urinary

Nursing Care of the Child with an Alteration in Urinary Elimination/Genitourinary Disorder

Variations in Anatomy & Physiology

  • Kidneys: Larger in relation to abdomen until adolescence.
  • Urethra:
    • Shorter and more proximal to rectum in female infants/children.
    • Shorter in boys which increases the risk of urinary tract infections (UTIs).
  • Glomerular Filtration Rate (GFR): Slower GFR in children makes them less able to concentrate urine and reabsorb amino acids, increasing dehydration risk.
  • Renal Maturity: Renal system reaches maturity by age 2.
  • Urine Output (OP):
    • Normal urine output is 0.5-2 ml/kg/hr.
    • Daily urine output is 400-500 ml/day.
    • For teens, it increases to 800-1400 ml/day.
  • Bladder Capacity:
    • 30 ml in newborns, increasing to about 250 ml by age 1 year.

Priority Nursing Problems

  • Impaired Urinary Elimination:
    • Primary incontinence: Never achieved dry periods.
    • Secondary incontinence: Onset after a period of urinary continence.
  • Excess Fluid Volume:
Priorities of Care for Impaired Urinary Elimination
  • Assessment:
    • Identify causative/contributing factors.
    • Assess degree of interference/disability.
  • Management:
    • Treat and prevent urinary alterations.
Priorities of Care for Excess Fluid Volume
  • Assessment:
    • Identify causative/contributing factors.
    • Assess degree of excess fluid.
  • Management:
    • Treat and prevent excess fluid volume.

Impaired Urinary Elimination

  • Enuresis (Bedwetting):
    • Etiology:
    • Diabetes Mellitus or Insipidus, Sickle Cell Disease, UTI, Constipation, Behavioral, Neurologic deficits.
    • History Cues:
    • Large amounts of fluid consumed before bedtime, caffeine.
    • Family disruption/stress regarding toilet training.
    • History of constipation and toilet training failures.
    • Physical Cues:
    • Daytime and nighttime incontinence.
    • Urine holding behaviors: squatting, dancing, rushing to bathroom.
    • Priority of Care:
    • Management of incontinence and promotion of wellness to prevent complications.
    • Education on fluid intake, bathroom habits, and potential medications.
    • Encourage child involvement in bed linen changes.
Therapeutic Measures for Enuresis
  • Conditioning therapy: Alarm sensors to wake child upon urination.
  • Pelvic exercises: Kegel exercises to strengthen muscles.
  • Medications:
    • Desmopressin (0.2-0.6 mg): Reduces urine volume in children >5 years. Administer at bedtime.
    • Caution for adverse effects: Headaches, nausea.
  • Lifestyle Adjustments:
    • Restrict fluid intake in evening, avoid caffeine and chocolate.
  • Non-punitive encouragement: Avoid pull-ups, implement reward systems.

Impaired Urinary Elimination & Excess Fluid Volume

  • Nephrotic Syndrome (Minimal Change Nephrotic Syndrome - MCNS):
    • Characteristics: Kidney filtration disorder resulting in excessive protein loss in urine (mainly albumin) due to damaged glomerular basement membrane.
    • Common in children: Typically presents by age 6.
    • History & Physical Cues:
    • Nausea/Vomiting, recent sudden weight gain, periorbital to generalized edema, skin pallor or breakdown, abdominal distention.
    • FROTHY URINE: Indicates excess proteinuria.
    • Increased irritability or fussiness.
    • Heart and lung sounds may suggest fluid overload.
  • Lab Values:
    • UA: Proteinuria, possible mild hematuria.
    • Serum Albumin: Decreased.
    • Total Serum Protein: Decreased.
    • Lipid Panel: Elevated cholesterol and lipids.
    • BUN/Creatinine: Elevated with renal failure.
Priority of Care for Nephrotic Syndrome
  • Monitoring:
    • Input/Output and urine protein levels.
    • Daily weights to track fluid retention.
  • Dietary Consult:
    • Sodium restriction to manage edema.
  • Medication Management:
    • Corticosteroids (Prednisone): 60 mg/m²/day for 4-6 weeks, tapering thereafter. Monitor for side effects such as weight gain and mood swings.
    • Diuretics (furosemide): May require potassium replacement.
  • Family Education:
    • Administer medications correctly and observe for adverse effects.
    • Use of urine dipsticks at home for monitoring protein levels.
    • Consult Kidney Foundation resources for additional support.

Acute Poststreptococcal Glomerulonephritis

  • Immune-mediated glomeruli injury resulting in alteration of glomerular filtration rate:
    • Physical Cues:
    • Recent history of pharyngitis/strep throat or skin infection.
    • Symptoms include fever, lethargy, headache, abdominal pain, vomiting, decreased urine output, hypertension.
    • Edema and signs of fluid overload or congestive heart failure (CHF).
    • Urine may appear grossly hematuric.
  • Lab Diagnostics:
    • UA: Hematuria, proteinuria.
    • BUN/Creatinine: Elevated.
    • ESR: Elevated.
    • ASO Titer: Positive.
Priority of Care for Acute Poststreptococcal Glomerulonephritis
  • Monitor fluid status and manage hypertension.
  • Maintain sodium and fluid restriction during acute phase.
  • Regular daily weights and monitoring of urine output.
  • Dietary adjustments as indicated.
  • Education for families on managing blood pressure and saline restrictions.
  • Possible requirement for dialysis if renal function worsens.

Hemolytic Uremic Syndrome (HUS)

  • Pathogenesis: Verotoxins cause microthrombi and ischemic changes in small blood vessels of the glomerulus, resulting in hemolytic anemia, thrombocytopenia, and acute renal failure.
  • Physical Cues:
    • Recent gastroenteritis and bloody diarrhea.
    • Symptoms: Pallor, edema, oliguria or anuria, altered neuro status.
  • Lab Diagnostics:
    • UA: Shows proteinuria, hematuria, and possible leukocytes.
    • Serum BUN/Creatinine: Elevated.
    • CBC: Moderate to severe anemia and thrombocytopenia.
Priority of Care for HUS
  • Maintaining fluid balance, managing hypertension, and monitoring acidosis and electrolyte abnormalities.
  • Implement contact precautions for E. coli.
  • Monitor for bleeding and fatigue, report any shocks to physician.
  • Possible dialysis requirement.
  • Family education on preventive measures against infection.

Urinary Structural Disorders

Hypospadias/Epispadias
  • Definitions:
    • Hypospadias: Abnormal urethral opening on the ventral surface of the penis.
    • Epispadias: Urethral opening on the dorsal penile surface.
  • Importance: If left uncorrected, can cause issues such as erectile dysfunction.
  • Management: Typically corrected during the first year of life; circumcision is usually delayed.
Reproductive Organ Disorders
Hydrocele
  • Definition: Collection of fluid in the scrotal sac.
  • Management: Usually resolves by 12 months with no interference with fertility.
Varicocele
  • Definition: Dilated venous varicosity along the spermatic cord.
  • Effects: Can lead to infertility due to low sperm count or motility.
  • Management: May require surgical intervention if not resolving.
Cryptorchidism
  • Definition: Undescended testicle(s).
  • Risks: Increased chance of infertility and testicular cancer if not corrected.
  • Management: Surgical repair if not descended by 12 months.
Testicular Torsion
  • Definition: Strangulation of blood vessels due to rotational injury.
  • Emergency: Requires immediate surgical intervention to restore blood flow.

Diagnostic and Assessment Procedures

Common Diagnostic Tests for GU Disorders
  • Tests:
    • CBC, Serum BUN, Creatinine, Electrolytes, Urinalysis.
    • Cystoscopy, Urodynamic Studies, VCUG, IVP, Renal Biopsy, Renal/Bladder Ultrasound.
Urine Collection Techniques
  • Suprapubic Aspiration: Used in neonates and infants for sterile urine sampling.
  • Urine Collection Bags: Used for routine or 24-hour collections in children.
  • Sterile Catheterization:
    • Size selection based on age: 6 Fr for infants (birth-2 years), 10-12 Fr for older children (10-16 years).

Common Medical Treatments

  • Urinary Diversion: Surgical diversion of ureters to the abdominal wall.
  • Urinary Catheterization: Indwelling Foley catheter stays in place via an inflated balloon.
  • Ureteral Stent: A temporary drainage solution.
  • Nephrostomy Tube: Provides external drainage from the kidney.
  • Postoperative Care: Meticulous monitoring of output and signs of infection.

Common Drugs for GU Disorders

  • Anticholinergic Agents: Used for bladder spasms.
  • Antibiotics: Key in treating urinary tract infections.
  • Desmopressin: Reduces urine volume for enuresis.
  • Corticosteroids: Anti-inflammatory used in nephrotic syndrome management.
  • Immunosuppressants: May be used in renal transplants.

Prenatal and Postnatal Considerations

  • Monitor for urinary issues from fetal developments on urinalysis.
  • Parents should be educated about proper hygiene, symptoms of infections, and follow-up care.
  • Emphasize timely interventions to prevent complications from structural or functional urinary issues in newborns.