Caring for the Child with a Renal, Urinary Tract, or Reproductive Condition

1
Chapter 32

• Caring for the Child with a Renal, Urinary Tract,
  or Reproductive Condition

2
A P Review

• Outer cortex
• Composed of the glomeruli and convoluted tubules
  of the nephron and blood vessels
• Inner medulla
• Composed of the renal pyramid

3
Fluid and Electrolyte Balance

• Compared to adults, children are at a greater
  risk for fluid and electrolyte imbalance.
  Children have
• A proportionately greater amount of body water
• Require more fluid intake and subsequently
  excrete more fluid
• A greater body surface area and a higher
  percentage of total body water
• A greater potential for fluid loss via the
  gastrointestinal tract and skin
• An increased incidence of fever, upper
  respiratory infections, and gastroenteritis
• A greater metabolic rate
• Immature kidneys that are inefficient at
  excreting waste products
• Kidneys that have a decreased ability to
  concentrate urine
• Increased risk for developing hypernatremia based
  on their inability to verbalize thirst

4
Calculation of Daily Maintenance Fluid
Requirements

• There are two methods of fluid maintenance.
• The surface area method is the most common and is
  used for
• children gt22 lb (10 kg) 15002000 mL/m2 per day
• Childs Weight Daily
  Maintenance Fluid Requirement
• 010 kg (022 lbs) 100 mL/kg of
  body weight
• 1120 kg (24.244lbs) 1000 mL 50
  mL/kg for each kg gt10
• gt20 kg (gt44 lbs) 1500 mL
  20 mL/kg for each kg gt20
• Note The method used to measure normal urinary
  output is 12 mL/kg per hour.

5
Types of Dehydration

• Isotonic
• Dehydration occurs when electrolyte and water
  deficits are present in balanced proportions
  (sodium and water are lost in equal amounts).
• Serum sodium remains in normal limits of 130150
  mEq/L.
• This is the most common type of dehydration.
  Hypovolemic shock is the greatest concern.
• Hypotonic
• Dehydration occurs when the electrolyte deficit
  exceeds the water deficit.
• The serum sodium concentration is lt130 mEq/L.
• Physical signs are more severe with smaller fluid
  losses.
• Hypertonic
• Dehydration is the most dangerous type and occurs
  when water loss is in excess of electrolyte loss.
• The sodium serum concentration is gt150 mEq/L.
• Seizures are likely to occur.

6
Nursing Care

• Obtain daily weights
• Measure intake and output
• Assess hydration status
• Laboratory tests include specific gravity,
  hematocrit, blood urea nitrogen (BUN),
  creatinine, Na, K and CA
• Assess type of acid-base disturbance
• Administer oral clear liquids as ordered (12 oz
  every hour)
• Start an IV for fluid and electrolyte replacement
  as ordered
• Ensure that the child has voided prior to
  administering intravenous Potassium (K)
• Cleanse perineal area and apply protective
  topical ointment
• Encourage parents to be involved in the care of
  child
• Educate parents about signs and symptoms of
  dehydration, re-hydration, and when to call the
  doctor
• Encourage parents to be compliant with follow-up
  appointment(s)

7
Disorders of the Renal and Urinary Systems
8
Urinary Tract Infections

• Signs and symptoms
• School-age new enuresis, strong-smelling urine,
  urgency, flank pain, and changes of personality
• Nursing care
• Collaborate with patient, family, and health care
  providers
• Explain treatment process to family
• Obtain history
• Administer IV fluids
• Administer oral or IV antibiotics
• Keep track of intake and output and odors

9
Vesicoureteral Reflux (VUR)

• Signs and symptoms
• Recurrent UTI, flank pain, abdominal pain, and
  enuresis
• Nursing care
• Surgery (reimplanting the ureter)
• Medical management (antibiotics and
  anticholinergic agents)
• Educate the parents about signs and symptoms of
  UTI and the importance of medication
• Postsurgicalmanage intake and output, pain
  control and infection

10
Unexplained Proteinuria

• Signs and symptoms
• Positive proteinuria by dipstick
• Nursing care
• Outpatient settinginstruct parent how to obtain
  a first-morning voided specimen
• Educate parents about other urological tests
• Reinforce proper follow-up care

11
Hematuria

• Signs and symptoms
• Blood in the urine
• Nursing care
• Educate parents and child about laboratory and
  procedural tests
• Explain cause of hematuria
• Educate parents and child about proper techniques
  of collecting a urine specimen
• Test urine with a dipstick

12
Post-Streptococcal Glomerulonephritis

• Signs and symptoms
• Gross hematuria, either tea- or coffee-colored
  urine, periorbital edema
• Nursing care
• Give antibiotic therapy
• Monitor fluid intake and output
• Administer diuretic medications and
  antihypertension drugs
• Teach family that severe glomerulonephritis may
  require peritoneal dialysis or hemodialysis
• Support family
• Assess child pharynx and upper respiratory tract
  for signs of acute infection
• Obtain a streptococcal culture (rapid or full
  streptococcal culture)
• Monitor for hypertension and urinary output
• Asses for risk of renal failure
• Educate parents about dietary restrictions
  (sodium, potassium, and fluid intake)

13
Hemolytic Uremic Syndrome

• Signs and symptoms
• Gastroenteritis (diarrhea and vomiting), as well
  as upper respiratory tract infection
• Triadthrombocytopenia, anemia, and acute renal
  failure (pallor, lethargy, anorexia, anemia, and
  irritability)
• Nursing care
• Tell family that child may be in the intensive
  care unit
• Monitor intake and output, LOC, signs of ICP,
  CHF, bleeding, and hypertension
• Monitor daily weights, electrolyte imbalances,
  and arterial blood gas
• Assess BUN and creatinine (renal status
  worsening)
• Assess lungs for CHF
• Assess peripheral and periorbital edema
• Monitor vital signs
• Tell family that electrocardiographic monitoring
  is recommended
• Understand that antibiotics are contraindicated

14
Henoch-Schonlein Purpura (HSP)

• Signs and symptoms
• Hematuria and hypertension, bloody diarrhea,
  crampy abdominal pain, purpural rash
• Joint pain and swelling, scrotal swelling
• Nursing care
• Administer corticosteroids
• Discuss immunosuppressant medications and
  possibility of renal transplant
• Monitor for signs of bleeding, pallor, vital sign
  alterations, abdominal pain, oliguria, and urine
  abnormalities

15
Chronic Glomerulonephritis

• Signs and symptoms
• Decreased urine output, high blood pressure,
  headaches, and other signs of fluid overload
• Nursing care
• Manage diet (restrict salt and fluid with
  low-potassium foods)
• Plasma exchange may be instituted in severe cases
• If hypertension is present, give diuretics
• Carefully monitor urine output, weight, and
  abdominal girth
• Monitor for complications
• Develop trusting, supportive, developmentally
  appropriate relationships
• Educate family that long-term follow-up includes
  biopsies
• Note that care is similar to that of acute and
  chronic renal failure
• If renal failure occurs, prepare for dialysis and
  renal transplant

16
Structural Defects of the Urinary System
17
Renal Trauma

• Signs and symptoms
• Flank tenderness, hematoma, a palpable mass, and
  other symptoms related to abdominal injury
• Nursing care
• Follow advanced trauma life-support guidelines
• If bruising without any urinary extravasationis
  found, ensure bedrest, analgesia, and
  prophylactic grades IV and V require referral to
  an urologist
• Gather detailed history of problem
• Perform nursing assessment, physical examination,
  and gather crucial information
• Surgery may be required (prepare child and
  family)
• After surgery, monitor vital signs, urinary,
  respiratory, cardiac, GI status, and surgical
  incision
• Monitor intake and output, weight, abdominal
  girth, administer IV fluids, and manage pain
• Report signs of renal perfusion
• Address psychosocial care

18
Acute Renal Failure (ARF)

• Signs and symptoms
• Fever, rash, bloody diarrhea, pallor, vomiting,
  diarrhea, abdominal pain, hemorrhage, shock,
  anuria, or polyuria
• Nursing care
• Support parents
• Administer medications
• Monitor nutritional intake and fluid intake and
  output
• Collaborate with health care team to prevent
  complications

19
Chronic Renal Failure

• Signs and symptoms
• Similar to those of acute renal failurefever,
  rash, bloody diarrhea, pallor, vomiting,
  abdominal pain, hemorrhage, shock, anuria or
  polyuria
• Nursing care
• Obtain history
• Obtain laboratory results
• Give medications
• Goals are mutually established with the patient
  and family
• Collaborate with health care team
• Facilitate care with nutritionists who will
  assist with meals
• Facilitate pastoral care
• Understand that nursing care is based on
  multisystem organ failure
• Provide patient teaching and referral to support
  groups

20
Dialysis in Pediatric Nursing
21
Peritoneal Dialysis

• Peritoneal dialysis (the process of dialysis uses
  the peritoneal membrane to filter blood and
  purify it)
• Nursing care
• Assist parents in learning peritoneal dialysis
• Monitor for peritonitis (antibiotics,
  hospitalization, and follow-up)
• Monitor abdominal catheter site for signs of
  infection or malfunctioning equipment
• Make certain that the returning dialysate
  solution remains clear

22
Hemodialysis

• Hemodialysis is dialysis through the blood, using
  a special machine. Children must be hemodialyzed
  three times a week at a dialysis center
• Signs and symptoms
• At the onset, a child may experience several side
  effects hypotension, dizziness, nausea, or
  muscle cramps.
• Nursing care
• Educate parents on how to keep the AV fistula
  site clean and safe
• No jewelry near access site
• No blood pressure on that arm
• Avoid carrying heavy objects, sleeping with arm
  under head or body
• Check pulse at the site daily
• Promote lifelong coping skills

23
Renal Transplantation

• Renal transplants are received from donors
• Children are maintained on dialysis until a
  kidney is available
• Children who receive a transplant are usually in
  end-stage renal disease
• Children receiving transplant must not be
  immunocompromised
• Nursing care
• Instruct family about long-term medications that
  prevent rejectioncyclosporine and steroids
• Give antihypertensive and diuretic medication as
  ordered
• Ensure a protein-restricted diet
• Facilitate care by accessing other members of the
  health care team

24
Functional Disorders of the Urinary Tract
25
Dysfunctional Elimination Syndrome/Voiding
Dysfunction

• Signs and symptoms
• Frequency, urinary incontinence, and urgency
• Nursing care
• Ask child about voiding
• Monitor stool elimination (maintain a normal
  bowel routine)
• Assess for emotional or social problems
• Teach girls with an inflamed perineum that they
  can take baking soda sitz baths and use barrier
  creams
• Promote adequate water intake
• Administer antibiotics (treatment and prophylaxis)

26
Enuresis

• Signs and symptoms
• Primary nocturnal enuresis (PNE)
• Do not awaken in response to a full bladder
• Secondary nocturnal enuresis (SNE)
• UTIs, constipation, diabetes mellitus,
  obstructive sleep apnea, psychological stress,
  and urge syndrome with dysfunctional voiding
• Nursing care
• Administer medications
• Desmopressin (DDAVP)
• Imipramine (Tofranil)
• Educate parents about developmental stage and
  child who is a deep sleeper
• Teach parents about avoidance of fluids close to
  bedtime
• Teach parents to use reward charts
• Teach parents that commercial items are available
• Teach parents about behavioral treatment
  (battery-operated bed-wetting alarm)

27
Exostrophy of the Bladder

• Signs and symptoms
• Visualization that the bladder is open on the
  abdominal wall
• Nursing care
• Surgery necessary within the first 48 hours of
  life
• Presurgical psychological and medical preparation
• Postsurgical care
• Keep area clean
• Teach caregiver that diaper should be loose
  fitted and changed frequently

28
Reproductive Disorders Affecting Girls
29
Vulvovaginitis

• Signs and symptoms
• Vulvar itching
• Vaginal candidiasis has thick curdy white
  discharge and is pruritic and foul-smelling
  (brown or green)
• Nursing care
• Teach young girls to avoid predisposing factors
• Teach young girls about over-the-counter
  antifungal remedies applied topically
• Instruct young girls to wipe from the front to
  the back after voiding
• Educate patients about complementary treatments

30
Labial Adhesions

• Signs and symptoms
• Thin film develops over the labia
• Nursing care
• Communicate that spontaneous resolution may occur
  over time
• Teach family about lysis of adhesions
• Treat with hormone cream
• Inform family that complications may include UTI

31
Amenorrhea

• Signs and symptoms
• Primary amenorrheadelayed puberty
• Secondary amenorrheas/s of pregnancy
• Hypothyroidismdry skin, dry hair, fatigue,
  hoarseness, constipation, and enlarged thyroid
  gland
• Hyperthyroidismoily skin and hair, diaphoresis,
  tachycardia, diarrhea, and a goiter
• Polycystic ovarian syndromeexcessive hair and
  obesity
• Corpus luteum cystspain in lower quadrants
• Nursing care
• Educate about pregnancy
• Assist with constructing a calendar depicting
  abnormal menstrual pattern
• Assess eating disorders and excessive exercise
• Assess family members who experienced amenorrhea

32
Reproductive Disorders Affecting Boys
33
Varicocele

• Signs and symptoms
• Feel like a bag of worms
• Distended veins in the scrotum on standing
• Accentuation of the veins with the Valsalva
  maneuver
• Decrease in visibility of the varicocele when
  in the supine position
• Small testes
• Nursing care
• Surgical ligation
• Postsurgical nursing care

34
Cryptorchidism

• Signs and symptoms
• A retractile testis has descended but retracts
  with exam and physical stimulation
• An ectopic testes is outside of the normal
  pathway
• Nursing care
• Surgical repair orchiopexy done between ages 1
  and 2
• Instruct caregiver to have the child wear loose
  clothing and use analgesics as ordered
• Instruct caregiver to observe for erythema,
  purulent discharge, fever, and increased pain at
  the incision site (indicative of infection)
• Instruct caregiver to change diapers more
  frequently and avoid having the older child
  engage in sports or straddle riding toys that
  might injure the surgical site

35
Hypospadias and Epispadias

• Signs and symptoms
• Hypospadiasopening of urethra below the tip on
  the bottom side of the penis
• Epispadiasopening of the urethra above the tip
  of the penis
• Nursing care
• Surgery performed before 18 months and before
  toilet training (urethral stent, Foley catheter
  in place, and compression dressing applied)
• Instruct parents to have the child soak in warm
  water for 20 minutes before the surgical
  follow-up appointment (loosen the dressing)
• Assess for postsurgical complications
• Monitor for signs of infection
• Watch for evidence of UTI
• Assess pain (oxybutynin chloride relieves bladder
  spasms)
• Assess parents knowledge deficit and feelings

36
Testicular Torsion

• Signs and symptoms
• Neonatescrotum appears dusky colored, a solid
  mass is palpated, scrotal edema, and minimal pain
  
• Older malessevere and persistent pain
• Nursing care
• Surgery within 48 hours
• Postoperative care

37
Reproductive Disorders Affecting Both Girls Boys
38
Ambiguous Genitalia

• Signs and symptoms
• External reproductive organs not easily
  identified as male or female
• Nursing care
• Discuss endocrinology and genetic referrals
• Surgery