1. Nursing Care of the Child with GU disorders
Revised, Fall 2010
GU dysfunction is based on several evaluative tools
As 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. Enuresis
Repeated involuntary voiding by a child old enough that bladder control is expected: about 5-6 yrs of age

3. Enuresis Multitreatment approach
Fluid restriction
Bladder exercises
Timed voiding
Enuresis alarms
Reward system
Medications
DDAVP

4. Urinary tract infections
Most common type of bacterial infections occurring in children
Bacteria passes up the urethra into the bladder
Most 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 children
Bacteria passes up the urethra into the bladder
Most common types of bacteria are those near the meatus…staph as well as e.coli

6. Contributing factors
Those with lower resistance, particularly those with recurrent infections
Unusual 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 males
Older 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 infections
Identify contributing factors to reduce the risk of re-infection
Prevent systemic spread of the infection
Preserve renal function
Antibiotic 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. FYI
The single most important host factor influencing the occurrence of UTI is urinary stasis
What is the chief cause of urinary stasis?
Delayed emptying, usually dr/t bladder neck spasmss
Ordinarily urine is sterile, but at 98.6 degrees, it provides an excellent culture medium
Technically by completely emptying cladder flushes away any organisms before they have an opportunity to multiply and invade surrounding tissue

9. Obstructive Uropathy

10. Vesicoureteral Reflux
Approximately 20% of children that have UTIs will be found to have vesicoureteral reflux on xray
Reflux 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 UTIs
Managed by time or surgery if a lower grade
Single doses each day of abx as long as reflux lasts
Urine 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

14. Diagnostics: VCUG
Voiding cystoureteral gram

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 scrotum
Dorsal chordee
Poor urinary sphincter control
Waddling 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 birth
Goals:
Bladder/abd wall closure
Preserve urinary function
Create normal appearing
genitalia
-improvement of sexual function
Bladder 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 intake
Do not allow to play on straddle toys
Prevent infection (no bathing or swimming until stents removed
Call dr if: temp >101; anorexia, pus or bleeding from stent, cloudy or foul smelling urine
Spasms due to presence of catheters; controlled by relaxants (Ditropan and Probanthine)

19. Etiology and Pathophysiology
Hypospadias:occurs from incomplete development of urethra in utero
Defect ranges from mild to severe
Undescended testes may also be present
Might interfere with fertility in the mature male if not corrected
Epispadias: rare and often associated with extrophy of bladder

20. hypospadias

21. Epispadias
Congenital urethral defect in which the uretheral opening is on the upper aspect of the penis and not on the end

22. Assessment
Usually discovered during
Newborn Physical Assessment

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 pain
Chordee may be reabsorbed
The child has not developed body image and
castration anxiety
d. The repair is easier before toilet training
Answer: 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. Cryptorchidism
Failure 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
Treatment
Objective of treatment
Treatment 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. Answer
The 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 exam
Palpate 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 diseases
Nephrotic syndrome (MCNS) or minimal-change nephrotic syndrome
Acute 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 cases 32

33. AGN Immune-complex disease causing inflammation of glomeruli of kidney
Usual organism is group A beta-hemolytic strep
Decreased glomerular filtration
Common 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 to
inc. Na and H2O
Protein molecules filter thru damaged
glomeruli
Damage leads to hematuria
High B/P; heart failure may ensue
Phases: edematous (4-10 days);
Diuresis phase

35. AGN Treatment and nursing care:
Bed rest may be recommended during the acute phase of the disease
A record of daily weight is the most useful means for assessing fluid balance
Treatment 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 filtration
Activity intolerance r/t fatigue
Altered patterns of urinary elimination r/t fluid retention and impaired filtration
Altered family process r/t child with chronic disease, hospitalizations

37. Nursing care specific to the child with AGN
Allow activities that do not expend energy
Diet should not have any added salt
Fluid restriction, if prescribed
Monitor weights
Education of the parents
Strenuous activity is usually restrictd until there is no evidence of protein or macroscopic hematuris, which may persist for months
The effectiveness of nursing intervention is determined by continual reassessment and evaluation of care

38. Nephrotic syndrome
Understanding kidneys and urine. The kidnesy lie to the sides of the upper abd., behind the intestines and are bean-shaped
A 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 Syndrome
Note 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 severity
Treatment of the underlying cause
Prognosis depends on the cause
Children usually have the “minimal change syndrome” which responds well to treatment
Diuretics help to clear the body of edema
May 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 kidneys
Steroid 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.

42. Child with nephrotic syndrome

43. Therapeutic management
Corticosteroids (prednisone)
Dietary management
Restriction of fluid intake
Prevention of infections
Monitoring for complications: infections, severe GI upset, ascites, or respiratory distress
In 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 removed
B. Important of monitoring the urine drainage from stents and urethral catheter
C. Need to assess the surgical site for bleeding or excessive drainage
D. The home care regimen that can be anticipated on David’s discharge from the hospital
Correct answer: A
Monitoring 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 regimen
David’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