1. Nursing Care of the Child with GU disorders
Summer 2009
Lea Melvin, MSN, RN, CRRN, CWOCN
Austin Community College
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. Radiography and other tests of urinary system function
Urine culture & sensitivity
Renal/
bladder US
VCUG
Imaging studies
Testicular US
Scout film
IVP
Renal bx, cysto
Be sure and don’t start abx prior to collecting the culture and sensitivity!
Scout film: flat plate xray of abd., pelvis for kidnesy, ureters, bladder (also called a flat plate or KUB
Nuclear cystogram: a radioactive fluid is injected through the uretheral cath until bladder is full; images generated before, during and after voiding
Voiding cystourethrography: contrast medium injected into bladder through cath until bladder is full; films taken before, during and after voiding
Whitaker perfusion test; injection of contrast material through renal pelvis and ureters pressure is measure d in renal pelvis and urinary bladder
Whitaker perfusion test

3. Physical tests for Gu function
Volume for polyuria, oliguria
Specific gravity
Osmolality
Appearance
Chemistries on urine (√ for blood, WBCs, bacteria, casts)
These values are age related: NB bladder capacity ml; children: capacity in ounces=ages (years)+2…4yo bladder capacity+6 oz=360mls
Osmolality: same as for specific gravity, but more sensitive
Appearance; does it contain sediment? Color? Cloudy?
Chemistries: appearance of casts is an indicator for tubular or glomerular disorders; degenerative process in advanced renal disease; pyelonelpritis, proteinuria; usually transient

4. Blood tests of renal function
BUN (blood urea nitrogen)
Uric acid
Creatinine
BUN range for NB: 4-18; for child If elevated, renal disease—acute or chronic (the higher the BUN the more severe the disease
Uric acid: increased suggests severe renal disease
Creatinine: ncreased suggests severe renal disease

5. Nursing responsibilities with testing
Responsible for preparation and collection of urine or blood
Maintains careful intake and output
Recognizes that renal disease can diminish the glomerular filtration rate
A number of substances can be used, but the most useful clinical estimation of glomerular filtration is the clearance of creatinine, and end product of protein metabolism in muscle and a substance that is freely filtered by the glomerulus and secreted by renal tubular cells. GFR=the amt of plasma from which a given substance is totally cleared in one minute. It is usually done on a hr. specimen.

6. Extrophy of the Bladder Hypospadius / Epispadius Cryptochidism
External Defects
Extrophy of the Bladder
Hypospadius / Epispadius
Cryptochidism

7. Hypospadias
Epispadias

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

9. Hypospadias Congenital urethral defect in which
the uretheral opening is on the
lower aspect of the penis and not
on the tip. May have associated chordee.
chordee (a fibrous band that causes the penis to curve downward),

10. Hypospadius Occurs from incomplete development of urethra in utero.
Occurs in 1 of 100 male children. Increased risk if father or siblings have defect.
Ranges from mild to severe.
Cyrptorchidism/Undescended testes may be found in conjunction with hypospadias.
mild (meatus is just below tip); to meatus on the perineum between scrotum, ventral foreskin lacking
Cryoptorchidism might interfere with fertility in the mature male if not corrected. Also associated with testicular cancer.

11. Assessment
Usually discovered during
Newborn Physical Assessment

12. Interventions Medical Treatment: Surgery
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.

13. The reason for surgery at about 1 year of age is because:
a. children will experience less pain.
b. chordee may be reabsorbed.
c. the child has not developed body image
and castration anxiety.
d. the repair is easier before toilet training.
C is the correct answer. The psychological effects are minimized when correction is done early.

14. Post –op Nursing Care
1. Assess pressure dressing (use to control bleeding.
2. Maintain urinary drainage.
3. Control bladder spasms.
Antispasmotics (relax the bladder muscle)
Pro-Banthine (probantheline)
Ditropan (oxybutinin)
Levsin (hyoscyamine)
1. Assess bleeding - Bleeding is controlled post-operatively by the use of pressure dressings. However, a small amount of bleeding for the first several days post-operatively is normal. A few drops of blood or a spot no larger than a quarter on the diaper is acceptable.
2. Maintain urinary drainage – care for catheter – foley/suprapbic, or urethral stent
3. Control Bladder Spasms usually due to the presence of the in-dwelling catheters are common post-operatively and are controlled by medications that relax the bladder (ie. Antispasmotics- Pro-Banthine and Ditropan)

15. 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.

16. 5. Increase fluids intake.
4. Control Pain.
5. Increase fluids intake.
6. Do not allow to play on any straddle toys.
7. Prevent infection. – no bathing or swimming until
stents removed.
8. Discharge teaching:
When to call doctor.
No bathing or swimming until stents removed.
Pain is usually controlled with Tylenol
5. Increase fluids intake – assists in
maintaining hydration and free flow of urine.
6. Do not allow to play on any straddle toys.
7. Prevent infection – no bathing or swimming until
stents removed.
8. Call Dr if:
temp is over 101
loss of appetite
pus or increased bleeding from stent
cloudy or foul smelling urine

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

18. Etiology and Pathophysiology
Testes usually descend into the scrotal sac during the 7-9 gestation
They may descend anytime up to 6 weeks after birth. Rarely descend after that time.
Cause unknown
Theories
Inadequate length of spermatic vessels
Lowered testosterone levels

19. Diagnosed on Newborn Physical Exam
Assessment
Diagnosed on Newborn Physical Exam

20. Therapeutic Interventions
Surgery
Orchiopexy done via laproscopy
Done around 1 year of age
Nursing Care – Post-op
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.

21. Why is early surgery important?
Morphologic changes to testis from higher temperature in abd cavity
Decreased sperm count=infertility?
Testicular cancer

22. Obstructive Uropathy Vesicoureteral reflux Posterior urethral valves
Ureteropelvic junction defect
Will discuss PUVs and UPJs with Congenital Midline Anomalies – here to help student organize data

23. Vesicoureteral Reflux
Abnormal backflow (retrograde) of urine from the bladder into the ureters and possibly kidneys when the bladder contracts during emptying/voiding.
Happens in infants with reflex emptying, during voiding in continent individual, in clients with spinal cord injuries or spina bifids with spastic AKA reflexic neurogenic bladder.

24. 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.

25. Pathophysiology
Reflux occurs because the valve that guards the entrance from the bladder to the ureter is defective from:
Primary reflux – congenital abnormal insertion of ureters into the bladder
Secondary reflux – repeated UTI’s cause scarring of valve
Bladder pressure that is stronger than usual, neurogenic bladder
Backflow happens at voiding when bladder contracts, urine is swept up the ureters
Results in stasis of urine in ureters or kidneys which in turn leads to infection or hydronephrosis.
Not really a valve per se; it is a tunneling of the ureteral insertion point that acts like a valve upon filling of the bladder.

26. Vesicoureteral Reflux Grades I through V
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

27. Assessment Fever, chills Vomiting
Straining/crying on urination, poor urine stream
Enuresis (bedwetting), incontinence in a toilet trained child, frequent urination.
Strong smelling urine
Abdominal or back/flank pain

28. 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

29. Diagnostic Tests Cystourethrogram (VCUG) Urine culture
Renal ultrasound
(RUS)
Renal unltrasound: measures the sound waves to determine and shape of kidneys, ureters and bladder
VCUG: uses xrays to examine the bladder and urethra. These tests require catheterization of the bladder and uses contrast.
Urine culture done every 2-3 months
VCUG
RUS or renal ultrasound - a non-invasive test in which a transducer is passed over the kidney producing sound waves which bounce off the kidney, transmitting a picture of the organ on a video screen. The test is used to determine the size and shape of the kidney, and to detect a mass, kidney stone, cyst, or other obstruction or abnormalities.

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

31. Goals of treatment Directed toward preventing UTIs
Managed by time or surgery if grade 4 or 5
Single doses each day of abx as long as reflux lasts
Urine cultures done q 6 wks –3 mos
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.
Urine cultures are don’t to identify silent infection = asymptomatic infection.

32. Nursing Care I&O - Keep records from stents and catheter separate.
Secure stents and catheter to prevent displacement.
Vital signs for signs of infection.
Control pain.
Discharge Teaching
- prevention of UTI
- importance of taking all antibiotics
- continue taking antiseptics even when have no symptoms.
Decreased output from stent could indicate obstruction.
Handle child gently Administer pain medications

33. Evaluation Follow-up = VCUG in 3-4 months Renal SPECT
RCG (radionucleaotide cystogram)
Renal unltrasound: measures the sound waves to determine and shape of kidneys, ureters and bladder
VCUG: uses xrays to examine the bladder and urethra. These tests require catheterization of the bladder and uses contrast
Renal SPECT: determines if infected refluxing urine has scarred the kidney.
RCG: examines the bladder using radio-isotopes which use less radiation, but is slightly lass accurate

34. 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
d. Escherichia coli, a common gram negative enteric bacterium.

35. Urinary Tract Infections

36. 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

37. 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 vary by age of child
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.

38. 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 because of resistant organisms. Penicillins, sulfonamides, cephalosporins, and nitrofuradantion. If anatomic defect such as primary reflux or bladder neck obstruction are present, surgical corrections of these abnormalities may be necessary to prevent recurrent infections. Aim of therapy and careful follow-up is to reduce the chance of renal scarring. However, recurrent infection of the urinary bladder predisposes the individual to transient episodes of vesicoureteral reflux from inflammation and holding because of painful urination.
Wipe front to back, increase fluids, no bubble baths, void after intercourse. Change diaper or menstrual pad q4hrs.

39. Therapeutic Interventions
Drug Therapy
Antibiotics – specific to causative organism
Analgesics – Tylenol
Nursing Care
Force fluids – childs choice
Dysuria – sit in warm water in bathtub and void into the water

40. Parent Teaching Change diaper frequently
Teach girls to wipe front to back
Discourage bubble baths
Encourage fluids frequently throughout day
Bathe daily
Adolescent girls when menstruating are to change of pad every 4 hours
Teach to void immediately after intercourse

41. 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 from bladder neck spasms
Ordinarily urine is sterile, but at 98.6 degrees, it provides an excellent culture medium
Technically by completely emptying bladder flushes away any organisms before they have an opportunity to multiply and invade surrounding tissue. In neurogenic bladder you can cure a UTI by increasing frequency of the catherization.

42. Glomerular diseases Acute glomerulonephritis (AGN)
Nephrotic syndrome (MCNS) or minimal-change nephrotic syndrome
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

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

44. Nephrotic syndrome
The kidneys lie to the sides of the upper abdomen, 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.

45. 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

46. 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.

47. Etiology
Insidious onset with periods of remission / exacerbations throughout life- No cure
95% idiopathic, possibly a hypersensitivity reaction.
Other causes: post acute glomerulonephritis, sickle cell disease, Diabetes Mellitus, or drug toxicity.
Usually seen in preschool yrs (2-4). M>F
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

48. Assessment Four most common characteristics: Massive proteinuria
Hypoalbuminemia (K+ normal, BP normal)
Edema – usually starts in periorbital area and dependent areas of the body and progresses to generalized, massive edema. Pitting edema of 4+. Caused by hypo albumin which causes shift of fluids to extracellular space. *There is an insidious weight gain- shoes don't fit, etc
Hyperlipidemia
* Of note is that there is no
hematuria or hypertension
Hyperlipidemia = result of liver increases production of lipoproteins to try to compensate for protein loss-lipids are to large to be lost in urine Book says hypertension.

49. Other signs and symptoms
Fatigue
Anorexia
Weight gain
Abdominal pain – from large amount of fluid in abdominal

50. 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.

51. 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 appetite, proteinuria, edema
d. body image change, hypotension
c. Poor appetite, proteinuria, edema
Don’t have hematuria, book says hypertension but notes disagree, do not have hypotension.

52. Acute Glomerulonephritis
Immune-complex disease which causes inflammation of the glomeruli of the kidney as a result of an infection elsewhere in the body.

53. Acute Glomerulonephritis
Infection from group A beta-hemolytic Streptococcus causes an
immune response that causes inflammation and damage to the glomeruli. More boys that girls.
Protein and red blood cells are allowed to pass through the glomeruli.
Blood flow to the glomeruli is reduced due to obstruction with
damaged cells and renal insufficiency results, leading to the
retention of sodium, water, and waste. 53

54. Etiology/Pathophysiology
Usual organism is Group A beta-hemolytic streptococcus
Organism not found in kidney, but the antigen-antibody complexes become trapped in the membrane of the glomeruli causing inflammation, obstruction and edema in kidney
The glomeruli become inflamed
and scarred, and slowly lose their
ability to remove wastes and excess
water from the blood to make urine.

55. 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 disease and tends to be more symptomatic. The disease is self-limiting.

56. 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 restricted 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

57. 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.

58. 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

59. Take a Break

60. Surgical procedures Vesicostomy Ureterostomy
Mitrafanoff catheterizable stoma
Malone Antegrade Colonic Enema stoma (MACE or ACE)

61. Post-op nursing care Care of stoma Skin protection
Care of stents, tubes, drains
Signs and symptoms of problems

62. Mitrafanoff appendiceal stoma
Creation of catheterizable channel from skin to bladder
Channel is created from reversed appendix that is attached to bladder that has usually been augmented (made bigger). End of appendix brought to skin has nipple valve created and is usually place in the umbilicus.

63. Post-op care for Mitrofanoff
Stoma with stents and catheter protruding from it.
Keep skin clean, dry and protected.
Discharged home with stents and catheter in place.
Teach care, prevention of infection, when to call, return visit.

64. Teaching for Mitranoff usually done as outpatient
Clean intermittent catheterization using long vinyl coude tipped catheter, usually a size 12
Must catheterize or will go into renal failure
Bladder neck is either closed or suspended to prevent leakage

65. Malone Antegrade Colonic Enema
Creation of catheterizable channel from ascending colon to skin of abdomen for purpose of giving colonic irrigation every other day
Renders the child bowel continent
Channel is fashioned from piece of small intestine and brought to skin in nipple valve

66. Post-op care for MACE Stoma with catheter protruding from it.
Keep skin clean, dry and protected.
Discharged home with catheter in place.
Teach care, prevention of infection, when to call, return visit.

67. Teaching for MACE Must irrigate every other day to maintain continence
Use mild enema solution
Maintain schedule for frequency
Allow time for evacuation

68. Nursing assessment Ask child where stomas are and which one is which
Allow child to do procedure as at home with usual ritual
Must be done even if child is ill with unrelated disorder