Presentation on theme: "Nursing Care of the Child with GU disorders"— Presentation transcript:
1 Nursing Care of the Child with GU disorders Revised, Fall 2010GU dysfunction is based on several evaluative toolsAs with most disorders of childhood, the incidence and type of kidney or urinary tract dysfunction changes with the age and maturation of the child
2 EnuresisRepeated involuntary voiding by a child old enough that bladder control is expected: about 5-6 yrs of age
4 Urinary tract infections Most common type of bacterial infections occurring in childrenBacteria passes up the urethra into the bladderMost common types of bacteria are those near the meatus…staph as well as e.coli
5 Urinary tract infections Most common type of bacterial infections occurring in childrenBacteria passes up the urethra into the bladderMost common types of bacteria are those near the meatus…staph as well as e.coli
6 Contributing factorsThose with lower resistance, particularly those with recurrent infectionsUnusual voiding and bowel habits may contribute to UTI in children“forget to go to bathroom”Symptoms: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 malesOlder 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.
7 Therapeutic management Eliminate the current infectionsIdentify contributing factors to reduce the risk of re-infectionPrevent systemic spread of the infectionPreserve renal functionAntibiotic 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 bec. Of resistant organisms. Penicillins, sulfonamides, cephalosporins, and nitrofuradantion. If anatomic defect such as primary reflux or bladder ncek obstruction are preesent, surgical corrections of these abnormalities may be necessary to prevent recurrent infections. Aim of therapy and careful follow-up is to reduce the change of renal scarring. However, recurrecnt infection of the urinary bladder predisposes the individual to transietn episodes of vesicoureteral reflux.
8 FYIThe single most important host factor influencing the occurrence of UTI is urinary stasisWhat is the chief cause of urinary stasis?Delayed emptying, usually dr/t bladder neck spasmssOrdinarily urine is sterile, but at 98.6 degrees, it provides an excellent culture mediumTechnically by completely emptying cladder flushes away any organisms before they have an opportunity to multiply and invade surrounding tissue
10 Vesicoureteral Reflux Approximately 20% of children that have UTIs will be found to have vesicoureteral reflux on xrayReflux 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
11 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.
12 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
13 Treatment for vesicoureteral reflux Directed toward preventing UTIsManaged by time or surgery if a lower gradeSingle doses each day of abx as long as reflux lastsUrine cultures done q 6 wks up to 3 months to make sure no “silent infection”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
16 Bladder Exstrophy Bladder wall extrudes through the abdominal wall Characteristic findings in bladder exstrophy include the following:Anterior vagina and rectum (which may prolapse)Epispadias, bifid clitoris, penis, or scrotumDorsal chordeePoor urinary sphincter controlWaddling gait due to outward and downward rotation of the anterior pelvic ring and pubic symphysis diastasis
17 Exstrophy of the Bladder, cont. Treatment: surgical reconstruction done 1st after birthGoals:Bladder/abd wall closurePreserve urinary functionCreate normal appearinggenitalia-improvement of sexual functionBladder exstrophy4 (hypogastric omphalocele) occurs in 3.3 per 100,000 births. The bladder develops at 5-9 weeks' gestation, and urine mixes with amniotic fluid by 10 weeks' gestation. The bladder is visible on ultrasonography by the end of the first trimester. Bladder mucosa is soft and pliable at birth, but within 48 hours of exposure, it becomes inflamed and polypoid. Later in life, it may undergo malignant degeneration. Surgical reconstruction to achieve continence, voluntary micturition, and correct vesicoureteral reflux is indicated.
18 Nursing care, cont. Control bladder spasms Control pain Increase fluid intakeDo not allow to play on straddle toysPrevent infection (no bathing or swimming until stents removedCall dr if: temp >101; anorexia, pus or bleeding from stent, cloudy or foul smelling urineSpasms due to presence of catheters; controlled by relaxants (Ditropan and Probanthine)
19 Etiology and Pathophysiology Hypospadias:occurs from incomplete development of urethra in uteroDefect ranges from mild to severeUndescended testes may also be presentMight interfere with fertility in the mature male if not correctedEpispadias: rare and often associated with extrophy of bladder
23 Ask yourself?Why would the nurse question an order to prepare the infant for a circumcision?
24 The reason for surgery at About 1 year of age is Because: Children will experience less painChordee may be reabsorbedThe child has not developed body image andcastration anxietyd. The repair is easier before toilet trainingAnswer: C
25 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.
26 CryptorchidismFailure of one or both of the testes to descend from abdominal cavity to the scrotum
27 Cryptorchidism Defined as failure of one or both testes to descend TreatmentObjective of treatmentTreatment may be medical for OLDER child (HcG) or surgical for the young (orchiopexy)Objectives of therapy: prevent damage to undescended testicle, decrease incidence of malignant tumor formation, avoid trauma and torsion, close inguinal canal, prevent cosmetic and psychoologic disability from emptoy scrotum“Orchiplexy” done to descend the testes because increased incidence of testicular CA in boys with undescended testes
28 Therapeutic interventions for undescended testes Surgery: Orchiopexy done via laproscopy (around 1 yr of age)Post-op nursing care: minimal activity for few days, allow to express fears about castration, mutilation by playng with puppets or dolls
29 Why is it important that the Testes are in the scrotal sac?
30 AnswerThe higher temperatures in the abdomen than in the scrotum results in morphologic changes to the testes-mainly concerned with lower sperm counts at sexual maturity
31 Assessment on NB examPalpate the testes separately between thumb and forefinger, with thumb and forefinger of other hand over the inguinal canal. A light may also be shined through the back side of the scrotum to visualize the testes
32 Glomerular diseasesNephrotic syndrome (MCNS) or minimal-change nephrotic syndromeAcute glomerulonephritis (AGN)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 cases32
33 AGN Immune-complex disease causing inflammation of glomeruli of kidney Usual organism is group A beta-hemolytic strepDecreased glomerular filtrationCommon in children (boys > girls)Assessment/diagnostic tests:AGN results from an infection elsewshere in the body (skin or pharynx) Assessemnt: sudden onset of hematuria, next oliguira. It affects the cardiac by causing edema, hypertension for hyperfolemia which can leaqd to CHF, pulmonary edema.Diagnostic: urinalysis (**all children should have a urinalysis 2 wks after strep infection)Diagnostic: ESR, ASO titer (measure antibody formation against strep)
34 What’s really happening in AGN? Decreased glomerular filtration leads toinc. Na and H2OProtein molecules filter thru damagedglomeruliDamage leads to hematuriaHigh B/P; heart failure may ensuePhases: edematous (4-10 days);Diuresis phase
35 AGN Treatment and nursing care: Bed rest may be recommended during the acute phase of the diseaseA record of daily weight is the most useful means for assessing fluid balanceTreatment and nursing care: depends on the severity of the diease and tends to be more symptomatic. The disease is self-limiting
36 Nursing diagnosis for the child with glomerulonephritis Fluid volume excess r/t to decreased plasma filtrationActivity intolerance r/t fatigueAltered patterns of urinary elimination r/t fluid retention and impaired filtrationAltered family process r/t child with chronic disease, hospitalizations
37 Nursing care specific to the child with AGN Allow activities that do not expend energyDiet should not have any added saltFluid restriction, if prescribedMonitor weightsEducation of the parentsStrenuous activity is usually restrictd until there is no evidence of protein or macroscopic hematuris, which may persist for monthsThe effectiveness of nursing intervention is determined by continual reassessment and evaluation of care
38 Nephrotic syndromeUnderstanding kidneys and urine. The kidnesy lie to the sides of the upper abd., behind the intestines and are bean-shapedA 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.
39 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
40 Contrast of normal gloumerular activity with changes seen in Nephrotic SyndromeNote 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.
41 Treatment of nephrotic syndrome Varies with degree of severityTreatment of the underlying causePrognosis depends on the causeChildren usually have the “minimal change syndrome” which responds well to treatmentDiuretics help to clear the body of edemaMay 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 kidneysSteroid 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.
43 Therapeutic management Corticosteroids (prednisone)Dietary managementRestriction of fluid intakePrevention of infectionsMonitoring for complications: infections, severe GI upset, ascites, or respiratory distressIn most children the response to steroids will occur in 7-21 days.
44 Critical thinking for client undergoing urinary tract surgery The Scotts are receiving pre-op instructions before their son David’s surgery for reimplantation of the ureters. David is 5 years old. In addition to discussion of post-op pain, tubes and dressings, the most significant other topic would be which of the following?A. Need to reassure David his genitals are intact and will function normally when the c atheters are removedB. Important of monitoring the urine drainage from stents and urethral catheterC. Need to assess the surgical site for bleeding or excessive drainageD. The home care regimen that can be anticipated on David’s discharge from the hospitalCorrect answer: AMonitoring urine drainage and assessing the surgical site are post-op priorities for the nurse. Parents, when present, will often notify the nurse of their observations. Parents will need to learn about the anticipate homedcare and follow-up regimenDavid’s concern about his genital being intact is the parents’ higher priority. Developmentally, he is most concerned about the possibility of mutilation, castration, and punishment for wrongdoing, which in his case may include accidental urination. His parents are the most appropriate persons to reassure him, and they need to know that this is a priority for them and David