Genitourinary Dysfunction Urinary Tract Infection

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Genitourinary Dysfunction Urinary Tract Infection Powered By Docstoc
Common Genitourinary Disorders
       • Enuresis

       • Urinary Tract Infection
       • Pyelonephritis

       •   Vesicoureteral reflux (VUR)
       •   Hydronephrosis
       •   Cryptorchidism
       •   Hypospadius
       •   Exstrophy of Bladder

       • Acute Glomerulonephritis
       • Nephrotic Syndrome
       • Acute Renal Failure
Toilet Training
         • 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
Toilet Training: Average age of Continence is 3 years
                        of age

                       Expected Developmental Milestones

                       Age             Bladder Control
                    1.5 years          Urinates regularly
                     2 Years           Aware of voiding
                    2.5 years           Can hold urine
                     3 years            Daytime control
                    3.5 years          Nighttime control
Signs of Readiness for Toilet
        • Physical Readiness
          – Child removes own clothes
          – Child is willing to let go of toy
          – Child is able to sit, squat, and walk well
          – Child 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
  – Patience

  – Personal choice on toilet or free
    standing potty chair
Enuresis Involuntary voiding of urine > 6
          • Primary
             – Never achieved dryness for 3
          • Secondary
             – Dry for 3-6 months then resumes
          • Diurnal
             – Wetting occurs only in daytime
          • Nocturnal
             – Wetting occurs only in nightime
           •   Neurological delay
           •   UTI
           •   Structural 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
       • Physical exam to r/o organic

       • Made by voiding diary
      • Organic- treat underlying cause

      • Nonorganic- most will outgrow by
        late childhood
Impact on child
        • May avoid activities
          – Sports
          – Sleepovers
        • Great source of stress
        • Concealing wet clothing is difficult
        • Odor is a concern
Enuresis: Nursing Diagnosis
       • Situational Low Self-Esteem
         related to bed- wetting or urinary
       • Impaired Social Interaction related
         to bed- wetting or urinary
       • Compromised Family Coping
         related to negative social stigma
         and increased laundry load
       • Risk for Impaired Skin Integrity
         related to prolonged contact with
• 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)
Urinary Tract Infection
(UTI) • Most common infection of GI tract
        • Fecal bacteria (E. coli) cause most
        • Girls>boys after age 1
        • In males uncircumcised>circumcised

        • Can lead to renal scarring, high
          blood pressure, End Stage Renal
Conditions that Predispose
Infants and Children to UTIs
 • Urinary tract obstructions
 • Voiding dysfunction resulting in
   urinary stasis
 • Anatomic differences in younger
 • Individual susceptibility to infection
 • Urinary retention while toilet-training
 • Bacterial colonization of the prepuce
   of uncircumcised infants
 • Infrequent voiding
 • Sexually active adolescent girls

    • Infants
      – Nonspecific
      – Fever or
      – Irritability
      – Dysuria (crying
        when voiding)
      – Change in urine
        odor or color
      – Poor weight gain
      – Feeding difficulties
      • Children
           –   Abdominal or suprapubic pain
           –   Voiding frequency
           –   Voiding urgency
           –   Dysuria
           –   New or increased incidence of enuresis
           –   Fever
           –   Malodorus urine
           –   Hematuria
          Infection travels to kidneys

    • Same s/s of UTI plus:
    • Higher fever
    • Back or flank pain (CVAT)
    • Nausea & vomiting
    • Look sick
Diagnostic tests
        • Urinealysis (UA)
          – Macro
          – Micro
          – 24 hour
        • Culture and Sensitivity (C & S)

        • Specimen collection
          –   Clean catch
          –   Pediatric urine collector
          –   Straight cath
          –   Foley cath
       • UA (Urinalysis)
            – Bacteriuria
            – Pyuria
       • Urine C&S: colony count = 100,000

       • Pyelonephritis
            – Above plus
            – Elevated WBC
            – Elevated ESR
            – Increased CRP
Management of Both
  • 7-10 day course of ABX
  • Dehydrated child and very
    young often require IV and hosp
  • Increase PO fluids
  • Analgesia
  • Antipyretics
  • Repeat urine C&S 3-5 days
    after tx
  • Proper toilet training
  • Teach proper wiping
  • Avoid tight clothing
  • Wear cotton underwear
  • Encourage children to avoid “holding”
  • Avoid bubble baths
  • Don’t force cranberry-increases acidity
  • Adolescent: urinate immediately after
Structural Defects
Vesicoureteral reflux (VUR)
       •Malformed valves at ureters and
       •Allows a backflow of urine up the
       ureter into the kidney

       •Can be congenital abnormality,
       graded 1-5
       •Grade 5: massive ureteral and renal
       pelvis dilation
Etiology and symptoms
       • Genetic origin
       • Girls>boys
       • Symptoms
         – Frequent UTI’s (most common)
         – Enuresis
         – Flank pain
         – Abdominal pain
Vesicoureteral reflux (VUR)
       • Grades 1-3: will usually resolve
         on own
       • Grades 4-5: valve repair
       • Prophylactic ABX
       • Teach child to double void
       • Urine C&S q 2-4 months until 3
     • Enlargement of the pelvis of
       the kidney secondary to a
       congenital narrowing of the
       ureteropelvic junction
     • May also be acquired
       secondary to kidney stones,
       tumors, blood clots

      • Usually free of symptoms initially
      • May have repeated UTI’s (urinary
      • Polyuria
      • Frequency
      • Flank pain
      • Increased BP
      • Abdominal palpation reveals a mass
     • If congenital, usually diagnosed in
     • IVP shows enlarged renal pelvis &
       site of obstruction

     • If untreated can destroy nephrons
     • Surgical correction of the obstruction
Cryptorchidism (UDT)
      •One or both testes fail to descend through
      the inguinal canal into the scrotal sac
      •Testis may be retractable
      • 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
Cryptorchidism (UDT)
      • 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
      • Increased risk for malignant testicle
        turoms in adulthood
      • Observation for first year
      • HCG- stimulates testosterone
        production and helps with
      • If testis fail to descend
        between 1-2 years of age
        then surgical treatment:
Surgical Management: usually outpatient

          • Post op instructions:
             –Loose clothing
             –Incision Care
             –Monitor for infection
             –Discuss future fertility & cancer
  – Congenital malformation
  – Urethral opening is below normal
    placement on glans of penis (ventral
  – May also have short chordee (fibrous
    band of the penis, will cause it to curve
  – dorsal placement of urethral opening
Hypospadius, epispadius,
Etiology and Symptoms
       • Cause is unknown
       • Defects in testosterone is possible
       • Possible genetic origin

       • Urinary stream deflected downward
       • Prepuce is small-Penis appears to look
       • May have chordee, undescended
         testes and inguinal hernia
Management of both
      • Out patient surgery to
        lengthens urethra
        (meatomy), position
        meatus at penile tip,
        release the chordee
      • Performed btw 12-18 mos
        of age
      • No circumcision
• Stent for urinary drainage and
• Double Diapering
• Strict I&O
• Pain Management
• Monitor for Infection
• No Hip-Holding, ride-on toys
• Possible fertility problems
Exstrophy of Bladder

   • Bladder lies open and exposed on abdomen
     (defect in abdominal wall)
   • Pelvic bone defects (non-closure of pelvic
   • Bladder is bright red & unable to contain
     urine, may also have defects in urethra
   • 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
Goals of Surgery
       • 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
• Post Op
•Suprapubic catheter-if unable to
restore function
•Immobilized Pelvis
•Strict I&O
•Antispasmotics: Probanthine
•Parental Emotional Support
Summary-Nursing Role
      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.
Disorders of the Kidney
Pediatric Normal Value age 2-12 yr
        • 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
Acute Glomerulonephritis (AGN)
   • 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
   • Usually seen 7-10 days after a strep infection
     (immune response to strep), may be other
     – APSGN (Acute Post Streptococcal
Signs & Symptoms
  • 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
  • Oliguria: < 1 ml/kg/hr = impending
    renal failure
Signs & Symptoms
  • Hypertension (due to decreased
    glomerular filtration rate) can be
  • 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
• No specific treatment- supportive
• Manage S&S (adequate rest- main tx)
• Monitor renal dysfunction
• Anti-hypertensive therapy (limit sodium &
  water or by diuretics & anti-hypertensive
• Prognosis is excellent
• Daily weight, accurate I & O until fully
  resolved (2 mos)
• Diuresis signals the beginning of resolution
Nursing Care- AGN/ASPGN
      • Monitoring fluid status- hypovolemia
        – I&0, VS, Electrolytes
      • Preventing infection-ARF risk for
        – Hand hygiene, screen visitors, watch
      • Preventing skin breakdown
        – Bed Rest is the Treatment
        – Check dependent areas
        – Sheets tight, free of crumbs, sm toys
Nursing Care- AGN/ASPGN
      • 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
Nephrotic Syndrome

     • Immune response to systemic
       infection alters the structure of the
       glomeruli to become permeable to
     • 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
Laboratory Findings
       • Proteinuria (24h urine 15
       • Hypoalbuminemia
       • Hyperlipidemia
       • Urine appears dark and
       • Negative ASO titer
      •   Reduce edema
      •   Protect skin from FVE
      •   Protect from Infection
      •   Prevent Hypovolemia
Reduce edema
• 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
• 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
Risk for impaired skin integrity
r/t edema & decreased

    • Frequent position changes q2h
    • Loose clothing
    • Semifowler’s for sleeping, elevate
      edematous body parts
    • Maintain good hygiene (daily baths, dry
    • Promote physical activity if able
      (promote circulation)
Risk for infection r/t
immunosuppressive therapy/treatment
of edema.

• Screen visitors for s/s of infection
• Administer ABX as ordered given
  for peritonitis prophylaxis
• Good handwashing for staff and
• Monitor child for s/s infection
Fluid volume excess (ECF) r/t
decreased excretion of sodium and
fluid retention.
       • Monitor I & O
       • Obtain accurate daily weights
       • Adhere to no-added salt diet
       • Monitor BP at least once each shift
       • Administer diuretics (potassium
       • Monitor pulmonary status (watch for
         fluid overload, pulmonary edema)
Risk for fluid volume deficit r/t effects of diuretics.

             • 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
Compare and Contrast
  AGN                        Nephrotic Syndroms

  School age child           Young child
  Dark Urine                 Dark Urine
  Oliguria                   Oliguria
  Strep Infection            Negative Strep
  Mild proteinuria           Severe proteinuria
  Serum protein unaffected   Hypoalbuminemia
  Hyperkalemia               Hyperlipidemia
  Increased BUN, Cr          Severe edema
  Mild edema                 Normal or low BP
  HTN                        Tx-prednisone, diuretics, IV
  TX- BP meds                albumin
Acute Renal Failure
  kidney is unable to excrete
  wastes and concentrate urine
Acute Renal Failure (ARF)
        • Sudden onset of impaired renal
        • Boys>girls
        • More common age < 5 years
        • Usually occurs secondary to
        • Most children regain renal
        • Can be life threatening
Types of ARF
         – Sudden decrease in renal blood flow result
           from dehydration, hypovolemia, shock,
           burns, CHF
         -damage to kidney tissue from
         antibiotic use and other nephrotoxic
         drugs, contrast dye, or infections of the
         – Urine is obstructed between the kidney and
           meatus causing back up of urine in kidney
           and diminishes renal function. Structural
           abnormality, tumor or calculi are the cause
Acute Renal Failure
       Signs & symptoms:
       •Oliguria (< 1ml/kg of weight)
       •HTN may be malignant
       •Pallor, listlessness
Laboratory Findings ARF
       •Increased BUN & creatinine

       •Azotemia (increased serum
       •Uremia (azotemia plus cerebral
Treatment: Mild ARF
       • 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)
Practice Questions!
     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.   “I should try to get her to drink a lot of water”
2.   “I will buy her cotton underwear”
3.   “Soaking in a bubble bath will reduce her
4.   “If I notice her wetting the bed, I need to have
     her checked for UTIs”
5.   “I should avoid giving her cranberry juice as it
     has been shown to make urine more acidic”
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
2. “Can you child urinate on command?”
3. “Is your child dry at night?”
4. “Does your child know when he is
   The nurse would include which of the
   following in the care of a child with
   acute glomerulonephritis?
   (select all that apply)

1. Careful handling of edematous
2. Observing the child for evidence of
3. Provide fun activities for the child on
4. Monitor for hematuria
5. 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. Maintain an adequate temperature
   around the testes
2. Prevent infection in the undescended
3. Prevent the development of cancer
4. Promote descent of the testes
• View the diagram below. Where is the
  site of malformation in a child with



• Am 18.4 kg child urinated 43.68ml.
  The last void was 3 hrs ago. The
  nurse evaluates this output to be:

1.   Oliguria
2.   Polyuria
3.   Normal output
4.   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
  APSGN/AGN (Select all that
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
• 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

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