Repeated involuntary voiding or
incontinence by a
child past the age of toilet training.
about 5-6 years of age
Enuresis
Multitreatment Approach
Fluid Restriction
Bladder exercises
Timed voiding
Enuresis alarms
Reward system
Medications
Test Yourself
•
Which of the following organisms is
the most common cause of UTI in
children?
a.
b.
c.
d.
staphylococcus
klebsiella
pseudomonas
escherichia coli
All are causative agents, Escherichia coli is the more common cause of first time UTI’s.
Urinary Tract Infections
• Etiology and Pathophysiology
– Tend to occur more in girls than in boys
because the urethra is shorter in girls and
is located close to the vagina and anus.
– Pathogens enter as an ascending infection
– Most common causative organism is
Escherichia coli
Assessment
• Typical symptoms of older children and
adults – dysuria, frequency, urgency,
burning,hematuria – may not be
present.
• Symptoms not always clear
– Fever
– Mild abdominal pain
– Bedwetting (enuresis)
– If gets worse – high fever, flank pain,
vomiting, malaise
Diagnostic Tests
• Urine for culture and sensitivity
– Clean catch
– Suprapubic aspiration
– Catheterization
• A Positive Test
– Bacteria colony count is more than 100.000/ml.
– Proteinuria may also be present indicating
presence of bacteria.
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
Therapeutic Interventions
• Parent Teaching
– Change diaper frequently
– Teach girls to wipe front to back
– Discourage bubble baths
– Encourage children to drink periodically during the
day
– Bathe daily
– Adolescent start menstruating – encourage
change of pad every 4 hours
– When girls become sexually active – teach to
urinate immediately after intercourse
Evaluation
• Follow up
– Return for repeat urinalysis – usually after 72
hours of treatment to be sure treatment is
working
– Girls who have more than three UTI’s, and boys
with first UTI should be referred to urologist for
further evaluation.
Common Sites for Obstruction
• Stenosis of ureteropelvic valve
• Stenosis of ureterovescicular junction
• Stenosis of the posterior urethral valve
Vesicoureteral Reflux
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.
Clinical Manifestations
1.
2.
3.
4.
Fever
Vomiting
Chills
Straining or crying on urination, poor urine
stream,
5. Enuresis (bedwetting), incontinence in a
toilet trained child, frequent urination.
6. Strong smelling urine
7. Abdominal or back/flank pain
Diagnostic Tests
1. Urine culture –
done every 2-3 months
2. cystourethrogram
3. 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.
Therapeutic Interventions
• Drug Therapy
– Antibiotics
• Penicillin
• Cephalosporins
– Urinary Antiseptics
• Nitrofurantoin
• Surgery
– Repair of significant anatomical anomalies,
uretheral implantation
Nursing Care following surgery
• Keep accurate record of intake and output. Keep
records from stents and catheter separate.
Decreased output from stent could indicate
obstruction.
• Secure stents and catheter to prevent displacement.
• Assess vital signs for signs of infection.
• Assess pain. Handle child gently Administer pain
medications
• Patient Teaching
- regarding prevention of UTI,
- importance of taking all antibiotics, continue
taking antiseptics even when have no symptoms.
Evaluation
• Follow-up
– Go in for a VCUG (voiding
cystourethrogram) after a few months
Cryptorchidism
Hypospadius / Epispadius
Failure of one or both of the testes to
descend from abdominal cavity to the
scrotum
Etiology and Pathophysiology
• Testes usually descend into the scrotal sac
during the 7-9 month 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
Answer:
• The higher temperatures in the
abdomen than in the scrotum results in
morphologic changes to the testis –
mainly concerned with lower sperm
counts at sexual maturity.
Assessment
Palpate the testes separately between thumb and
forefinger, with thumb and forefinger of other
hand over the inguinal canal.
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.
• Hypospadias
– Congenital urethral defect in which
the uretheral opening is on the
lower aspect of the penis and not
on the tip.
• Epispadias
– Congenital urethral defect in which the
uretheral opening is on the upper aspect of
the penis and not on the end
Etiology and Pathophysiology
• Epispadias – rare and often associated with extrophy of
bladder.
• Hypospadias
– Occurs from incomplete development of urethra in utero.
– Occurs in 1 of 100 male children. Increased risk if father
or siblings have defect.
– Defect ranges from mild (meatus is just below tip); to
meatus on the perineum between scrotum, ventral
foreskin lacking
– May have accompanying chordee (a fibrous band that
causes the penis to curve downward),
– Undescended testes – found in conjunction with
hypospadias
– Might interfere with fertility in the mature male if not
corrected.
Assessment
Usually discovered during
Newborn Physical Assessment
Ask Yourself?
• Why would the nurse
question an order to prepare
the infant for a circumcision?
Answer:
• The nurse would question the
order for a circumcision because
the foreskin is used in
reconstruction and repair of the
defect.
• What is the relation of
epispadius or
hypospadius to
infertility?
Answer:
• If the urethral opening is not at the end
of the penis, then the male will not be
able to deposit his sperm at the
opening of the os of the cervix.
Interventions
• Medical Treatment:
– Surgery
• Reconstructive – repositions uretheral
opening at tip of penis
• Stent placed in urethra to maintain
patency
• Chordee – released and urethra
lengthened.
•
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= answer
Post –op Nursing Care
1. Assess bleeding - Bleeding is controlled postoperatively 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 / suprapubic, or urethral stent. Use double
diapering.
A double diapering technique protects the urinary stent
after surgery. The inner diaper collects stool and the
outer diaper collects urine.
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- ProBanthine and Ditropan)
4. Control Pain – may be given 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
Acute Postinfectious
Glomerulonephritis
Immune-complex disease which
causes inflammation of the
glomeruli of the kidney as a
result of an infection elsewhere
in the body.
Etiology and Pathophysiology
• Usual organism is Group A beta-hemolytic
streptococcus
• Organism not found in kidney, but the antigenantibody 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.
Acute Glomerulonephritis
• Decreased glomerular filtration leads to accumulation
of sodium and water in bloodstream causing
increased intravascular and interstitial fluid volume,
or edema
• Protein molecules filter through the damaged
glomeruli – proteinuria
• Damage to glomeruli leads to hematuria.
• High B/P, Heart failure may result
• Common in boy 5-10 years old. Occurs 1-2 weeks
after a Strep respiratory infection or after impetigo.
• Has 2 phases
– Edematous phase – 4-10 days
– Diuresis phase
Assessment
1. Renal:
a. Moderate Proteinuria
b. Sudden onset of hematuria (tea-colored, reddishbrown, or smoky) and next develops oliguria
c. Excessive foaming of urine
2. Cardiovascular:
• a. Edema-usually eyes, hands, feet, not generalized
• b. Hypertension from hypervolemia which can lead to
• c. Cardiac involvement CHF- orthopnea / dyspnea,
•
cardiac enlargement, pulmonary edema
3.Neuro
a. Encephalopathy (headache, irritability,
convulsions, coma-from cerebral edema)
Test Yourself
• A 6 year old is admitted with R/O AGN.
Which of the following symptoms would
the child most likely have?
a.
b.
c.
d.
normal blood pressure, diarrhea
periorbital edema, grossly bloody urine
severe, generalized edema, ascites
severe flank pain, vomiting
Diagnostic Tests
Urinalysis- protein (moderate), RBC's, WBC's, Specific
Gravity elevated.
*All children should have a urinalysis 2 wks after strep
infection.
Blood• 1) ASO titer (antistreptolysin O) (antibody formation
against Streptococcus) is elevated, indicating a recent
hemolytic streptococcal infection Normal titer is 170-330
Todd units; IgG antibodies against Streptococcus may be
found
• 2) ESR (erythrocyte sedimentation rate) elevated
showing inflammatory process
• 3) BUN(urea nitrogen)& creatinine elevated indicating
glomeruli damage
Therapeutic Interventions
1. Depends on the severity of the disease. No
specific treatment. Bedrest encouraged. Disease
is self-limiting!
2. Treat at home if normal BP & adequate output.
3. Must be hospitalized if:
– BP increases
– gross hematuria
– oliguria present.
•
This way the child can be monitored closely and
prevent complications. Rarely develops into acute
renal failure
Main Goals:
Relieve Hypertension
Reestablish fluid and electrolyte balance by:
• Keep accurate record of I&O. Be sure that child
does not exceed maximum intake ordered.
• Record characteristics of urine output including
presence of proteinuria and hematuria.
• Check and record specific gravity with each voiding
• Monitor vital signs and neuro vital signs
• Monitor and record amount of edema at least once
a shift.
•
•
•
•
•
Daily weights
Bedrest for 4-10 days during acute phase. Semifowlers position to assist with breathing. Quiet
play.
Oxygen therpay
Diet therapy
• Limit salt intake with hypertension or edema
• Limit protein if BUN elevated
• Decrease intake of Potassium if output
decreased
Drug therapy
•
•
•
Antibiotics
Digitalization
Antihypertensives- vasodilators
Critical Thinking
• With a diagnosis of AGN, which of these
nursing diagnoses should receive
priority?
a.
b.
c.
d.
fluid volume excess
risk for impaired skin integrity
risk for injury
activity intolerance
Critical Thinking
When teaching parents about known
antecedent infections in acute
glomerulonephritis, which of the following
should the nurse cover?
A.
B.
C.
D.
Herpes simplex
Scabies
Varicella
Impetigo
Nephrotic Syndrome
Chronic renal disorder in which the basement
membrane surfaces of the glomeruli are
affected, causing loss of protein in the urine.
The glomeruli membrane has increased
permeability permitting albumin and protein to
pass through the membrane and excreted in
the urine.
Note the contrast between the normal glomerular anatomy and the changes that exist in
nephrotic syndrome permitting protein to be excreted in the urine.
Clinical Manifestations
Four most common characteristics:
1. Edema - May have periorbital edema
upon rising in morning and shifts
during the day.
2. Massive proteinuria and hypoproteinemia
3. Hypoalbuminemia
4. Hyperlipidemia
Other signs and symptoms
• Fatigue
• Anorexia
• weight gain
• Abdominal pain – from large amount of fluid
in abdominal
Ask Yourself?
• Which of the following signs and symptoms
are characteristic of minimal change
nephrotic syndrome?
a.
b.
c.
d.
Answer = C
gross hematuria, proteinuria, fever
hypertension, edema, fatigue
poor appetitie, proteinuria, edema
body image change, hypotension
Diagnostic Tests
• 1.
Urinalysis – protein-to-creatitine (PR/CR) ratio of
first morning void to assess for proteinuria. Urine
appears dark and frothy.
• 2.
Blood tests – hypoalbuminemia, elevated
cholesterol and triglycerides, elevated hgb, hct,
platelets
Try this
•
Prednisone is the primary drug used in
treating NS. What are the side effects
and nursing implications?
•
What teaching should the nurse
include with respect to this
medication?
Answers:
• Nursing Implications related to
Prednisone therapy
• See Drug Guide on p. 1057.
Complications
• Children with Nephrotic Syndrome are
prone to infection related to:
– Loss of immunoglobins in the urine
– Corticosteroid Therapy
Therapeutic Interventions
1. Administer medications – assess for side effects
–
Prednisone, Albumin, Diuretics
2. Prevention of infection – avoid people with infections.
May be placed on protective isolation.
3. Keep accurate record of I&O. Measure abdominal
girth, weigh daily.
4. Test urine for protein and specific gravity to see if
treatment is effective
5. Diet:
– Normal diet for child’s age
– A “no added salt” diet is recommended during
steroid treatment.
6. Promote rest
7. Discharge teaching