done around 1 year of age Nursing Care – Post-op Assess from bleeding and S/S of infection. 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.

Acute Glomerulonephritis

Etiology and Pathophysiology Usual organism: Group A beta-hemolytic streptococcus Organism not found in kidney Glomeruli become inflamed and scarred

Edema: renal capillary permeability. with renal vascular spasms Edema: renal capillary permeability with renal vascular spasms glomerular filtration accumulation of Na+ and H2O in the blood stream causing increased intravascular and interstitial fluid volume Proteinuria: Protein molecules filter through the damaged glomeruli Hematuria: RBCs can pass through to the urine

Manifestations Common in boy 5-10 years old. Occurs 1-2 weeks after a respiratory infection or after impetigo. Has 2 phases Edematous phase – 4-10 days Diuresis phase- self limiting

Assessment 1. Renal: a. Moderate proteinuria b. Sudden onset of hematuria (tea-colored, reddish-brown, or smoky) and next develops oliguria c. Excessive foaming of urine

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

Assessment cont… 3.Neuro a. Encephalopathy: headache irritability convulsions coma-from cerebral edema

Test Yourself A 6 year old is admitted with R/O acute glomerular nephritis which of the following symptoms is the child most likely have? a. normal blood pressure, diarrhea b. periorbital edema, grossly bloody urine c. severe, generalized edema, ascites d. 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- ASO titer: (antistreptolysin O) (antibody formation against Streptococcus) is elevated, indicating a recent streptococcal infection ESR: (erythrocyte sedimentation rate) elevated showing inflammatory process BUN: (urea nitrogen) & creatinine elevated indicating glomerular damage CBC:WBCs normal range, H&H decreased. Lytes: elevated potassium, low serum bicarbonate

Therapeutic Interventions 1. Depends on the severity of the disease. No specific treatment, supportive care. 2. Treat at home if normal BP & adequate output. 3. Must be hospitalized if: BP increases gross hematuria oliguria present. To monitor for complications *Rarely develops into acute renal failure

Main Goals: Relieve Hypertension and Re-establish fluid and electrolyte balance: Keep accurate record of I&O. Record characteristics of urine output 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.

Interventions cont… Daily weights Bed rest for 4-10 days during acute phase Oxygen therapy Diet therapy Drug therapy

Clinical Judgment: A child is admitted and diagnosed with having AGN. Prioritize the following nursing diagnoses. a. fluid volume excess b. risk for impaired skin integrity c. anxiety d. activity intolerance

Clinical Judgment: When teaching parents about known antecedent infections in acute glomerulonephritis, which of the following should the nurse cover? a. Herpes simplex b. Streptococcus c. Varicella d. Impetigo

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

Etiology and Pathophysiology Insidious onset with periods of remission / exacerbations throughout life- No cure Idiopathic cause (95%) immune response is strongly suspected. Other causes: may develop after acute glomerulonephritis, sickle cell disease, Diabetes Mellitus, or drug toxicity. Age of onset preschool yrs.- 2-4 yrs, males more common Increased permeability which allows protein to leak into the urine (proteinuria). Shift of protein out of the vascular system causes fluid from the plasma to seep into the interstitial spaces and body cavities, particularly the abdomen (ascites). Edema and hypovolemia

Nephrotic Syndrome Assessment Findings: Four most common characteristics: Massive proteinuria Low serum albumin (K+ normal) Edema Malnourishment

Assessment Hyperlipidemia Shiny, pale skin Brittle hair Hypercoagulability (increased risk for thrombosis) Fatigue Abdominal pain (ascites)

Ask Yourself? Which of the following signs and symptoms are characteristic of minimal change nephrotic syndrome? a. gross hematuria, proteinuria, fever b. hypertension, edema, fatigue c. poor appetitie, proteinuria, edema d. body image change, hypotension

Diagnostics Based on history Characteristic symptoms Lab findings with serum albumin and sodium decreased BUN, Cholesterol and Electrolytes may be ordered Urinalysis reveals massive proteinuria (50 mg/kg/day) (primary indicator of nephrotic syndrome)

Therapeutic Interventions Reduce edema Keep accurate record of I&O. Measure abdominal girth, weigh daily Test urine for protein and specific gravity to see if tx is effective Diet: Normal diet for child’s age recommended No salt added High caloric Possible fluid restrictions

Treatment Diuretics-cautious use Antihypertensive Antibiotic Analgesics Albumin if resistant to diuretic Protective Isolation

Interventions Provide good skin care – edematous tissue fragile Child / Parent teaching – measures to prevent infections, medication administration, monitoring of intake and output Provide rest periods

Usually spontaneous resolution even with relapses (by age 30) Prognosis: Usually spontaneous resolution even with relapses (by age 30) 20% may develop chronic renal failure

If you have any questions or concerns regarding this presentation please contact Marlene Meador RN, MSN, CNE mmeador@austincc.edu