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

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

3. 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

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

5. 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

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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

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

14. 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

15. 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.

16. Vesicoureteral Reflux

17. 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

18. 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

19. Diagnostic Tests Urine culture Voiding Cystourethrogram
Renal ultrasound

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

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

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

23. 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

24. 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

25. 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

26. 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

27. Epispadias
Hypospadias

28. 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.

29. Hypospadias

30. Assessment
When is this anomaly typically diagnosed?

31. 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.

32. 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

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

34. 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

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

36. 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.

37. Acute Glomerulonephritis

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

39. 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

40. 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

41. 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

42. 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

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

44. 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

45. 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

46. 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

47. 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.

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

49. 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

50. 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

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

52. 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 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

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

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

55. 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

56. 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)

57. 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

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

59. 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

60. 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

61. If you have any questions or concerns regarding this presentation please contact Marlene Meador RN, MSN, CNE