EXAM 3: Nursing Care of the Child with an Alteration in Elimination/GU/Enuresis/Renal/Repro/Structural

What is urinary elimination?

refers to the secretion and excretion of body waste through the urinary/renal system

What accounts for a large portion of GU d/o in infants?

congenital disorders

What are the 2 common urinary disorders common in infants in children?

enuresis and UTI

What is the role and function of the kidneys?

- Maintain blood volume and pressure (equilibrium)
- Ensure balance of Na, Cl, K, Ca, H, pH, and Ph
- Eliminate products of metabolism such as urea, uric acid, and creatine
- Urine formation

What is urine formation?

filtration, reabsorption, and secretion

What is the structural and functional unit of the kidneys?

the nephrons
(they filter water and wastes across the glomerular capillaries •to maintain the body fluid level, electrolyte composition, and pH)

What are the urinary differences between adults and infants?

- Kidneys are large in relation to the size of the body-which means less protection of injury

- Decreased GFR and absorption - blood flow through the kidneys is slower

- Renal development not complete until 2 years - Increased risk for dehydration

- Bladder capacity of newborn @ 30 mL

- Young children have shorter urethras

- Most children with acute renal failure regain normal function

- Reproductive organs - immature at birth until hormonal changes in puberty

What is the specific gravity and BUN/Cr levels in infants?

- Lower specific gravity - less ability to concentrate urine
- BUN/Creatinine lower in infant and toddlers

What are children vulnerable to with shorter urethras?

UTIs

What is the expected urine output across the age groups?

Infant and child 0.5 to 1 mL/kg/hr

- 1yo – 400-500mL/day

- Adolescent 800-1400 mL/day

- Average adult - 800 to 2,000 mL/day

- Average voids – 3yo to adult 3-8/day

What is enuresis?

- Inappropriate urination during the day or night at least twice a week for at least 3 months
- Should be evaluated for children who have a developmental or chronical age of at least 5 yrs old
- Rule out other causes of incontinence (medication adverse effects, medical condition) prior to diagnosis of enuresis

What is primary enuresis?

a child has never been free of bed-wetting for any extended periods of time

What is secondary enuresis?

a child started bed-wetting after development of urinary control

What are the RFs for enuresis?

family hx, bladder dysfunction, males, emotional events, behavioral d/o

What are the expected findings of enuresis?

- Alteration in toilet training, voiding behaviors, and bowel movement patterns
- Chronic or acute illness (UTI, DM, sickle cell disease, neurological deficits)
- Fluid Intake (esp at bedtime)
- Restlessness, urinary freq and urgency

How do we dx and evaluate enuresis?

- Functional bladder capacity screening - bladder capacity studies
- Record of enuresis pattern

Wha is the nursing care for enuresis?

- Behavioral therapy
- Conditioning therapy
- Medication

What is included in enuresis behavioral therapy and emotional problems associated w it?

- reward system
- kegal/pelvic exercises
- retention control measures - large po challenge and hold urine for long as possible - stretching bladder
- Wake schedules

Emotional Problems: Low self esteem, altered body image, social isolation and fears

How can we use conditioning therapy for enuresis?

Stimulus training (urine sensor monitor - buzz when wet)

What is Desmopressin acetate?

PO, given at bedtime monitor I/O electrolytes (esp. Na) restrict the child's fluid intake after dinner, administer the medication at bedtime, possible adverse reactions include headaches, nausea. Nasal spray can be irritation and can cause hyponatremia and seizures in children NO LONGER DONE FOR CHILDREN
(antidiuretic hormone)

What is Imipramine hydrochloride?

child suicidal thoughts, therapeutic effectiveness, length of tx 4-6 weeks, then taper slowly, administer w/ food, one hour before bed, adverse reactions, avoid sun exposure, avoid OTC medication
- Monitor HR and BP
- Tricyclic antidepressant

What is oxybutynin chloride?

reduces bladder contractions, monitor for effectiveness and possible adverse reactions (dry mouth and constipation)

What is included in the genitourinary assessment?

- Urine characteristics
- Reporting from parent/child
- Pain or discomfort
- Appearance of genitalia
- Edema (local/generalized)
- Labs/Diagnostics

How do we get a clean catch specimen on a child/infant?

- Teach parent with child depending on the age
- Specimen cup, urine bag, cotton ball method
- Sterile: straight cath/foley

What are the most common labs/diagnostics for urinary d/o?

- Urinalysis, Culture & Sensitivity
- RFP (electrolytes, BUN, Creatinine, GFR)
- Renal Ultrasound
- Voiding Cystourethrogram (VCUG)
- Cystoscopy
- Abdominal/Renal CT

How do we interpret a U/A?

- Specific gravity: concentration
- PH: increases w UTI
- Protein: may be 1st indicator of renal disease
- Glucose: diabetes
- Ketone: acidsosis/DKA
- Leukocytes: present with WBCs and bacteria
- Nitrates: present with bacteria
- RBCs: trauma, stones, infection, glomerulonephritis
- Bacteria: infection
- Casts: pyelonephritis, glomerulonephritis, renal disease

What is the most important factor leading to a UTI?

urinary stasis (for children)

What are other factors that can contribute to a UTI?

- Incomplete bladder emptying
- Reflux or over-distention
- Dysfunction of voiding mechanism
- Neurogenic bladder
- Extrinsic factors such as bladder neck obstruction
- Constipation
- Irritation
- Catheters, tight clothing, poor hygiene, local inflammation, bubble baths- Urinary tract anomalies
- Uncircumcised penis
- Sexual activity

What is UTI and what is it caused by?

- Broad range of bacterial infections of the urinary tract
- Neonatal period, most frequently seen in males
- After 4 months more common in females
- E-coli causes 75-90% of infections
- Inflammation causes irritability and spasm of bladder walls, urinary frequency, urgency, hematuria

What are the manis of a UTI in a newborn?

jaundice, tachypnea, cyanosis, hypothermia, fever

What are the manis of a UTI in a child < 2 yo?

- Fever or hypothermia
- Irritability/lethargy
- Vomiting, diarrhea or poor feeding
- Foul smelling urine
- Frequent urination
- Pallor
- Dehydration
- Diaper rash

What are the manis of a UTI for a child over 2?

- Poor appetite, vomiting, growth failure
- Enuresis, frequency and urgency urination,
- Dysuria
- Pallor
- Hematuria,
- Bbd pain, flank pain
- Fever/chills
- Constipation
- Malodorous urine

What is included in the nursing care of UTIs?

Goal is to prevent!
- Teach good hygiene
- Encourage fluids
- Monitor Urine Output
- Avoid holding urine
- Push fluids
- Avoid tight clothes
- Cotton underwear
- Avoid bubble baths
- Prepare for Dx Procedures
- Mild analgesic
- Good hygiene if sexually active (shower and urinate after sex)

What are the goals of decreasing infection in a UTI?

- eliminate current infection with antibiotics
- prevent systemic spread
- preserve renal function- push fluids
- Alteration in elimination
- Fluid volume deficit (fluid and electrolyte imbalance)

What is obstructive uropathy?

Structural or functional obstruction in the urinary system

What is the tx of obstructive uropathy?

Sx procedures that divert the flow of urine to bypass the obstruction, including surgical repair with the insertion of a ureteral stent, pyelostomy, or cutaneous ureterostomy tubes.

What is a chordee and the tx?

Ventral curvature of the penis
- Treatment: Sx release of the fibrous band

What is a bladder exstrophy?

Eversion of the posterior bladder through the anterior bladder wall and lower abd wall; exposed bladder, urethra, and ureteral orifices through the suprapubic area; and epispadias present

What is the tx for a bladder exstrophy?

cover the exposed bladder with sterile nonadherent dx and prepare child for immediate sx

What is the nursing care of a bladder exstrophy?

prevent infection and skin breakdown, cath a stoma, manage bladder spasms

What the education needed for a bladder exstrophy?

care of stoma due to some kind of urinary diversion (continent, catheterizable stoma, or a stoma requiring pinching)/

What is hypospadias?

ureteral opening located just below the glans penis, behind the glans penis, or on the ventral surface of the penile shaft. Meatus opening below the glans penis, meatus opening along the ventral surface of the penis, scrotum, or perineum, possible chordee present.

What is epispadias?

Male: wide pubic symphysis, urethral opening on the dorsal surface of penis, possible bladder exstrophy of the bladder

Female: wide urethra, bifid clitoris, possible exstrophy of the bladder

What are the therapeutic procedures for epispadias?

surgery performed the 1st year of life - hold on circumcision until post sx, stent and catheter

What is phimosis?

Narrowing of the preputial opening of the foreskin, inability to retract foreskin of penis, normal finding in infants and young boys and usually disappears as the child grows.

What is the nursing action of phimosis?

Proper hygiene for the phimotic foreskin is external cleansing during routine bathing, the foreskin should not be forcibly retracted.

What is cryptorchidism?

- Undescended testes or inability to palpate testes withing scrotum

- Premature infants have higher incidence

- Typically descends on its own but if not will need surgical repair (orchiopexy) performed at 6-24 months

- Increased risk of testicular malignancy

- Decreased sperm production

What are complications of cryptorchidism?

failure to descend exposes the testes to the heat of the body, leading to low sperm counts at sexual maturity

What is a hydrocele?

fluid in scrotum, enlarged scrotal sac, can resolve spontaneously

When is surgery recommended for a hydrocele?

sx repair if not resolved in 1 year

What is a varicocele?

elongation, dilation, or tortuosity of the veins on the spermatic cord superior to the testicle. Some males experience discomfort during sexual stimulation

What is a testicular torsion?

EMERGENCY
- The testis rotates on its spermadic cord
- Cuts off blood supply

What are the symptoms of a testicular torsion?

- Engorgement
- Scrotal Pain/Abdominal pain
- Nausea and vomiting

Can occur after trauma
Treatment
Surgery (IMMEDIATE)

What is ambiguous genitalia?

erroneous or abnormal sexual differentiation

What is ambiguous genitalia?

- Karyotyping is performed to determine the infant's chromosomal pattern and gonadal function tested
- Erroneous of abnormal sexual differentiation
- Adrenal function should also be tested bc of the high risk of adrenal insuff
- Genetic counseling can help family understand the cause

What is included pre op for structural disorders?

- Provide education to the child and family related to procedure, provide emotional support to child and family
- Encourage parent to express concerns and fears related to sx procedure ad outcome
- If NPO if necessary - explain the parameters

What is included post op for structural disorders?

- Assess pain with pain scale
- Administration of pain medication and anticholinergics - decrease bladder spasms
- Monitor I/Os
- Provide wound and or dx care
- Monitor urinary caths, drains, tubes, or stints
- Monitor for signs of infection
- Educate measures to prevent infections, no tub baths for 1 week or prescribed, surgery is not a punishment, and it will not mutilate the body limit activity

What is included in the infection prevention of structural disorders?

- Observe for findings of infection
- Teach patient and family to report any findings of infection immediately

What are the emotional problems associated with structural disorders?

- Poor self-esteem, altered body image, social isolation, fears
- Support child and family by listening to concerns and correcting misconceptions
- Play therapy for toddlers and preschoolers
- Encourage peer to peer social networking for older children
- Consider support groups

What is acute glomerulonephritis?

Inflammation of the glomerulus
- Unable to filter plasma = retention of sodium and water
- Injury causes blood in urine

What is acute post streptococcal?

- Immune reaction to group A beta hemolytic streptococcus
- Clinical symptoms usually appear 7-21 days after infection
- Acute clinical episode is usually self-limiting, with resolution occurring in 6-12 weeks

What is included in the clinical assessment of AGN?

- Hematuria, cola colored urine.

- Hypertensive

- Edema, abrupt onset, mild periorbital or lower extremities.

- Usually school age child.

What are the labs included in AGN?

- Red blood cell, casts, small protein in urine.
- Normal serum albumin, cholesterol, triglycerides, decreased Hct, Hgb.
- Altered electrolytes, elevated BUN and creatinine.

What can a cellular cast be composed of in AGN?

may be composed of any of the cells found in the urine sediment, such as RBC, WBC, or renal tubular epithelial cell. Bacterial cell casts have also been described as have casts consisting of a mixture of cell types

What is the main nursing goal of AGN?

- Primary goal: Maintain fluid volume/manage HTN

- If HTN uncontrolled can lead to encephalopathy/seizures

What else is included in the management and nursing care of AGN?

- Fluid volume excess (tissues)
- May need anti hypertensives
- Ca channel blockers, beta blockers or ACE inhibitors
- Limit sodium, water, and protein
- Diuretics
- I&O, daily weights
- Antibiotics (streptococcal)
- Phosphate binders - decrease absorption of phosphate in GI Tract.

What is nephrotic syndrome?

- Most common presentation of glomerular injury

- Alteration in renal function r/t glomerular injury change occurs in basement membrane of glomerulus. Membrane becomes permeable to proteins.

- Characterized by massive proteinuria, hypoproteinemia, hyperlipidemia, and edema

What is nephrotic syndrome characterized by?

massive proteinuria!

What are the CMs of nephrotic syndrome?

- Frothy, cloudy urine

- Massive edema with slow onset, worsens as day progresses.

- Hypovolemia

- Normotensive

- Pallor, fatigue

- Usually toddler, preschool.

What will the labs for nephrotic syndrome look like?

- Proteinuria 4+
- Hypoalbuminemia (<2.5)
- Elevated cholesterol and triglycerides.
- Elevated Hgb, Hct Platelets.
- Glomerular filtration rate normal to high
- Total calcium decreased
- HYponatremmia (possible)

What is included in the tx and nursing care of nephrotic syndrome?

- Corticosteroids (Continued until urine is protein free and remains so for 2 weeks)
- Immunosuppressive therapy if unresponsive to steroid
- Albumin and diuretics
- Salt restrictive diet (edema phase)
- Antibiotics to prevent infection

How long do you continue corticosteroids when dx with nephrotic syndrome?

Continued until urine is protein free and remains so for 2 weeks

What happens after long term use of steroids?

Steroid Induced Cushings Syndrome

Long term use of steroids- side effects:
- Increased risk of infection
- Hyperglycemia
- GI bleeding
- Obesity
- HTN

What is Hemolytic Uremic Syndrome (HUS)?

3 distinct features
- Hemolytic anemia
- Thrombocytopenia
- Acute renal failure

What is hemolytic anemia?

results from fragmentation of RBC's

What is thrombocytopenia?

Platelets become trapped within small vessels

What is acute renal failure?

- Bacterial toxins damages the endothelial cells of capillary wall
- E-coli, salmonella, shigella
- Results in occlusion of capillary, especially the glomerular vessels with platelets and fibrin occlusion causes further damage to RBCs as they try to move through it and will then be sequestered in the spleen
- Leads to decreased GFR and renal failure.

What are the CMs pf HUS?

- Vomiting, diarrhea, poor appetite
- Oliguria
- Irritability
- Seizures
- Pallor
- Edema

What are the hemorrhagic signs of HUS?

- bruising
- jaundice
- petechiae
- bloody diarrhea

What are the labs seen in HUS?

- Signs of renal failure such as: Low Na, elevated K, elevated BUN & creatinine
- Low H/H, low platelet
- Increased liver enzymes and bilirubin

What is the management of HUS?

- Fluid replacement
- Treatment of elevated BP
- Correction of acidosis and electrolyte imbalances
- Peritoneal or hemodialysis
- Blood transfusions (use with caution to prevent circulatory overload)
- Monitor I & O
- Daily Weights
- Monitor closely for bleeding
- Provide emotional support for child and parental anxiety
- Family Education

What are the obstruction locations of Obstructive Uropathy?

- Upper or Lower tract
- Unilateral or Bilateral
- Complete or Incomplete
- Congenital or Acquired - Obstructive Pathology

What is obstructive uropathy?

Obstruction of urine flow resulting in dilation of affected kidney (hydronephrosis)

What ae complications of obstructive uropathy?

Complications include recurrent UTI renal in sufficiency and progressive damage to the kidney resulting in kidney failure

What are common disorders of obstructive uropathy?

- UPJ- ureteropelvic junction
- UVJ-ureterovesical junction
- Ureterocele Posterior urethra valves (males only)

What is included in the health history of OU?

recurrent UTI, incontinence, fever, foul-smelling urine, flank pain, abdominal pain, urinary frequency, urgency, dysuria, hematuria

What is the management of OU?

- Surgical correction
- Assess urine output via such as vesicostomy, nephrostomy, suprapubic tube, urethral catheter
- Analgesics
- Antispasmodics
- Education

What are the complications of OU?

- Hydronephrosis
- Vesicoureteral Reflux (VUR)

What is vesicoureteral reflux? (VUR)

- Abnormal backflow of urine from the bladder into the ureters and possibly the kidneys
- Reflux prevents complete emptying of bladder
- Typically presents graded on scale 1-5
- High incidence in siblings

What is primary VUR?

congenital abnormality at the vesicoureteral junction caused incompetence of the valve

What is secondary VUR?

caused by other structural or functional problems such as neurogenic bladder or bladder dysfunction

What is the treatment for VUR?

Goal: Prevent pyelonephritis and subsequent renal scarring
- Grade I-III handled conservatively, treated with meds
- Hygiene, prophylactic antibiotics
- Grade IV-V surgical repair needed

What are the nursing considerations for children undergoing renal surgery?

- Assess & medicate for bladder spasms
- Antispasmodics- oxybutynin (Ditropan)
- Pain control
- May have drains- monitor output
- Will have foley after surgery- monitor output
- Urine will be bloody but will clear 2-3 days
- Keep accurate I & O records
- Monitor fluid & electrolyte balance
-, Measure daily weights
- Early ambulation/ADT
Prophylactic antibiotics