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Pediatric Genitourinary Disorders. Enuresis. 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

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slide2

Enuresis

Repeated involuntary voiding or incontinence by a

child past the age of toilet training.

about 5-6 years of age

enuresis multitreatment approach
EnuresisMultitreatment Approach

Fluid Restriction

Bladder exercises

Timed voiding

Enuresis alarms

Reward system

Medications

slide4

Urinary Tract

Infection

test yourself
Test Yourself
  • Which of the following organisms is the most common cause of UTI in children?

a. staphylococcus

b. klebsiella

c. pseudomonas

    • escherichia coli

All are causative agents, Escherichia coli is the more common cause of first time UTI’s.

urinary tract infections
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
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
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
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 interventions1
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
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
Common Sites for Obstruction
  • Stenosis of ureteropelvic valve
  • Stenosis of ureterovescicular junction
  • Stenosis of the posterior urethral valve
pathophysiology
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
Clinical Manifestations
  • Fever
  • Vomiting
  • Chills
  • Straining or crying on urination, poor urine stream,
  • Enuresis (bedwetting), incontinence in a toilet trained child, frequent urination.
  • Strong smelling urine
  • Abdominal or back/flank pain
diagnostic tests1
Diagnostic Tests
  • Urine culture –

done every 2-3 months

  • cystourethrogram
  • 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 interventions2
Therapeutic Interventions
  • Drug Therapy
    • Antibiotics
      • Penicillin
      • Cephalosporins
    • Urinary Antiseptics
      • Nitrofurantoin
  • Surgery
    • Repair of significant anatomical anomalies, uretheral implantation
nursing care following surgery
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

takingantiseptics even when have no symptoms.

evaluation1
Evaluation
  • Follow-up
    • Go in for a VCUG (voiding cystourethrogram) after a few months
cryptorchidism hypospadius epispadius
Cryptorchidism

Hypospadius / Epispadius

Structural Defects

failure of one or both of the testes to descend from abdominal cavity to the scrotum

Cryptorchisism

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

etiology and pathophysiology
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
slide24

Why is it important that the

testes are in the scrotal sac?

answer
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.
assessment1
Assessment

Diagnosed on Newborn Physical Exam

Palpate the testes separately between thumb and forefinger, with thumb and forefinger of other hand over the inguinal canal.

therapeutic interventions3
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.
slide28

Hypospadias

Epispadias

slide29
Hypospadias
    • Congenital urethral defect in which

the uretheral opening is on the

lower aspect of the penis and not

on the tip.

slide30
Epispadias
    • Congenital urethral defect in which the uretheral opening is on the upper aspect of the penis and not on the end
etiology and pathophysiology1
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.
assessment2
Assessment

Usually discovered during

Newborn Physical Assessment

ask yourself
Ask Yourself?
  • Why would the nurse question an order to prepare the infant for a circumcision?
answer1
Answer:
  • The nurse would question the order for a circumcision because the foreskin is used in reconstruction and repair of the defect.
answer2
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
Interventions
  • Medical Treatment:
    • Surgery
      • Reconstructive – repositions uretheral opening at tip of penis
      • Stent placed in urethra to maintain patency
      • Chordee – released and urethra lengthened.
slide38
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
Post –op Nursing Care

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 / suprapubic, or urethral stent. Use double diapering.

slide40

A double diapering technique protects the urinary stent after surgery. The inner diaper collects stool and the outer diaper collects urine.

slide41
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)

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
slide42

Acute Postinfectious

Glomerulonephritis

acute postinfectious glomerulonephritis

Acute PostinfectiousGlomerulonephritis

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

etiology and pathophysiology2
Etiology and 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.

slide46
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
assessment3
Assessment

1. Renal:

a. Moderate Proteinuria

b. Sudden onset of hematuria (tea-colored, reddish-brown, or smoky) and next develops oliguria

c. Excessive foaming of urine

2. Cardiovascular:

  • a.Edema-usually eyes, hands, feet, not generalized
  • b.Hypertensionfrom 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 yourself1
Test Yourself
  • A 6 year old is admitted with R/O AGN. Which of the following symptoms would 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 tests2
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 interventions4
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
Main Goals: Relieve Hypertension Reestablish fluid and electrolytebalance 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.

slide52
Daily weights
  • Bedrest for 4-10 days during acute phase. Semi-fowlers 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
Critical Thinking
  • With a diagnosis of AGN, which of these nursing diagnoses should receive priority?

a. fluid volume excess

b. risk for impaired skin integrity

c. risk for injury

d. activity intolerance

critical thinking1
Critical Thinking

When teaching parents about known

antecedent infections in acute

glomerulonephritis, which of the following

should the nurse cover?

A. Herpes simplex

B. Scabies

C. Varicella

D. Impetigo

nephrotic syndrome

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.

slide57

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 manifestations1
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
Other signs and symptoms
  • Fatigue
  • Anorexia
  • weight gain
  • Abdominal pain – from large amount of fluid in abdominal
ask yourself1
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 appetitie, proteinuria, edema

d. body image change, hypotension

Answer = C

diagnostic tests3
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
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
Answers:
  • Nursing Implications related to Prednisone therapy
  • See Drug Guide on p. 1057.
complications
Complications
  • Children with Nephrotic Syndrome are prone to infection related to:
    • Loss of immunoglobins in the urine
    • Corticosteroid Therapy
therapeutic interventions5
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