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Enuresis Urinary Tract Infection Pyelonephritis Vesicoureteral reflux (VUR) Hydronephrosis Cryptorchidism Hypospadius Exstrophy of Bladder Acute Glomerulonephritis Nephrotic Syndrome Acute Renal Failure Myelination of spinal cord necessary before child can control bowel and bladder function; occurs between 12-18 months However, child is usually not ready until 18-24 months Waiting until 24-30 months makes the job easier Expected Milestones Age Developmental Bladder Control 1.5 years 2 Years 2.5 years 3 years 3.5 years Urinates regularly Aware of voiding Can hold urine Daytime control Nighttime control Physical Readiness ◦ ◦ ◦ ◦ Child Child Child Child removes own clothes is willing to let go of toy is able to sit, squat, and walk well has been walking for 1 year Psychological Readiness ◦ Child notices wet diaper ◦ Child indicates need for diaper change ◦ Child communicates need to go to the bathroom and can get there by self ◦ Child wants to stay dry Parent Readiness ◦ Requires many toileting sessions a day ◦ Need to be able to give child undivided attention ◦ Patience ◦ Personal choice on toilet or free standing potty chair Primary ◦ Never achieved dryness for 3 months Secondary ◦ Dry for 3-6 months then resumes wetness Diurnal ◦ Wetting occurs only in daytime Nocturnal ◦ Wetting occurs only in nightime Neurological UTI Structural delay disorder Chronic renal failure Disease with polyuria (DM) Chronic constipation Sleep arousal problem Sleep disorders from enlarged tonsils, sleep apnea Psychological stress Family history Inappropriate toilet training May avoid activities ◦ Sports ◦ Sleepovers Great source of stress Concealing wet clothing is difficult Odor is a concern Situational Low Self-Esteem related to bed- wetting or urinary incontinence Impaired Social Interaction related to bed- wetting 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 Organic- treat underlying cause Nonorganic- most will outgrow by late childhood Assess parent and child’s motivation and readiness If willing to be active participant then management includes: ◦ ◦ ◦ ◦ ◦ ◦ Alarms Timed voiding Bladder exercises Elimination diets Behavioral therapy Medications DDAVP Ditropan Tofranil (Imipramine) Most common infection of GI tract Fecal bacteria (E. coli) cause most UTI’s Girls>boys after age 1 In males uncircumcised>circumcised Can lead to renal scarring, high blood pressure, End Stage Renal Disease Urinary tract obstructions Voiding dysfunction resulting in urinary stasis Anatomic differences in younger children Individual susceptibility to infection Urinary retention while toilet-training Bacterial colonization of the prepuce of uncircumcised infants Infrequent voiding Sexually active adolescent girls ◦ Nonspecific ◦ Fever ◦ Irritability ◦ Dysuria (crying when voiding) ◦ Change in urine odor or color ◦ Poor weight gain ◦ Feeding difficulties ◦ Abdominal or suprapubic pain ◦ Voiding frequency ◦ Voiding urgency ◦ Dysuria ◦ Fever ◦ Malodorus urine ◦ Hematuria ◦ New or increased incidence of enuresis Urinealysis (UA) ◦ Macro ◦ Micro ◦ 24 hour Culture and Sensitivity (C & S) Specimen collection ◦ ◦ ◦ ◦ Clean catch Pediatric urine collector Straight cath Foley cath UA (Urinalysis) ◦ Bacteruria ◦ Pyuria Urine C&S: colony count = 100,000 Pyelonephritis ◦ Above UA and C&S findings plus Elevated WBC Elevated ESR Increased CRP Infection travels to kidneys Same symptoms of UTI plus: ◦ ◦ ◦ ◦ Higher fever Back or flank pain (CVAT) Nausea & vomiting Look sick 7-10 day of antibiotics by mouth Dehydrated child and very young often require IV antibiotics Increase PO fluids Analgesia Antipyretics 7-10 days of IV antibiotics Increase PO fluids Analgesia Antipyretics Proper toilet training Teach proper wiping Avoid tight clothing Wear cotton underwear Encourage children to avoid “holding” urine Avoid bubble baths Don’t force cranberry-increases acidity Adolescent: urinate immediately after intercourse Malformed and bladder valves at ureters Allows a backflow of urine up the ureter into the kidney Can be congenital abnormality, graded 1-5 Grade Grade 1-3 frequent UTI 4- 5: massive ureteral and renal pelvis dilation reflux Genetic origin Girls>boys Symptoms ◦ ◦ ◦ ◦ Frequent UTI’s (most common) Enuresis Flank pain Abdominal pain Prophylactic antibiotics Teach child to double void Grades 1-3: will usually resolve on own Grades 4-5: valve repair Urine C&S every 2-4 months Enlargement of the pelvis of the kidney Caused by ◦ ◦ ◦ ◦ Congenital narrowing of the ureteropelvic junction Kidney stones Tumors Blood clots Usually free of symptoms initially May have repeated UTI’s (urinary stasis) Polyuria Frequency Flank pain Increased BP Abdominal palpation reveals a mass If untreated can destroy nephrons Surgical correction of the obstruction One or both testes fail to descend through the inguinal canal into the scrotal sac In 85% right testis is affected The affected side or bilateral scrotum appears flaccid or smaller than normal Unknown why this fails ◦Increased abd pressure ◦Hormonal influences Common in the premature infant and LBW infant Incidence decreases with age Many resolve spontaneously by 12 months age If still present at age 1, descent usually does not occur Associated with lower sperm production Increased risk for malignant testicle turoms in adulthood Observation for first year HCG- stimulates testosterone production and helps with descent If testis fail to descend between 1-2 years of age then surgical treatment: Orchiopexy Post op instructions ◦ Loose clothing ◦ Incision Care ◦ Monitor for infection ◦ Analgesia ◦ Ice ◦ Discuss future fertility & cancer risk ◦ Congenital malformation ◦ Urethral opening is below normal placement on glans of penis (ventral surface-underside) ◦ May also have short chordee (fibrous band of the penis, will cause it to curve downward) Epispadius ◦ dorsal placement of urethral opening Cause is unknown Defects in testosterone is possible Possible genetic origin Symptoms Urinary stream deflected downward Prepuce is small-Penis appears to look circumcised May have chordee, undescended testes and inguinal hernia Out patient surgery to lengthens urethra (meatomy), position meatus at penile tip, release the chordee Performed btw 12-18 mos of age No circumcision Post-op: Stent for urinary drainage and patency Double Diapering Strict I&O Pain Management Monitor for Infection No Hip-Holding, rideon toys Possible fertility problems Bladder lies open and exposed on abdomen (defect in abdominal wall) Bladder is bright red & unable to contain urine Surgical closure of abdominal wall, reconstruction of bladder, urethra and genitalia “continent urinary reservoir” Prevent infection Protect skin integrity Protect exposed bladder Parental education (straight catheterization) Keep infant’s legs flexed Closure of the bladder and abdominal wall Urinary continence, with preservation of renal function Creation of functional and normal-appearing genitalia Correction to promote later sexual functioning Suprapubic catheter-if unable to restore function Immobilized Pelvis Strict I&O Antispasmotics: Probanthine (Pyridium) Analgesics Parental Emotional Support Structural Disorders of GU System Many children are discharged with stents or catheters. Teach parents how to change dressings, double diaper, care for catheters, assess pain and give analgesics, and recognize signs of possible obstruction or infection. Parents should encourage the child to participate in age-appropriate activities. Chemistry Panel ◦ ◦ ◦ ◦ ◦ ◦ Potassium: 3.5-5.8 Sodium: 135-148 Urea Nitrogen: 3.5-7.1 Creatinine: 0.2-0.9 Calcium: 2.2-2.7 Albumin: 3.2-4.7 Blood Gases ◦ Bicarbonate: 18-25 Urinalysis ◦ Protein: None ◦ Specific Gravity: 1.001-1.030 Sudden inflammation of the glomeruli of the kidney resulting in acute renal failure Peak age 5-10 years, boys>girls Capillary walls of kidney become permeable; allows red blood cells and protein to pass into urine Usually seen 7-10 days after a strep infection (immune response to strep), may be other organisism URI preceding symptoms Sudden onset of hematuria (smokey or tea-colored urine) Proteinuria (+1 to +4) Edema (worse in the morning) of eyelids and ankles; sodium and fluid are retained Oliguria: < 1 ml/kg/hr = impending renal failure Hypertension (due to decreased glomerular filtration rate) can be severe HTN may lead to pulmonary edema (listen for crackles) Fever, malaise, abdominal pain, HA, vomiting- feel sick Presenting symptoms Urinalysis ◦ proteinuria +1 to +4, ◦ 24h urine 1 gram protein ◦ hematuria Increased BUN, creatinine • Electrolytes Imbalance (from inadequate glomerular filtration) ◦ high serum potassium ◦ low serum bicarbonate BP may increase, if > 160/100 can lead to encephalopathy ASO Titer (antistreptolysin): indicates presence of antibodies to streptococcal bacteria No specific treatment- supportive Manage S&S (adequate rest- main tx) Monitor renal dysfunction Anti-hypertensive therapy (limit sodium & water or by diuretics & antihypertensive meds) Prognosis is excellent Daily weight, accurate I & O until fully resolved (2 mos) Diuresis signals the beginning of resolution Monitoring fluid status- hypovolemia ◦ I&0, VS, Electrolytes Preventing infection-ARF risk for infection ◦ Hand hygiene, screen visitors, watch CBC Preventing skin breakdown ◦ Bed Rest is the Treatment ◦ Check dependent areas ◦ Sheets tight, free of crumbs, sm toys Meeting nutritional needs ◦ ◦ ◦ ◦ ARF anorexia is common no added salt, low protein diet Encourage food from home Age appropriate quantity Providing emotional support to the child and family ◦ Guilt is common from untreated strep Immune response to systemic infection alters the structure of the glomeruli to become permeable to protein resulting in: ◦ Massive urinary protein loss ◦ Generalized tissue edema Highest incidence at age 3 Generalized Edema ◦ Periorbital edema ◦ Abdominal edema ◦ Scrotal edema Poor nutrition Growth retardation Renal failure Proteinuria (24h urine 15 grams) Hypoalbuminemia Hyperlipidemia Urine appears dark and frothy Negative ASO titer Reduce edema Protect skin from FVE Protect from Infection Prevent Hypovolemia Prednisone 2mg/kg/day for 4-8 weeks ◦ Long term steroid use is concern ◦ Treat until child is in remission (zero to trace urine protein for 5-7 consecutive days) Diuretic therapy used only if poor response to steroids May need IV albumin (helps restore normal plasma osmotic pressure) Give parental support and education re: urine protein checks Frequent position changes q2h Loose clothing Semifowler’s for sleeping, elevate edematous body parts Maintain good hygiene (daily baths, dry completely) Promote physical activity if able (promote circulation) Screen visitors for s/s of infection Administer ABX as ordered given for peritonitis prophylaxis Good handwashing for staff and family Monitor child for s/s infection Monitor I & O Obtain accurate daily weights Adhere to no-added salt diet Monitor BP at least once each shift Administer diuretics (potassium intake) Monitor pulmonary status (watch for fluid overload, pulmonary edema) Watch for low BP & increased pulse => hypovolemia Report if child has output of less than 1 ml/kg/hr of urine Increased Hbg, Hct and platelets may indicate hemoconcentration or low intravascular volume Observe for s/s dehydration r/t use of diuretics AGN Nephrotic Syndroms School age child Dark Urine Oliguria Strep Infection Mild proteinuria Serum protein unaffected Hyperkalemia Increased BUN, Cr Mild edema HTN TX- BP meds Young child Dark Urine Oliguria Negative Strep Severe proteinuria Hypoalbuminemia Hyperlipidemia Severe edema Normal or low BP Tx-prednisone, diuretics, IV albumin kidney is unable to excrete wastes and concentrate urine Sudden onset of impaired renal function Boys>girls More common age < 5 years Usually occurs secondary to infection Most children regain renal function Can be life threatening ◦ Dehydration ◦ Hypovolemia ◦ Antibiotic ◦ Contrast dye ◦ Infections of the kidney ◦ Structural abnormality ◦ Tumor or calculi Oliguria (< 1ml/kg of weight) HTN may be malignant Dehydration Pallor, listlessness Hyperkalemia Hyponatremia Hypocalcemia Increased Azotemia BUN & creatinine (increased serum nitrogen) Uremia (azotemia plus cerebral irritation) Increase renal perfusion and restore electrolyte balance Depends on Cause General Treatment Includes: ◦ Fluid restriction ◦ Daily weight ◦ TPN to minimize protein catabolism Kayexalate for hyperkalemia ◦ I & O (Foley) The nurse is teaching the parents of a preschooler information about urinary tract infections and ways to reduce their recurrence. Statements from the parents that indicate an understanding of ways to prevent UTI’s include (select all that apply) 1. 2. 3. 4. 5. “I should try to get her to drink a lot of water” “I will buy her cotton underwear” “Soaking in a bubble bath will wash away the bacteria” “She should avoid urinating in public restrooms ” “I should give her cranberry juice daily” The parent of a 2 ½ year old child asks the nurse about potty training. Which assessment question should the nurse ask to assess the child’s developmental readiness? 1. “Can you child hold urine voluntarily?” 2. “Can you child urinate on command?” 3. “Is your child dry at night?” 4. “Does your child know when he is voiding?” The nurse would include which of the following in the care of a child with acute glomerulonephritis? (select all that apply) 1. 2. 3. 4. 5. Careful handling of edematous extremities Observing the child for evidence of HTN Provide fun activities for the child on bedrest Monitor for hematuria Encouraging salty foods The newborn has been diagnosed with cryptorchidism. The MD has ordered HCG to be administered. The mother asks the nurse why the baby is receiving the drug. The nurse explains it will: 1. 2. 3. 4. Maintain an adequate temperature around the testes Prevent infection in the undescended tests Prevent the development of cancer Promote descent of the testes View the diagram below. Where is the site of malformation in a child with VUR? A B C D 1. 2. 3. 4. Am 18.4 kg child urinated 43.68ml. The last void was 3 hrs ago. The nurse evaluates this output to be: Oliguria Polyuria Normal output Anuria The following results are from a chemistry panel on a 5-year-old child. Which of the following labs confirm the child is in AGN (Select all that apply) 1. Potassium 5.9 2. Urea Nitrogen 7.4 3. Albumin 3.8 4. Creatinine 0.6 5. 15 g 24/hr proteinuria Answer 1,2,3 1. Potassium 5.9 (hyperkalemia) 2. Urea Nitrogen 7.4 (Inc BUN) 3. Albumin 3.8 (Normal) 4. Creatinine 0.6 (should be inc) 5. 15 g 14/hr proteinuria (way to high) The nurse is treating a 33 lb child with Nephrotic Syndrome. The nurse calculates the appropriate dose of prednisone to be: 1. 10 mg qd 2. 20 mg qd 3. 30 mg qd 4. 40 mg qd