Nursing Care of the Child with GU disorders Summer 2009 Lea Melvin, MSN, RN, CRRN, CWOCN Austin Community College GU dysfunction is based on several evaluative tools As with most disorders of childhood, the incidence and type of kidney or urinary tract dysfunction changes with the age and maturation of the child

Radiography and other tests of urinary system function Urine culture & sensitivity Renal/ bladder US VCUG Imaging studies Testicular US Scout film IVP Renal bx, cysto Be sure and don’t start abx prior to collecting the culture and sensitivity! Scout film: flat plate xray of abd., pelvis for kidnesy, ureters, bladder (also called a flat plate or KUB Nuclear cystogram: a radioactive fluid is injected through the uretheral cath until bladder is full; images generated before, during and after voiding Voiding cystourethrography: contrast medium injected into bladder through cath until bladder is full; films taken before, during and after voiding Whitaker perfusion test; injection of contrast material through renal pelvis and ureters pressure is measure d in renal pelvis and urinary bladder Whitaker perfusion test

Physical tests for Gu function Volume for polyuria, oliguria Specific gravity Osmolality Appearance Chemistries on urine (√ for blood, WBCs, bacteria, casts) These values are age related: NB bladder capacity 30-60 ml; children: capacity in ounces=ages (years)+2…4yo bladder capacity+6 oz=360mls Osmolality: same as for specific gravity, but more sensitive Appearance; does it contain sediment? Color? Cloudy? Chemistries: appearance of casts is an indicator for tubular or glomerular disorders; degenerative process in advanced renal disease; pyelonelpritis, proteinuria; usually transient

Blood tests of renal function BUN (blood urea nitrogen) Uric acid Creatinine BUN range for NB: 4-18; for child 5-18. If elevated, renal disease—acute or chronic (the higher the BUN the more severe the disease Uric acid: increased suggests severe renal disease Creatinine: ncreased suggests severe renal disease

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 A number of substances can be used, but the most useful clinical estimation of glomerular filtration is the clearance of creatinine, and end product of protein metabolism in muscle and a substance that is freely filtered by the glomerulus and secreted by renal tubular cells. GFR=the amt of plasma from which a given substance is totally cleared in one minute. It is usually done on a 12-24 hr. specimen.

Extrophy of the Bladder Hypospadius / Epispadius Cryptochidism External Defects Extrophy of the Bladder Hypospadius / Epispadius Cryptochidism

Hypospadias Epispadias

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. chordee (a fibrous band that causes the penis to curve downward),

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. mild (meatus is just below tip); to meatus on the perineum between scrotum, ventral foreskin lacking Cryoptorchidism might interfere with fertility in the mature male if not corrected. Also associated with testicular cancer.

Assessment Usually discovered during Newborn Physical Assessment

Interventions Medical Treatment: Surgery 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. C is the correct answer. The psychological effects are minimized when correction is done early.

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) 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/suprapbic, or urethral stent 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)

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

5. Increase fluids intake. 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. Pain is usually controlled with Tylenol 5. 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

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

Diagnosed on Newborn Physical Exam Assessment Diagnosed on Newborn Physical Exam

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 reflux Posterior urethral valves Ureteropelvic junction defect Will discuss PUVs and UPJs with Congenital Midline Anomalies – here to help student organize data

Vesicoureteral Reflux Abnormal backflow (retrograde) of urine from the bladder into the ureters and possibly kidneys when the bladder contracts during emptying/voiding. Happens in infants with reflex emptying, during voiding in continent individual, in clients with spinal cord injuries or spina bifids with spastic AKA reflexic neurogenic bladder.

What is vesicoureteral reflux? Normally the ureter passes through a tunnel inside the bladder wall for a distance before it opens into the bladder. Pressure from urine filling the bladder should close off this tunnel within the bladder wall. This “closing off” prevents urine from flowing back up into the kidneys. If the tunnel is too short or the opening is too large, the ureter may not squeeze shut properly and urine will freely reflux or pass backwards toward the kidney during urination. Reflux of infected urine toward the kidney can cause a serious kidney infection (pyelonephritis) and can cause damage to the kidney and high blood pressure later in life.

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. Not really a valve per se; it is a tunneling of the ureteral insertion point that acts like a valve upon filling of the bladder.

Vesicoureteral Reflux Grades I through V Reflux can be mild, moderate, or severe and is graded on a scale of one through five; one is the mildest and five is the most severe

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

Vesicoureteral Reflux Approximately 20% of children that have UTIs will be found to have vesicoureteral reflux on xray Reflux is a condition where urine flows back up the ureters in the wrong directions and into the kidney during urination. The condition is present from birth and does run in families

Diagnostic Tests Cystourethrogram (VCUG) Urine culture Renal ultrasound (RUS) Renal unltrasound: measures the sound waves to determine and shape of kidneys, ureters and bladder VCUG: uses xrays to examine the bladder and urethra. These tests require catheterization of the bladder and uses contrast. Urine culture done every 2-3 months VCUG RUS or 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

Goals of treatment Directed toward preventing UTIs Managed by time or surgery if grade 4 or 5 Single doses each day of abx as long as reflux lasts Urine cultures done q 6 wks –3 mos All children with any grade of reflux should receive a single dose of antibiotics each day to help prevent urinary tract infection. In children with mild to moderate reflux grade 1, 2, 3 there is an excellent chance that the reflux will disapper as the child grows. However only about 1/3 of the children with grade even fewer of those with grade 5 reflux can expect it to resolve spontaneously. Urine cultures are don’t to identify silent infection = asymptomatic infection.

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. Decreased output from stent could indicate obstruction. Handle child gently Administer pain medications

Evaluation Follow-up = VCUG in 3-4 months Renal SPECT RCG (radionucleaotide cystogram) Renal unltrasound: measures the sound waves to determine and shape of kidneys, ureters and bladder VCUG: uses xrays to examine the bladder and urethra. These tests require catheterization of the bladder and uses contrast Renal SPECT: determines if infected refluxing urine has scarred the kidney. RCG: examines the bladder using radio-isotopes which use less radiation, but is slightly lass accurate

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 d. Escherichia coli, a common gram negative enteric bacterium.

Urinary Tract Infections

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 vary by age of child Symptoms: infants and toddlers may become irritable, have fever, vomiting and diarrhea or may develop feeding problems with failure to gain weight. There is a significant incidence of UTI in adolescents, esp those who are sexually active. The peak incidence of UTIs is not cause by structual anomalies occurs between 2-6 yrs of age. Females have 10-30% more UTIs than males Older children may have wetting episodes, c/o burning or frequency or urinations, fever, abd pain, back or flank pain or even blood in the urine.

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 Antibiotic therapy should be inititated on the basis of identification of the pathogen, the child’s history of antibiotic use, and the location of the infection. Several antimicrobial drugs are available but all of them can occasionally be ineffective because of resistant organisms. Penicillins, sulfonamides, cephalosporins, and nitrofuradantion. If anatomic defect such as primary reflux or bladder neck obstruction are present, surgical corrections of these abnormalities may be necessary to prevent recurrent infections. Aim of therapy and careful follow-up is to reduce the chance of renal scarring. However, recurrent infection of the urinary bladder predisposes the individual to transient episodes of vesicoureteral reflux from inflammation and holding because of painful urination. Wipe front to back, increase fluids, no bubble baths, void after intercourse. Change diaper or menstrual pad q4hrs.

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 frequently Teach girls to wipe front to back Discourage bubble baths Encourage fluids frequently throughout day Bathe daily Adolescent girls when menstruating are to change of pad every 4 hours Teach to void immediately after intercourse

FYI The single most important host factor influencing the occurrence of UTI is urinary stasis What is the chief cause of urinary stasis? Delayed emptying, usually from bladder neck spasms Ordinarily urine is sterile, but at 98.6 degrees, it provides an excellent culture medium Technically by completely emptying bladder flushes away any organisms before they have an opportunity to multiply and invade surrounding tissue. In neurogenic bladder you can cure a UTI by increasing frequency of the catherization.

Glomerular diseases Acute glomerulonephritis (AGN) Nephrotic syndrome (MCNS) or minimal-change nephrotic syndrome Nephrotic syndrome is a disorder char. by increased glomerular permeability to plasma protein, which results in massive urinary protein loss. The glomerulus is responsible for the initial step in the formation or urine, and the filtration rate depends on an intact glomerular membrane. MCNS or minimal-change nephrotic syndrome will be the subject of our discussion bec. It constititues 80% of nephrotic syndrome cases

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

Nephrotic syndrome The kidneys lie to the sides of the upper abdomen, behind the intestines and are bean-shaped. A large renal artery takes blood to each kidney. This artery divides into many tiny blood vessels through the kidney. In the outer part of the kidneys tiny blood vessels cluster together to form structures called glomeruli.

Nephrotic syndrome, cont In nephrotic syndrome, a condition present when the kidneys leak protein. Normal urine contains virtually no protein. In nephrotic syndromne, the urine contains large amts of protein and results in proteinuira, Nephrotic sydrome is NOT a final diagnosis. It is a syndrome that occurs when enough protein is lost in the urine to cause fluid retention. This condition causes 9 in 10 cases of nephrotic syndrome in children under the age of FIVE years

Contrast of normal gloumerular activity with changes seen in Nephrotic Syndrome Note the contrast between the normal glomerular anatomy and the changes that exist in nephrotic syndrome permitting protein to be excreted in the urine. The lower albumin blood level stimulates the liver to generate lipids and excessive clotting factors. Edema results from decreased oncotic plasma pressure, renin-angiotensin-aldosterone activation, and antidiuretic hormone secretion.

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 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

Assessment Four most common characteristics: Massive proteinuria Hypoalbuminemia (K+ normal, BP normal) 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 Hyperlipidemia * Of note is that there is no hematuria or hypertension Hyperlipidemia = result of liver increases production of lipoproteins to try to compensate for protein loss-lipids are to large to be lost in urine Book says hypertension.

Other signs and symptoms Fatigue Anorexia Weight gain Abdominal pain – from large amount of fluid in abdominal

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 Diuretics help to clear the body of edema May have high BP as a result; treatment is usually advised to bring HTN down. ACE inhibitor is commonly used for this, and this also limits the amt of protein that leaks from the kidneys Steroid meds may work well to stop the leak of protein in minimal change disease. Steroids may be used to reduce inflammation and abnormal immune responses in various types of kidney disorders.

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 appetite, proteinuria, edema d. body image change, hypotension c. Poor appetite, proteinuria, edema Don’t have hematuria, book says hypertension but notes disagree, do not have 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 Infection from group A beta-hemolytic Streptococcus causes an immune response that causes inflammation and damage to the glomeruli. More boys that girls. Protein and red blood cells are allowed to pass through the glomeruli. Blood flow to the glomeruli is reduced due to obstruction with damaged cells and renal insufficiency results, leading to the retention of sodium, water, and waste. 53

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.

AGN Treatment and nursing care: Bed rest may be recommended during the acute phase of the disease A record of daily weight is the most useful means for assessing fluid balance Treatment and nursing care: depends on the severity of the disease and tends to be more symptomatic. The disease is self-limiting.

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 Strenuous activity is usually restricted until there is no evidence of protein or macroscopic hematuris, which may persist for months The effectiveness of nursing intervention is determined by continual reassessment and evaluation of care

Therapeutic management Corticosteroids (prednisone) Dietary management Restriction of fluid intake Prevention of infections Monitoring for complications: infections, severe GI upset, ascites, or respiratory distress In most children the response to steroids will occur in 7-21 days.

Nursing diagnosis for the child with glomerulonephritis Fluid volume excess r/t to decreased plasma filtration Activity intolerance r/t fatigue Altered patterns of urinary elimination r/t fluid retention and impaired filtration Altered family process r/t child with chronic 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

Mitrafanoff appendiceal 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 Mitranoff usually 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