Transcript Nursing Care of the Child with GU disorders

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
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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
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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
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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
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Vesicostomy
Ureterostomy
Mitrafanoff catheterizable stoma
Malone Antegrade Colonic Enema
stoma (MACE or ACE)
Post-op nursing care
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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