Download Nocturnal Enuersis

NOCTURNAL ENURESIS
DACY GASTON, RN, BSN
SOUTH UNIVERSITY
DEMOGRAPHICS
• PATIENTS NAME: A.L.
• D.O.B. 2/15/2008 (7 YEARS OLD)
• ATTENDS 3RD GRADE
• LIVES IN RINCON, GA AT HOME WITH HIS MOM, DAD, BROTHER AND SISTER.
• UNINSURED
• ESTABLISHED PATIENT
CHIEF COMPLAINT AND HPI
• CHIEF COMPLAINT “WETTING THE BED AT NIGHT”
• HISTORY OF PRESENT ILLNESS: A.L. IS A 7 YEAR OLD CAUCASIAN MALE PATIENT WHO
PRESENTS TO THE CLINIC WIT HIS PARENTS. THE MOTHER STATES THAT HE HAS BEEN WETTING
THE BED DURING THE NIGHT ON AND OFF FOR THE PAST 2 MONTHS AND IT HAS GOTTEN
WORSE. AT FIRST IT STARTED OUT AS ONCE A WEEK BUT NOW IT HAS GOTTEN TO BE 3-4 TIMES
A WEEK AND IT IS AFFECTING HIS SELF ESTEEM BECAUSE HE IS AFRAID TO SPEND THE NIGHT AT
HIS FRIENDS HOUSES FOR SLEEPOVERS. THEY HAVE NOT TRIED ANYTHING YET, AND THAT IS
WHY THEY ARE HERE FOR SOME INITIAL HELP.
MEDICAL/SURGICAL HISTORY
• PAST MEDICAL HISTORY: NONCONTRIBUTORY
• PAST SURGICAL HISTORY: NONCONTRIBUTORY
• MEDICATIONS: OCCASIONALLY USES OTC FLU OR NASAL SPRAY, NO PRESCRIPTIONS
• IMMUNIZATIONS: UP TO DATE, LAST FLU SHOT OCTOBER 2015
• MEDICATIONS: NO MEDICATIONS, DOESN’T TAKE ANYTHING OTC
• ALLERGIES: NKDA
• ADL’S: PATIENT IS DRESSING HIMSELF, BRUSHING TEETH, IS POTTY TRAINED AND HELPS OUT WITH
HOUSEHOLD CHORES
• SAFETY: +SEAT BELTS, - FALLS, + GENERAL SAFETY/HEALTH MEASURES
• DEVELOPMENT: APPROPRIATE FOR DEVELOPMENTAL AGE.
FAMILY HISTORY
• PATERNAL GRANDFATHER-60, LIVING, HTN, HYPERLIPIDEMIA- BOTH CONTROLLED
• PATERNAL GRANDMOTHER-58, LIVING, GERD- CONTROLLED
• MATERNAL GRANDFATHER-56, LIVING, HTN-CONTROLLED
• MATERNAL GRANDMOTHER-52, LIVING, HYPOTHYROID-CONTROLLED
• MOTHER-34, HYPOTHYROID, GERD-CONTROLLED
• FATHER-36, HTN, HYPERLIPIDEMIA-CONTROLLED
• SISTER-3, NO HEALTH ISSUES, FULLY IMMUNIZED
• BROTHER-5, NO HEALTH ISSUES, FULLY IMMUNIZED
SOCIAL HISTORY
• PATIENT LIVES AT HOME WITH HIS MOM, DAD, BROTHER AND SISTER
• THEY HAVE ONE DOG AND TWO CATS
• IT IS A NON-SMOKING HOUSEHOLD
• MOM AND DAD WORK AT GULFSTREAM
• GRANDPARENTS LIVE NEARBY AND HELP OUT WHEN NEEDED
• PATIENT ENJOYS SPORTS AND PLAYS SOCCER AND BASEBALL
SUBJECTIVE/REVIEW OF SYSTEMS
• GENERAL: (GIVEN BY MOTHER/FATHER AND SOME BY THE CHILD)- NO COMPLAINTS OF RECENT ILLNESS,
CHANGES IN LIFESTYLE, NIGHT SWEATS, OR CHANGES IN WEIGHT.
• HEENT: DENIES DIZZINESS OR CHANGES IN VISION OR HEARING. REGULAR EYE EXAMS.
• SKIN: DENIES CHANGES IN COLOR, TEXTURE, DENIES LESIONS OR NEW GROWTHS, MOLES, LUMPS OR
WARTS.
• NECK: DENIES DYSPHAGIA, TENDERNESS OR PAIN.
• PULMONARY: DENIES CHANGES IN BREATHING, SHORTNESS OF BREATH OR COUGH.
• CARDIOLOGY: DENIES PALPITATIONS, CHANGES IN HEART RATE OR CHEST PAIN.
• GASTRO: DENIES NAUSEA, VOMITING, CONSTIPATION, DIARRHEA OR CHANGES IN STOOL PATTERN,
CONSISTENCY OR COLOR
• GENITOURINARY: SEE HPI, DENIES DYSURIA, POLYURIA, OR HEMATURIA.
• ENDOCRINE: DENIES FATIGUE, INSOMNIA, OR CHANGES IN SLEEPING PATTERN
DIAGNOSTIC DATA
• URINALYSIS PERFORMED BEFORE EXAMINATION:
NORMAL, NO SIGNS OF INFECTION, RED
BLOOD CELLS, GLUCOSE, KETONES, PROTEIN, SPECIFIC GRAVITY 1.010.
• FINGER STICK (FASTING GLUCOSE)-TO RULE OUT DIABETES-NEED TO CONFIRM WITH
RESULTS OF FULL BLOOD PANEL
• CBC WITH DIFF, HGA1-C, CMP, LIPIDS
• RATIONALE: NOCTURNAL ENURESIS INVOLVES A COMPLETE HISTORY AND PHYSICAL TO RULE OUT ANY
ANATOMICAL ABNORMALITIES, UNDERLYING ABNORMAL PATHOPHYSIOLOGY OR PRESENCE OF
CONSTIPATION. IN ADDITION, EVERY CHILD WITH SUSPECTED NOCTURNAL ENURESIS WITH NO HISTORY OF
CONSTIPATION OR PHYSICAL ABNORMALITIES SHOULD PERFORM A COMPLETE URINALYSIS TO FURTHER RULE
OUT ANY UNDERLYING ABNORMALITIES.
(Jacques, 2013)
OBJECTIVE DATA AND PHYSICAL EXAM
• GENERAL: PATIENT IS PLEASANT 7 YEAR OLD LITTLE BOY WHO APPEARS WELL NOURISHED,
GROOMED AND IS APPROPRIATELY DRESSES. DOES NOT APPEAR AT ANY DISTRESS AT
THIS MOMENT AND HAS COMPLAINED OF NO PAIN.
• VITAL SIGNS:
• BLOOD PRESSURE: 94/64, HR 76 REGULAR RATE, RR 18 UNLABORED, TEMP 98.4, SPO2 100%
• HEIGHT: 4’6
• WEIGHT: 65 LBS
• BMI: 15.7 (54TH PERCENTILE-NORMAL FOR DEVELOPMENTAL AGE)
OBJECTIVE DATA AND PHYSICAL EXAM
SKIN: WARM TO TOUCH, - BRUISES,- RASHES, - SCARRING
HEAD: NORMOCEPHALIC WITH APPROPRIATE HAIR DISTRIBUTION
EYES: PERRLA, + RED REFLEX, - STRABISMUS, - DISCHARGE, EOM INTACT
EARS: SYMMETRICAL, CLEAR EXTERNAL AUDITORY CANALS BILATERALLY, PINNAE NORMAL SHAPE AND SIZE, TYMPANIC MEMBRANES
VISUALIZED BILATERALLY WITH APPROPRIATE LIGHT REFLEX, SMALL AMOUNT OF CERUMEN BILATERALLY.
NOSE: SEPTUM MIDLINE, PINK MUCOSA, - POLYPS, -DISCHARGE.
THROAT: UVULA MIDLINE, NO CROWDING, NO TONSILLAR ENLARGEMENT, EXUDATE OR ERYTHEMA. +GAG REFLEX, - PND.
NECK: FULL ROM, TRACHEA MIDLINE, - LYMPHADENOPATHY BILATERALLY, NO PALPABLE MASSES, CYSTS OR NODES.
CARDIOVASCULAR: RRR, NO MURMURS, GALLOPS OR RUBS. <1 SEC CAP REFILL, 3+ PULSES IN ALL EXTREMITIES.
PULMONARY: SYMMETRICAL STRUCTURE, BREATH SOUNDS CLEAR BILATERALLY UPPER AND LOWER LOBES. NO STRIDOR, WHEEZING,
CRACKLES, RONCHI, OR RUBS.
ABDOMEN: BS X4 NORMOACTIVE, SOFT, NON-TENDER, NON-DISTENDED, NO ORGANOMEGALY, NO REBOUND TENDERNESS.
GENITOURINARY: PENIS AND TESTICLES APPROPRIATE FOR AGE, NO LUMPS, LESIONS, OR TENDERNESS NOTES ON PALPATION.
MUSCULOSKELETAL: SYMMETRIC, +ROM, 10 FINGERS, 10 TOES, - SCOLIOSIS, - JOINT SWELLING, - CLUBBING.
NEURO: NO FOCAL DEFICITS, EXTREMITIES MOVE SYMMETRICALLY WITH APPROPRIATE TONE, DTR;S INTACT, + SENSATION BILATERALLY, GAIN
NORMAL.
PATHOPHYSIOLOGY AND PREVALENCE
ENURESIS IS DEFINED AS INTERMITTENT URINARY INCONTINENCE DURING SLEEP IN A CHILD
AT LEAST FIVE YEARS OF AGE. APPROXIMATELY 5% TO 10% OF ALL SEVEN-YEAR-OLDS
HAVE ENURESIS, AND AN ESTIMATED 5 TO 7 MILLION CHILDREN IN THE UNITED STATES HAVE
ENURESIS. THE PATHOPHYSIOLOGY OF PRIMARY NOCTURNAL ENURESIS INVOLVES THE
INABILITY TO AWAKEN FROM SLEEP IN RESPONSE TO A FULL BLADDER, COUPLED WITH
EXCESSIVE NIGHTTIME URINE PRODUCTION OR A DECREASED FUNCTIONAL CAPACITY OF
THE BLADDER. INITIAL EVALUATION SHOULD INCLUDE A HISTORY, PHYSICAL EXAMINATION,
AND URINALYSIS
(Baird, Seehusen, & Bode, 2014)
HEALTH CONSEQUENCES & PSYCHOLOGICAL
EFFECTS
• THERE ARE NO SIGNIFICANT HEALTH-RELATED CONSEQUENCES OF ENURESIS, ALTHOUGH
THE PRESENCE OF ENURESIS COULD BE A MARKER FOR MEDICAL CONDITIONS SUCH AS
URINARY TRACT INFECTIONS OR VESICOURETERAL REFLUX. OTHER PSYCHOSOCIAL
CONSEQUENCES RESULT FROM THE SHAMING, BLAMING AND CHARACTEROLOGICAL
ATTRIBUTIONS THAT ARE DIRECTED AT INCONTINENT CHILDREN IN ADDITION TO AN
INCREASED RISK OF CHILD ABUSE SECONDARY TO INCONTINENCE
(American Psychological Association, 2015)
PRIMARY DIAGNOSIS
&
DATA USED TO RULE IN OR OUT
• AFTER URINALYSIS, ROS, HPI, OBJECTIVE AND SUBJECTIVE DATA
ANALYSIS: THE INITIAL DIAGNOSIS OF NOCTURNAL ENURESIS IS
MADE.
• STILL PENDING BLOOD WORK FOR FINAL NOCTURNAL ENURESIS
DIAGNOSIS, WILL CONFIRM AFTER LABORATORY BLOOD WORK,
CBC, CMP, LIPIDS, HGA1-C.
DIFFERENTIALS/DIAGNOSIS/ASSESSMENT
• PRIMARY DIAGNOSIS: NOCTURNAL ENURESIS ICD 10: N39.44
• DIFFERENTIAL DIAGNOSIS:
• 1) UNSPECIFIED URINARY INCONTINENCE ICD 10: R32
• 2) URINARY TRACT INFECTION OF UNKNOWN ORIGIN ICD 10: N39.0
• 3) DIABETES TYPE I W/ UNSPECIFIED COMPLICATIONS ICD 10: E11.8
• 4) DIABETES TYPE II W/ UNSPECIFIED COMPLICATIONS ICD 10: E10.8
PLAN
MOST IMPORTANTLY IS EDUCATION TO PROMOTE
NONJUDGEMENT OF THE CHILD AND INCREASE SELF ESTEEM!!
PLAN
• 1) EDUCATION FOR PARENTS AND PATIENT ON NOCTURNAL ENURESIS IS FIRST ARE FOREMOST.
ACCORDING TO HAY, LEVIN, DETERDING, & ABZUG (2014), EDUCATION IS CRUCIAL AND MUST
REMAIN PROFESSIONAL AND NONJUDGMENTAL BECAUSE OF THE FRAGILE SELF-ESTEEM OF THE
CHILD. THE GOAL OF TREATMENT IS TO HELP THE CHILD ESTABLISH CONTINENCE AND TO BUILD AND
MAINTAIN HIS SELF-ESTEEM.
• 2)
EDUCATION TO PARENTS ABOUT IMPORTANCE OF DAILY FLUID INTAKE ACCORDING TO AMBIENT
TEMPERATURE, DIETARY INTAKE, AND PHYSICAL ACTIVITY CAN HELP DECREASE THE FREQUENCY OF NE. ADVISE
THE CHILD OR AND PARENTS THAT THE CONSUMPTION OF CAFFEINE-BASED DRINKS SHOULD BE AVOIDED, AND
EATING A HEALTHY DIET IS AN IMPORTANT FORM OF TREATMENT FOR BEDWETTING (DEPARTMENT OF HEALTH
AND HUMAN SERVICES, 2011).
• 3)
ADVISE THE CHILD OR YOUNG PERSON OF THE IMPORTANCE OF USING THE TOILET AT REGULAR INTERVALS
THROUGHOUT THE DAY (DHHS, 2011).
• 4)
BEHAVIORAL STRATEGIES SUCH AS FLUID LIMITATIONS AT A CERTAIN POINT BEFORE BEDTIME, AND TO TRAIN
THE CHILD TO USE THE BATHROOM AT FREQUENT INTERVALS DURING THE DAY, AND TO EXPLAIN THAT ADEQUATE
DAILY FLUID INTAKE IS IMPORTANT IN THE MANAGEMENT OF BEDWETTING (DHHS, 2011).
PLAN CONTINUED
• 5)
IF BEHAVIORAL STRATEGIES DO NOT WORK AFTER 3 MONTHS, START AN ALARM SYSTEM TO WAKE THE CHILD
AT CERTAIN POINTS SO HE CAN VOID. THE URINE ALARM RELIES ON A CLASSICAL OR OPERANT CONDITIONED
RESPONSE STRENGTHENED OVER TIME AS THE CHILD WAKES WHEN THE ALARM SOUNDS, STOPS VOIDING URINE,
fiNISHES URINATING IN THE TOILET, CHANGES WET BEDDING OR CLOTHING, AND RESETS THE DEVICE (AXELROD,
TORNEHL, & FONTANINI-AXELROD, 2014).
• 6)
FOLLOW UP AT 3 MONTHS, IF NOT SUCCESSFUL TO FLUID RESTRICTION, DIET, BEHAVIORAL CHANGES AND THE
ALARM SYSTEM ALL FAIL, THEN A REFERRAL TO UROLOGIST IS NEEDED.
• 7)
START PATIENT ON DDAVP WHICH WILL BE CONFIRMED AFTER UROLOGY CONSULT. DDAVP (BETTER KNOWN
AS DESMOPRESSIN), CAN BE OFFERED AS A FIRST-LINE TREATMENT IF ALARMS ARE ASSESSED AS UNSUITABLE. IT
CAN PROVIDE RAPID ONSET OR SHORT-TERM IMPROVEMENT IN BEDWETTING. DESMOPRESSIN IS A SYNTHETIC
FORM OF A NATURALLY OCCURRING ANTI-DIURETIC HORMONE CALLED ARGININE VASOPRESSIN (NORFOLK &
WOOTTON, 2012).
• 8)
FOLLOW UP WITH UROLOGIST AND PATIENT AT 6 MONTHS.
REFERENCES:
• AMERICAN PSYCHOLOGICAL ASSOCIATION. (2015). FACT SHEET: ENURESIS IN CHILDREN AND ADOLESCENTS.
RETRIEVED FROM HTTP://WWW.APADIVISIONS.ORG/DIVISION-54/EVIDENCE-BASED/ENURESIS.ASPX.
• AXELROD, M. I., TORNEHL, C., & FONTANINI-AXELROD, A. (2014). ENHANCED RESPONSE USING A
MULTICOMPONENT URINE ALARM TREATMENT FOR NOCTURNAL ENURESIS. JOURNAL FOR SPECIALISTS IN
PEDIATRIC NURSING, 19(2), 172-182.
• DEPARTMENT OF HEALTH AND HUMAN SERVICES. (2011). NOCTURNAL ENURESIS: THE MANAGEMENT OF
BEDWETTING IN CHILDREN AND YOUNG PEOPLE. RETRIEVED FROM:
HTTP://WWW.GUIDELINE.GOV/CONTENT.ASPX?ID=25680#SECTION420
• HAY, W., LEVIN, M., DETERDING, R., ABZUNG, M. (2014). CURRENT DIAGNOSIS AND TREATMENT: PEDIATRICS
(22ND ED.) MC-GRAW HILL. ISBN: 978-0-07-182734-8.
• JACQUES, E. (2013). TREATING NOCTURNAL ENURESIS IN CHILDREN AND YOUNG PEOPLE. BRITISH JOURNAL
OF SCHOOL NURSING, 8(6), 275-278
• NORFOLK, S., & WOOTTON, J. (2012). NOCTURNAL ENURESIS IN CHILDREN. NURSING STANDARD, 27(10), 4956.
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