Providing Patient Centered
Care for the Child Experiencing
a Genitourinary Disorder
Marlene Meador RN, MSN, CNE
Pediatric Differences in the Urinary
Tract:
Kidney function
Bladder capacity
Bladder control
Recovery
Enuresis
 Difficulty with urination control
 Nocturnal – Enuresis at night
 Diurnal – Enuresis during the day
 Primary – Never having experienced a period
of dryness
 Secondary – Occurs when a 6-12 month of
dryness has preceded the onset of enuresis
Possible Cause:
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Physical
Bladder capacity
Urinary tract abnormality
Neurologic alterations
Obstructive sleep apnea
Constipation
UTI
Pinworm infestation
Diabetes mellitus
Voiding dysfunction
Treatment
 Limit fluids after supper and void before bed
 Imagery
 Let child keep record of progress
 Rewards can be used
 Behavioral use of alarm that detects moisture
 Imipramine HCL – Tricyclic Antidepressant
 Despropressin acetate – tablet or nasal spray which
has antidiuretic effect
 Address the emotional side with all involved
Risk Factors:
 Emotional
Family disruption
Inappropriate pressure during training
Inadequate attention to voiding cues
Decreased self-esteem
Sexual abuse
Diagnosis
 Diagnosis is based on history and symptoms
 Repeated involuntary voiding or
incontinence past the age of toilet training.
 Urinalysis and culture are done
 Measurement of urine flow and bladder
capacity with voiding cystourethrogram
Treatment
 Limit fluids after supper and void before bed
 Imagery
 Let child keep record of progress
 Rewards can be used
 Behavioral use of alarm that detects moisture
 Imipramine HCL – Tricyclic Antidepressant
 Despropressin acetate – tablet or nasal spray which
has antidiuretic effect
 Address the emotional side with all involved
Nursing Diagnoses
 Situational low self-esteem related to bed-
wetting or urinary incontinence
 Impaired social interaction related to bedwetting or urinary incontinence
 Compromised family coping related to
negative social stigma and increased laundry
load
 Risk for impaired skin integrity related to
prolonged contact with urine
Urinary Tract Infections
Etiology and Pathophysiology
Why are girls more likely to have a
UTI than boys?
What is the most common
causative pathogen?
 May be bacterial, viral or fungal infection
Assessment
 Typical symptoms of older children & adults:
 Dysuria
 Frequency & urgency
 Burning
 Hematuria (usually older child)
 Symptoms for infants and young children can be
vague and nonspecific:
 Fever
 Mild abdominal pain
 Enuresis
 If severe: High fever, flank pain, vomiting,
malaise
Diagnostic Tests
 Urine for culture and sensitivity
 Clean catch
 Suprapubic aspiration
 Catheterization
 Positive Urinalysis
 Bacteria colony count of more than
100,000/ml.
 Presence of protein
Therapeutic Interventions
 Drug Therapy
 Antibiotics
 Analgesics – Tylenol
 Antipyretic
 Nursing Care
 Force fluids for rehydration
 Prescribed antibiotics
 Promote comfort
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.
Vesicoureteral Reflux
Pathophysiology
 Urinary Reflux – defective ureterovesicular valve
that guards the entrance from the bladder to the
ureter :
 Primary reflux – congenital abnormality
 Secondary reflux – repeated UTI’s
 Neurogenic bladder – stronger than usual
bladder pressure.
 Backflow – while voiding when bladder contracts,
urine is swept up the ureters
 Stasis of urine in ureters or kidneys which in turn
leads to hydronephrosis
Assessment
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
1.
2.
3.
4.
Diagnostic Tests
1. Urine culture
2. Voiding Cystourethrogram
3. Renal ultrasound
Therapeutic Interventions
 Drug Therapy
 Antibiotics
Penicillin
 Cephalosporins
 Urinary Antiseptics
 Nitrofurantoin
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 Surgery
 Repair of significant anatomical anomalies,
uretheral implantation
Nursing Care
 Keep accurate record of intake and output
 Secure stents and catheter
 Assess vital signs
 Assess comfort level
 Patient Teaching
Evaluation
 Follow-up:
 Repeat VCUG (voiding
cystourethrogram) after a few months
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
Bladder Exstrophy
 A rare defect in which the bladder wall
extrudes through the lower abdominal wall
 Due to failure of abdominal wall to close in
fetal development
 Upper urinary tract usually normal
 1:400,000 live births
 Treatment is surgical reconstruction in stages
Goals of Surgical Reconstruction
 Bladder and abdominal wall closure
 Urinary continence, with preservation of
renal function
 Creation of functional and normal –
appearing gentitalia
 Improvement of sexual functioning
Nursing Care
 Pre-op focus-prevent infection
 Post-operative focus – Immobilize to promote healing
of surgical site
 Monitor renal function – assess I&O and urine
chemistries to detect renal damage
 Maintain patency of drainage tubes
 Analgesics
 Antibiotics as ordered
 Emotional support of parents
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.
Hypospadias
Assessment
When is this anomaly
typically diagnosed?
Interventions
 Medical Treatment:
 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.
Clinical Judgment:
What is the rationale for the corrective surgery
occurring prior to the child’s first birthday?
a. the procedure is less painful for a child
b. chordee may be reabsorbed
c. the child has not developed body image
and castration anxiety
d. the repair increases the ease of toilet
training
Post–operative Nursing Care
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Assess bleeding
Maintain urinary drainage
Control Bladder Spasms
Prophylactic antibiotics
Control Pain
Increase fluid intake
 Do not allow to play on any straddle
toys.
 Prevent infection
 Call Dr if:
 temp is over 101
 loss of appetite
 pus or increased bleeding from stent
 cloudy or foul smelling urine
Failure of one or both of the testes to
descend from abdominal cavity to the
scrotum
Therapeutic Interventions
 Surgery
 Orchiopexy done via laproscopy
 Done around 1 year of age
 Nursing Care – Post-op
 Assess from bleeding and S/S of infection.
 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.
Acute Glomerulonephritis
Etiology and Pathophysiology
 Usual organism: Group A beta-hemolytic
streptococcus
 Organism not found in kidney
 Glomeruli become inflamed
and scarred
 Edema: renal capillary permeability with
renal vascular spasms
glomerular filtration
 accumulation of Na+ and H2O in the
blood stream causing increased
intravascular and interstitial fluid volume
 Proteinuria: Protein molecules filter
through the damaged glomeruli
 Hematuria: RBCs can pass through to the
urine
Manifestations
 Common in boy 5-10 years old. Occurs 1-
2 weeks after a respiratory infection or
after impetigo.
 Has 2 phases
 Edematous phase – 4-10 days
 Diuresis phase- self limiting
Assessment
1.
Renal:
a. Moderate proteinuria
b. Sudden onset of hematuria (teacolored, reddish-brown, or smoky) and
next develops oliguria
c. Excessive foaming of urine
Assessment Cont…
2. Cardiovascular:
 a. Edema-usually eyes, hands, feet, not
generalized (dependent edema)
 b. Hypertension from hypervolemia which can
lead to
 c. Cardiac involvement CHF- orthopnea /
dyspnea, cardiac enlargement, pulmonary
edema
Assessment cont…
3.Neuro
a. Encephalopathy:
headache
irritability
convulsions
coma-from cerebral edema
Test Yourself
 A 6 year old is admitted with R/O acute
glomerular nephritis which of the following
symptoms is the child most likely have?
a. normal blood pressure, diarrhea
b. periorbital edema, grossly bloody urine
c. severe, generalized edema, ascites
d. 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 ASO titer: (antistreptolysin O) (antibody formation
against Streptococcus) is elevated, indicating a recent
streptococcal infection
 ESR: (erythrocyte sedimentation rate) elevated showing
inflammatory process
 BUN: (urea nitrogen) & creatinine elevated indicating
glomerular damage
 CBC:WBCs normal range, H&H decreased.
 Lytes: elevated potassium, low serum bicarbonate
Therapeutic Interventions
1. Depends on the severity of the disease.
No specific treatment, supportive care.
2. Treat at home if normal BP & adequate
output.
3. Must be hospitalized if:
 BP increases
 gross hematuria
 oliguria present.
To monitor for complications
*Rarely develops into acute renal failure
Main Goals:
Relieve Hypertension and Re-establish fluid
and electrolyte balance:
 Keep accurate record of I&O.
 Record characteristics of urine output
 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.
Interventions cont…
 Daily weights
 Bed rest for 4-10 days during
acute phase
 Oxygen therapy
 Diet therapy
 Drug therapy
Clinical Judgment:
 A child is admitted and diagnosed with having
AGN. Prioritize the following nursing
diagnoses.
a. fluid volume excess
b. risk for impaired skin integrity
c. anxiety
d. activity intolerance
Clinical Judgment:
When teaching parents about known
antecedent infections in acute
glomerulonephritis, which of the following
should the nurse cover?
a. Herpes simplex
b. Streptococcus
c. Varicella
d. Impetigo
Chronic renal disorder in which the
basement membrane surfaces of the
glomeruli are affected, causing loss of
protein in the urine.
Etiology and Pathophysiology
 Insidious onset with periods of remission / exacerbations
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throughout life- No cure
Idiopathic cause (95%) immune response is strongly
suspected.
Other causes: may develop after acute glomerulonephritis,
sickle cell disease, Diabetes Mellitus, or drug toxicity.
Age of onset preschool yrs.- 2-4 yrs, males more common
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
Nephrotic Syndrome
Assessment Findings:
Four most common characteristics:
1.Massive proteinuria
2.Low serum albumin (K+ normal)
3.Edema
4.Malnourishment
Assessment
Hyperlipidemia
Shiny, pale skin
Brittle hair
Hypercoagulability (increased risk for
thrombosis)
5. Fatigue
6. Abdominal pain (ascites)
1.
2.
3.
4.
Ask Yourself?
 Which of the following signs and symptoms
are characteristic of minimal change nephrotic
syndrome?
a.
b.
c.
d.
gross hematuria, proteinuria, fever
hypertension, edema, fatigue
poor appetitie, proteinuria, edema
body image change, hypotension
Diagnostics
 Based on history
 Characteristic symptoms
 Lab findings with serum albumin and sodium
decreased
 BUN, Cholesterol and Electrolytes may be
ordered
 Urinalysis reveals massive proteinuria (50
mg/kg/day) (primary indicator of nephrotic
syndrome)
Therapeutic Interventions
 Reduce edema
 Keep accurate record of I&O. Measure
abdominal girth, weigh daily
 Test urine for protein and specific gravity to
see if tx is effective
 Diet:
 Normal diet for child’s age recommended
 No salt added
 High caloric
 Possible fluid restrictions
Treatment
 Diuretics-cautious use
 Antihypertensive
 Antibiotic
 Analgesics
 Albumin if resistant to diuretic
 Protective Isolation
Interventions
 Provide good skin care – edematous
tissue fragile
 Child / Parent teaching – measures to
prevent infections, medication
administration, monitoring of intake and
output
 Provide rest periods
Prognosis:
Usually spontaneous resolution even
with relapses (by age 30)
20% may develop chronic renal
failure
If you have any questions or
concerns regarding this
presentation please contact
Marlene Meador RN, MSN, CNE
mmeador@austincc.edu