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Nursing Care of the Child with GU disorders Summer 2009 Lea Melvin, MSN, RN, CRRN, CWOCN Austin Community College Radiography and other tests of urinary system function Urine culture & sensitivity Renal/ bladder US Testicular US Scout film VCUG Imaging studies IVP Renal bx, cysto Whitaker perfusion test Physical tests for Gu function • • • • • Volume for polyuria, oliguria Specific gravity Osmolality Appearance Chemistries on urine (√ for blood, WBCs, bacteria, casts) Blood tests of renal function • BUN (blood urea nitrogen) • Uric acid • Creatinine Nursing responsibilities with testing • Responsible for preparation and collection of urine or blood • Maintains careful intake and output • Recognizes that renal disease can diminish the glomerular filtration rate External Defects Extrophy of the Bladder Hypospadius / Epispadius Cryptochidism • Epispadias – Congenital urethral defect in which the uretheral opening is on the upper aspect of the penis and not on the end • Hypospadias – Congenital urethral defect in which the uretheral opening is on the lower aspect of the penis and not on the tip. May have associated chordee. Hypospadius • Occurs from incomplete development of urethra in utero. • Occurs in 1 of 100 male children. Increased risk if father or siblings have defect. • Ranges from mild to severe. • Cyrptorchidism/Undescended testes may be found in conjunction with hypospadias. Assessment Usually discovered during Newborn Physical Assessment 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. • 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. Post –op Nursing Care 1. Assess pressure dressing (use to control bleeding. 2. Maintain urinary drainage. 3. Control bladder spasms. Antispasmotics (relax the bladder muscle) Pro-Banthine (probantheline) Ditropan (oxybutinin) Levsin (hyoscyamine) A double diapering technique protects the urinary stent after surgery. The inner diaper collects stool and the outer diaper collects urine. 4. 5. 6. 7. Control Pain. Increase fluids intake. Do not allow to play on any straddle toys. Prevent infection. – no bathing or swimming until stents removed. 8. Discharge teaching: When to call doctor. No bathing or swimming until stents removed. Cryptorchidism 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 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 Assessment 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. Why is early surgery important? • Morphologic changes to testis from higher temperature in abd cavity • Decreased sperm count=infertility? • Testicular cancer Obstructive Uropathy Vesicoureteral reflux Posterior urethral valves Ureteropelvic junction defect Vesicoureteral Reflux Abnormal backflow (retrograde) of urine from the bladder into the ureters and possibly kidneys when the bladder contracts during emptying/voiding. What is 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. Vesicoureteral Reflux Grades I through V Assessment 1. 2. 3. 4. 5. 6. Fever, chills Vomiting Straining/crying on urination, poor urine stream Enuresis (bedwetting), incontinence in a toilet trained child, frequent urination. Strong smelling urine Abdominal or back/flank pain Vesicoureteral Reflux • Approximately 20% of children that have UTIs will be found to have vesicoureteral reflux on xray Diagnostic Tests 1. Urine culture 2. Cystourethrogram (VCUG) 3. Renal ultrasound (RUS) Therapeutic Interventions • Drug Therapy – Antibiotics • Penicillin • Cephalosporins – Urinary Antiseptics • Nitrofurantoin • Surgery – Repair of significant anatomical anomalies, uretheral implantation Goals of treatment • Directed toward preventing UTIs • Managed by time or surgery if grade 4 or 5 • Single doses each day of abx as long as reflux lasts • Urine cultures done q 6 wks –3 mos Nursing Care • I&O - Keep records from stents and catheter separate. • Secure stents and catheter to prevent displacement. • Vital signs for signs of infection. • Control pain. • Discharge Teaching - prevention of UTI - importance of taking all antibiotics - continue taking antiseptics even when have no symptoms. Evaluation • Follow-up = VCUG in 3-4 months • Renal SPECT • RCG (radionucleaotide cystogram) 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 Urinary Tract Infections Urinary tract infections • Most common type of bacterial infections occurring in children • Bacteria passes up the urethra into the bladder • Most common types of bacteria are those near the meatus…staph as well as e.coli Contributing factors • Those with lower resistance, particularly those with recurrent infections • Unusual voiding and bowel habits may contribute to UTI in children • “forget to go to bathroom” • Symptoms vary by age of child Therapeutic management • Eliminate the current infections • Identify contributing factors to reduce the risk of re-infection • Prevent systemic spread of the infection • Preserve renal function 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 Parent Teaching Change diaper frequently Teach girls to wipe front to back Discourage bubble baths Encourage fluids frequently throughout day Bathe daily Adolescent girls when menstruating are to change of pad every 4 hours Teach to void immediately after intercourse FYI • The single most important host factor influencing the occurrence of UTI is urinary stasis • What is the chief cause of urinary stasis? Glomerular diseases • Acute glomerulonephritis (AGN) • Nephrotic syndrome (MCNS) or minimalchange nephrotic syndrome Nephrotic Syndrome Chronic renal disorder in which the basement membrane surfaces of the glomeruli are affected, cause loss of protein in the urine. Nephrotic syndrome Nephrotic syndrome, cont Contrast of normal gloumerular activity with changes seen in Nephrotic Syndrome Etiology • Insidious onset with periods of remission / exacerbations throughout life- No cure • 95% idiopathic, possibly a hypersensitivity reaction. • Other causes: post acute glomerulonephritis, sickle cell disease, Diabetes Mellitus, or drug toxicity. • Usually seen in preschool yrs (2-4). M>F Assessment Four most common characteristics: 1. Massive proteinuria 2. Hypoalbuminemia (K+ normal, BP normal) 3. Edema – usually starts in periorbital area and dependent areas of the body and progresses to generalized, massive edema. Pitting edema of 4+. Caused by hypo albumin which causes shift of fluids to extracellular space. *There is an insidious weight gain- shoes don't fit, etc 4. Hyperlipidemia * Of note is that there is no hematuria or hypertension Other signs and symptoms Fatigue Anorexia Weight gain Abdominal pain – from large amount of fluid in abdominal Treatment of nephrotic syndrome • • • • Varies with degree of severity Treatment of the underlying cause Prognosis depends on the cause Children usually have the “minimal change syndrome” which responds well to treatment 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 appetite, proteinuria, edema body image change, hypotension Acute Glomerulonephritis Immune-complex disease which causes inflammation of the glomeruli of the kidney as a result of an infection elsewhere in the body. Acute Glomerulonephritis Etiology/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. AGN • Treatment and nursing care: • Bed rest may be recommended during the acute phase of the disease • A record of daily weight is the most useful means for assessing fluid balance Nursing care specific to the child with AGN • Allow activities that do not expend energy • Diet should not have any added salt • Fluid restriction, if prescribed • Monitor weights • Education of the parents Therapeutic management • • • • • Corticosteroids (prednisone) Dietary management Restriction of fluid intake Prevention of infections Monitoring for complications: infections, severe GI upset, ascites, or respiratory distress Nursing diagnosis for the child with glomerulonephritis • Fluid volume excess r/t to decreased plasma filtration • Activity intolerance r/t fatigue • Altered patterns of urinary elimination r/t fluid retention and impaired filtration • Altered family process r/t child with chronic disease, hospitalizations Take a Break Surgical procedures • • • • Vesicostomy Ureterostomy Mitrafanoff catheterizable stoma Malone Antegrade Colonic Enema stoma (MACE or ACE) Post-op nursing care • • • • Care of stoma Skin protection Care of stents, tubes, drains Signs and symptoms of problems Mitrafanoff appendiceal stoma • Creation of catheterizable channel from skin to bladder • Channel is created from reversed appendix that is attached to bladder that has usually been augmented (made bigger). End of appendix brought to skin has nipple valve created and is usually place in the umbilicus. Post-op care for Mitrofanoff • Stoma with stents and catheter protruding from it. • Keep skin clean, dry and protected. • Discharged home with stents and catheter in place. • Teach care, prevention of infection, when to call, return visit. Teaching for Mitranoff usually done as outpatient • Clean intermittent catheterization using long vinyl coude tipped catheter, usually a size 12 • Must catheterize or will go into renal failure • Bladder neck is either closed or suspended to prevent leakage Malone Antegrade Colonic Enema • Creation of catheterizable channel from ascending colon to skin of abdomen for purpose of giving colonic irrigation every other day • Renders the child bowel continent • Channel is fashioned from piece of small intestine and brought to skin in nipple valve Post-op care for MACE • Stoma with catheter protruding from it. • Keep skin clean, dry and protected. • Discharged home with catheter in place. • Teach care, prevention of infection, when to call, return visit. Teaching for MACE • Must irrigate every other day to maintain continence • Use mild enema solution • Maintain schedule for frequency • Allow time for evacuation Nursing assessment • Ask child where stomas are and which one is which • Allow child to do procedure as at home with usual ritual • Must be done even if child is ill with unrelated disorder