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

2. 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

3. 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

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

5. 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

6. 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 years reading >90th percentile or greater than 120/80 indicate prehypertension
Renal

7. 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
Renal- Definition of HTN

8. 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

9. 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

10. 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

11. 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

12. National Kidney and Urologic Diseases Information Clearinghouse (NKUDIC)
Resource for Nephrotic Syndrome
Renal

13. 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

14. 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

15. Renal Wilm’s Tumor (Nephroblastoma) Most often 2-3 years
Palpable mass on 1 side or other abdomen
Fast growing- doubles in size in 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

16. Renal Wilm’s Tumor Treatment Nephrectomy- involved kidney only
Post op care of patient
Chemotherapy or Radiation as needed for Staging
Single Kidney
Link to AAP recommendations for children with a single kidney
Renal

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

18. 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
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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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