NURSING MANAGEMENT
OF GENITOURINARY
DYSFUNCTION:
Theoretical Skills and Knowledge,
Scientific Principles, Critical
Thinking, Healthcare Promotion,
Wellness and Illness, and Stress
Adaptation
Lecture Objectives:
1.
2.
3.
4.
5.
Describe common renal and urinary
disorders that occur in children.
Assess a child for a renal or urinary tract
disorder.
Formulate nursing diagnoses related to
renal or urinary tract disorders.
Establish outcomes related to the care of
a child with renal or urinary disorder.
Plan nursing care related to urinary or
renal disorders.
Lecture Objectives (cont.)
6.
7.
8.
9.
10.
11.
Implement nursing care for the child with a
renal or urinary disorder.
Evaluate outcomes for achievment and
effectiveness of care.
Analyze methods for making nursing care of the
child with a renal or urinary disorder more
family centered.
Compare and contrast acute and chronic renal
failure.
Discuss the types of renal dialysis.
Assess for signs of kidney transplant rejection.
Reading Assignment:

Wong, Perry & Hockenberry
Ch. 50; p 1643-1669
Renal System Assessment

Physical assessment
– Palpation, percussion

Health history
– Previous UTIs, calculi, stasis,
retention, pregnancy, STDs, bladder
cancer
– Meds: antibiotics, anticholinergics,
antispasmodics
– Urologic instrumentation
– Urinary hygiene
– Patterns of elimination
Nursing Assessment
of Urinary Tract Infection
(UTI)
Nausea, vomiting, anorexia,
chills, nocturia, frequency,
urgency
 Suprapubic or lower back pain,
bladder spasms, dysuria,
burning on urination

Nursing Assessment
of Urinary Tract Infection
(UTI)

Objective data
– Fever
– Hematuria, foul-smelling urine; tender,
enlarged kidney
– Leukocytosis, positive findings for
bacteria, WBCs, RBCs, pyuria,
ultrasound, CT scan, IVP
Diagnostic Studies
Renal scan
 Cystogram
 Retrograde
pyelogram
 Ultrasound
 CT
 MRI
 Renal arteriogram

UA
 Urine C&S
 BUN
 Creatinine
 KUB
 IVP
 VCG/VCUG

Normal Urinalysis
pH: 5 to 9
Sp gr: 1.001 to 1.035
Protein: <20 mg/dl
Urobilinogen: up to 1
mg/dl
 None of the following:




– Glucose
– Ketones
– Hgb
– WBCs
– RBCs
– Casts
– Nitrite
Normal Characteristics of Urine
Color range
 Clear
 Newborn production—approx 1-2
ml/kg/hr
 Child production—approx 1 ml/kg/hr

Urinary Tract Infection (UTI)
Is it really that
serious?
 Concept of
“asymptomatic
bacteria” in urinary
tract

Urinary Tract Infection (UTI)

Causes

Escherichia coli most
common pathogen
 Streptococci

Staphylococcus
saprophyticus

Occasionally fungal and
parasitic pathogens
Classification of UTI

Upper tract: involves renal
parenchyma, pelvis, and ureters
– Typically causes fever, chills, flank
pain

Lower tract: involves lower urinary
tract
– Usually no systemic manifestations
Classification of UTI
Lower tract
 Cystitis
 Urethritis
 Glomerulonephritis

Upper tract
 Pyelonephritis
 VUR

Classification of UTI
Uncomplicated infection
 Complicated infections

– Stones
– Obstruction
– Catheters
– Diabetes or neurologic
disease
– Recurrent infections
Types of UTIs
Recurrent—repeated episodes
 Persistent—bacteriuria despite
antibiotics
 Febrile—typically indicates
pyelonephritis
 Urosepsis—bacterial illness; urinary
pathogens in blood

Etiology and
Pathophysiology of UTI

Physiologic and mechanical
defense mechanisms maintain
sterility
– Emptying bladder
– Normal antibacterial properties of
urine and tract
– Ureterovesical junction
competence
– Peristaltic activity
Etiology and Pathophysiology of
UTI
Alteration of defense
mechanisms increases risk
of UTI
 Organisms usually
introduced via ascending
route from urethra
 Less common routes

– Bloodstream
– Lymphatic system
Etiology and Pathophysiology of
UTI

Contributing factor: urologic
instrumentation
– Allows bacteria present in opening of
urethra to enter urethra or bladder

Sexual intercourse promotes
“milking”
of bacteria from perineum and
vagina
– May cause minor urethral trauma
Etiology and Pathophysiology of
UTI
UTIs rarely result from
hematogenous route
 For kidney infection to occur
from hematogenous
transmission, must have prior
injury to urinary tract

– Obstruction of ureter
– Damage from stones
– Renal scars
Etiology and Pathophysiology of
UTI

UTI is a common nosocomial
infection
– Often E. coli
– Seldom Pseudomonas

Urologic instrumentation
common predisposing factor
Clinical Manifestations of UTI

Symptoms
– Dysuria
– Frequent urination (>q2h)
– Urgency
– Suprapubic discomfort or
pressure
Clinical Manifestations of UTI
Urine may contain visible blood or
sediment (cloudy appearance)
 Flank pain, chills, and fever
indicate infection of upper tract
(pyelonephritis)

Pediatric Manifestations
Frequency
 Fever in some cases
 Odiferous urine
 Blood or blood-tinged urine
 Sometimes NO symptoms
except generalized sepsis

Pediatric Manifestations
Pediatric patients with
significant bacteriuria may have
no symptoms or nonspecific
symptoms like fatigue or
anorexia
 So how do you find out?

Diagnostic Studies of UTI
Dipstick
 Microscopic
urinalysis
 Culture

Diagnostic Studies of UTI
Clean-catch is preferred
 U-bag for collection from child
 Specimen obtained by
catheterization or suprapubic
needle aspiration has more
accurate results

– May be necessary when clean-catch
cannot be obtained
Diagnostic Studies of UTI
Sensitivity testing determines
susceptibility to antibiotics
 Imaging studies for suspected
obstruction

– IVP or Abd CT
Collaborative Care for UTI
Drug Therapy: Antibiotics
Uncomplicated cystitis: shortterm course of antibiotics
 Complicated UTIs: long-term
treatment

Collaborative Care for UTI
Drug Therapy: Antibiotics






Trimethoprim-sulfamethoxazole (TMPSMX) or nitrofurantoin
Amoxicillin
Cephalexin
Others
– Gentamycin, carbenicillin ++
Pyridium (OTC)
Combination agents (e.g., Urised) used to
relieve pain
– Preparations with methylene blue tint
Collaborative Care for UTI
Drug Therapy

For repeated UTIs
– Prophylactic or suppressive
antibiotics
– TMP-SMX administered daily to
prevent recurrence or single
dose before events likely to
cause UTI
Etiology and Pathophysiology
of Acute Pyelonephritis
Inflammation caused by
bacteria, fungi, protozoa, or
viruses infecting kidneys
 Urosepsis: systemic infection
from urologic source

– Can lead to septic shock and death
in 15% of cases
Etiology and Pathophysiology
of Acute Pyelonephritis
Usually infection is
via ascending
urethral route
 Frequent causes

– E. coli
– Proteus
– Klebsiella
– Enterobacter
Etiology and Pathophysiology
of Acute Pyelonephritis
Commonly starts in renal
medulla and spreads to
adjacent cortex
 Recurring episodes lead to
scarred, poorly functioning
kidney and chronic
pyelonephritis

Clinical Manifestations
of Acute Pyelonephritis

Vary from mild to “classic” and very severe

Presenting symptoms
– N/V, anorexia, chills, nocturia, frequency,
urgency
– Suprapubic or low back pain, dysuria
– Fever, hematuria, foul-smelling urine

Costovertebral tenderness

Symptoms often subside in a few days, even
without therapy
– Bacteriuria and pyuria still persist
Diagnostic Studies
of Acute Pyelonephritis
Urinalysis
 WBC casts
 CBC
 Imaging studies (IVP
or CT)
 Ultrasound

Collaborative Care
of Acute Pyelonephritis
Hospitalization
 Parenteral
antibiotics

Collaborative Care
of Acute Pyelonephritis
Relapses treated with 6-week
course of antibiotics
 Reinfections treated as
individual episodes or
managed with long-term
therapy

– Prophylaxis may be used for
recurrent infections
Types of Glomerulonephritis

Most are postinfectious
– Pneumococcal, streptococcal,
or viral
May be distinct entity or
 May be a manifestation of
systemic disorder

– SLE
– Sickle cell disease
– Others
Glomerulonephritis
Symptoms

Generalized edema due to
decreased glomerular filtration
– Begins with periorbital
– Progresses to lower extremities
and then to ascites
HTN due to increased ECF
 Oliguria

Glomerulonephritis Symptoms

Hematuria
– Bleeding in upper urinary
tract→smoky urine

Proteinuria
– Increased amount of protein =
increased severity of renal disease
Acute Post-Streptococcal
Glomerulonephritis






Is a noninfectious renal disease
– Autoimmune
Onset 5 to 12 days after other type of
infection
Often group A ß-hemolytic streptococci
Most common in 6 to 7 years old
Uncommon in <2 years old
Can occur at any age
Diagnosing APSG
Prognosis
95%—rapid improvement to
complete recovery
 5% to 15%—chronic
glomerulonephritis
 1%—irreversible damage

Nursing Management of
APSG

Manage edema
– Daily weights
– Accurate I&O
– Daily abdominal girth

Nutrition
– Low sodium, low to
moderate protein
Susceptibility to infections
 Bed rest is not necessary

Nephrotic Syndrome
Most common presentation of
glomerular injury in children
 Characteristics

– Proteinuria
– Hypoalbuminemia
– Hyperlipidemia
– Edema
– Massive urinary protein loss
Types of Nephrotic
Syndrome

Minimal change nephrotic syndrome
(MCNS)
– AKA
 Idiopathic nephrosis
 Nil disease
 Uncomplicated nephrosis
 Childhood nephrosis
 Minimal lesion nephrosis
Congenital nephrotic syndrome
 Secondary nephrotic syndrome

Changes in Nephrotic
Syndrome

Glomerular membrane
– Normally impermeable to large proteins
– Becomes permeable to proteins,
especially albumin
– Albumin lost in urine
(hyperalbuminuria)
– Serum albumin decreased
(hypoalbuminemia)
– Fluid shifts from plasma to interstitial
spaces
 Hypovolemia
 Ascites
Nephrotic Syndrome
Management


Supportive care
Diet

Steroids
– Low to moderate protein
– Sodium restrictions when large
amount edema present
– 2 mg/kg divided into BID doses
– Prednisone drug of choice ($$ and
safest)
Immunosuppressant therapy
(Cytoxan)
 Diuretics

Family Issues
Chronic condition with relapses
 Developmental milestones
 Social isolation

– Lack of energy
– Immunosuppression/protection
– Change in appearance due to
edema
– Self-image
Nursing Interventions
Aseptic technique during
catheterizations
 Avoid unnecessary catheterization
and early removal of indwelling
catheters

 Prevents nosocomial infections
– Wash hands before and after contact
– Wear gloves for care of urinary system
Nursing Interventions
Routine and thorough perineal care
for all hospitalized patients
 Avoid incontinent episodes by
answering call light and offering
bedpan at frequent intervals

Nursing Interventions

Ensure adequate fluid intake
(patient with urinary problems may
think will be more uncomfortable)
– Dilutes urine, making bladder less
irritable
– Flushes out bacteria before they can
colonize
– Avoid caffeine, alcohol, citrus juices,
chocolate, and highly spiced foods
 Potential bladder irritants
Nursing Interventions
Discharge to home instructions
 Follow-up urine culture

 Recurrent symptoms typically occur in 1 to 2
weeks after therapy
– Encourage adequate fluids even after
infection
– Low-dose, long-term antibiotics to
prevent relapses or reinfections
– Explain rationale to enhance compliance
Hemolytic-Uremic
Syndrome
Pathophysiology
 Diagnostic evaluation
 Therapeutic
management
 Prognosis
 Nursing consideration

Wilms’ Tumor
Etiology
 Diagnostic evaluation
 Therapeutic management

– Surgical removal
– Chemotherapy and/or
radiation

Nursing considerations
Renal Failure
Acute renal failure (ARF)
 Chronic renal failure
(CRF)

Acute Renal Failure (ARF)
Definition: kidneys suddenly unable
to regulate volume and composition
of urine
 Not common in children
 Principal feature is oliguria

– Associated with azotemia, metabolic
acidosis, and electrolyte disturbances

Most common pathologic cause:
transient renal failure resulting from
severe dehydration
Acute Renal Failure (ARF)
Pathophysiology—usually
reversible
 Diagnostic evaluation
 Therapeutic management
 Nursing considerations

Complications of ARF
Hyperkalemia
 Hypertension
 Anemia
 Seizures
 Hypervolemia
 Cardiac failure with pulmonary
edema

Chronic Renal Failure (CRF)
Begins when diseased kidneys
cannot maintain normal chemical
structure of body fluids
 Clinical syndrome called uremia

Potential Causes of CRF
Congenital renal and urinary
tract malformations
 VUR associated with recurrent
UTIs
 Chronic pyelonephritis
 Chronic glomerulonephritis

CRF (cont’d)
Pathophysiology
 Diagnostic evaluation
 Therapeutic management

– Manage diet, hypertension,
recurrent infections, seizures

Nursing considerations
Dialysis
Peritoneal
dialysis
 Hemodialysis
 Hemofiltration

Peritoneal Dialysis
The preferred method of dialysis for
children
 Abdominal cavity acts as
semipermeable membrane for
filtration
 Can be managed at home in some
cases
 Warmed solution enters peritoneal
cavity by gravity, remains for period of
time before removal

Hemodialysis
Requires creation of a vascular
access and special dialysis
equipment
 Best suited for children who can be
brought to facility 3 times/week
for 4 to 6 hours
 Achieves rapid correction of fluid
and electrolyte abnormalities

Transplantation
From living related donor
 From cadaver donor
 Primary goal is LT survival of
grafted tissue
 Role of immunosuppressant therapy
