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Nursing Care of the Child with GU disorders

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Title: Nursing Care of the Child with GU disorders


1
Nursing Care of the Child with GU disorders
  • Summer 2009
  • Lea Melvin, MSN, RN, CRRN, CWOCN
  • Austin Community College

2
Radiography and other tests of urinary system
function
Urine culture sensitivity Renal/ bladder US
VCUG Imaging studies
Testicular US Scout film
IVP Renal bx, cysto
Whitaker perfusion test
3
Physical tests for Gu function
  • Volume for polyuria, oliguria
  • Specific gravity
  • Osmolality
  • Appearance
  • Chemistries on urine (v for blood, WBCs,
    bacteria, casts)

4
Blood tests of renal function
  • BUN (blood urea nitrogen)
  • Uric acid
  • Creatinine

5
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

6
External Defects
  • Extrophy of the Bladder
  • Hypospadius / Epispadius
  • Cryptochidism

7
Hypospadias
Epispadias
8
  • Epispadias
  • Congenital urethral defect in which the uretheral
    opening is on the upper aspect of the penis and
    not on the end

9
  • 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.

10
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.

11
Assessment
Usually discovered during Newborn
Physical Assessment
12
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.

13
  • 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.

14
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)

15
A double diapering technique protects the urinary
stent after surgery. The inner diaper collects
stool and the outer diaper collects urine.
16
  • 4. Control Pain.
  • 5. Increase fluids intake.
  • 6. Do not allow to play on any straddle toys.
  • 7. Prevent infection. no bathing or swimming
    until
  • stents removed.
  • 8. Discharge teaching
  • When to call doctor.
  • No bathing or swimming until stents removed.

17
Cryptorchidism
  • Failure of one or both of the testes to descend
    from abdominal cavity to the scrotum

18
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

19
Assessment
Diagnosed on Newborn Physical Exam
20
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.

21
Why is early surgery important?
  • Morphologic changes to testis from higher
    temperature in abd cavity
  • Decreased sperm countinfertility?
  • Testicular cancer

22
Obstructive Uropathy
  • Vesicoureteral reflux
  • Posterior urethral valves
  • Ureteropelvic junction defect

23
Vesicoureteral Reflux
  • Abnormal backflow (retrograde) of urine from the
    bladder into the ureters and possibly kidneys
    when the bladder contracts during
    emptying/voiding.

24
What is vesicoureteral reflux?
25
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 UTIs 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.

26
Vesicoureteral RefluxGrades I through V
27
Assessment
  • 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

28
Vesicoureteral Reflux
  • Approximately 20 of children that have UTIs will
    be found to have vesicoureteral reflux on xray

29
Diagnostic Tests
  • Urine culture
  • Cystourethrogram
  • (VCUG)
  • Renal ultrasound
  • (RUS)

30
Therapeutic Interventions
  • Drug Therapy
  • Antibiotics
  • Penicillin
  • Cephalosporins
  • Urinary Antiseptics
  • Nitrofurantoin
  • Surgery
  • Repair of significant anatomical anomalies,
    uretheral implantation

31
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

32
Nursing Care
  • IO - 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.

33
Evaluation
  • Follow-up VCUG in 3-4 months
  • Renal SPECT
  • RCG (radionucleaotide cystogram)

34
Test Yourself
  • Which of the following organisms is the most
    common cause of UTI in children?
  • a. staphylococcus
  • b. klebsiella
  • c. pseudomonas
  • d. escherichia coli

35
Urinary Tract Infections
36
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
    meatusstaph as well as e.coli

37
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

38
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

39
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

40
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

41
FYI
  • The single most important host factor influencing
    the occurrence of UTI is urinary stasis
  • What is the chief cause of urinary stasis?

42
Glomerular diseases
  • Acute glomerulonephritis (AGN)
  • Nephrotic syndrome (MCNS) or minimal-change
    nephrotic syndrome

43
Nephrotic Syndrome
  • Chronic renal disorder in which the basement
    membrane surfaces of the glomeruli are affected,
    cause loss of protein in the urine.

44
Nephrotic syndrome
45
Nephrotic syndrome, cont
46
Contrast of normal gloumerular activity with
changes seen in Nephrotic Syndrome
47
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). MgtF

48
Assessment
  • Four most common characteristics
  • Massive proteinuria
  • Hypoalbuminemia (K normal, BP normal)
  • 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
  • Hyperlipidemia
  • Of note is that there is no
  • hematuria or hypertension

49
Other signs and symptoms
  • Fatigue
  • Anorexia
  • Weight gain
  • Abdominal pain from large amount of fluid in
    abdominal

50
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

51
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 appetite, proteinuria, edema
  • d. body image change, hypotension

52
Acute Glomerulonephritis
  • Immune-complex disease which causes inflammation
    of the glomeruli of the kidney as a result of an
    infection elsewhere in the body.

53
Acute Glomerulonephritis
54
Etiology/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.

55
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

56
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

57
Therapeutic management
  • Corticosteroids (prednisone)
  • Dietary management
  • Restriction of fluid intake
  • Prevention of infections
  • Monitoring for complications infections, severe
    GI upset, ascites, or respiratory distress

58
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

59
  • Take a Break

60
Surgical procedures
  • Vesicostomy
  • Ureterostomy
  • Mitrafanoff catheterizable stoma
  • Malone Antegrade Colonic Enema stoma (MACE or ACE)

61
Post-op nursing care
  • Care of stoma
  • Skin protection
  • Care of stents, tubes, drains
  • Signs and symptoms of problems

62
Mitrafanoffappendiceal 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.

63
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.

64
Teaching for Mitranoffusually 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

65
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

66
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.

67
Teaching for MACE
  • Must irrigate every other day to maintain
    continence
  • Use mild enema solution
  • Maintain schedule for frequency
  • Allow time for evacuation

68
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
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