to show an in-depth understanding of the genito-urinary disorders in children and the process of...

To show an in-depth understanding of the genito-urinary disorders in children and the

process of care in the nursing management

Aim

By the end of this session, the student should be able to:Understand the anatomy and physiology of the renal

system and structure and functionIdentify the differences between adult and children GU

systemDescribe the most common diagnostic investigations and

procedures for GU disorders

Understand the general assessment of children with genitourinary disorders

Understand the common genitourinary disorders in children

Plan the nursing management for children with GU disorders

Begins during 1st week of gestationCompleted by end of 1st year after birthExcretion less than adultBy the age of 6 to 12 months, filtration and

absorption is nearly like adultsFor healthy infant, the kidneys operate at a

functional level appropriate for the size of the body.

Nephron

Glomeruli – filter water and solutes from blood Tubules – reabsorb needed substances (water,

protein, electrolytes, glucose, amino acids) from filtrate and allow unneeded substances to leave the body in urine

Urine formed in the nephron, passes into renal pelvis, through ureter into bladder and out of body through urethra

Urine formed in the nephron, passes into renal pelvis, through

ureter into bladder and out of body through urethra

Glomeruli : filter water and solutes from

blood

Tubules : reabsorb needed

substances (water, protein, electrolytes, glucose, amino acids) from filtrate and allow

unneeded substances to leave the body in urine

Maintaining body fluid volume and composition

Secretes hormones:-Renin – helps with the regulation of blood

pressureErythropoietin – stimulates red blood cell

production by the bone marrowMetabolised Vitamin D – responsible for

calcium metabolism

Urinalysis

CT Scan- an x-ray procedure that combines many x-ray images with the aid of a computer to generate cross-sectional views and, if needed, three-dimensional images of the internal organs and structures of the body. 

gross indicator of renal function

(BUN) test measures the amount of nitrogen in blood that comes from the waste product urea.

Urea is made when protein is broken down in body.

Blood urea nitrogen (BUN) and creatinine tests can be used together to find the BUN-to-creatinine ratio (BUN:creatinine). body in the urine.

  A blood urea nitrogen (BUN) test is done to determine :

kidneys are working normally.

kidney disease is getting worse.

See if treatment of kidney disease is working.

See if severe dehydration is present. Dehydration generally causes BUN levels to rise

more than creatinine levels. This causes a high BUN-to-creatinine ratio. Kidney disease or

blockage of the flow of urine from kidney causes both BUN and creatinine levels to go up.

KUB (Kidney, Ureter, Bladder) x-rayRenal Biopsy

Renal Ultrasound

An injection of x-ray contrast media via a needle or cannula into the vein, typically in the arm. The contrast is excreted or removed from the bloodstream via the kidneys, and the

contrast media becomes visible on x-rays almost immediately after injection

a urologic procedure where the physician injects contrast into the ureter in order to visualize the ureter and kidney. 

Micturating Cystourethrography (MCUG) – serial x-ray of the bladder and urethra after IV infusion of iodine-bound contrast medium ( to detect blockage)

Urinary tract infection (UTI)Nephrotic syndromeAcute Post-Streptococcal Glomerulonephritis (APSGN)

Vesicoureteral refluxHypospadias

DefinitionUTI is the presence of bacteria in the urineInfection usually occur at the upper urinary

tract or at the lower urinary tract

IncidenceCommon age of onset for UTI is 2-6 yearsGirl>Boy - Female has shorter urethraUncircumcised male prone to develop UTI

Causative organisms – E. ColiRoute of entry -bacteria ascending from

the area outside of the urethra.Vesico-ureteral refluxInfections – URTI, GEPoor perineal hygiene - fecal organisms

are the most common infecting organisms due to the proximity of the rectum to the urethra.

Short female urethra

Urethritis – infection of the urethra

Cystitis – an infection in the bladder that has moved up from

the urethra

Pyelonephritis – a urinary infection of the kidney as a result of an infection in the urinary tract

Unexplained fever (febrile fits)

Abdominal pain

Poor growth Foul-smelling

urine

Weight loss(failure to weight gain)

Irritability

VomitingPoor feeding

Urinary frequency/urgency

DysuriaFoul-smelling urineCloudy urineIncontinence during

day and/or nightIncreased irritability

Nausea and vomitingLow abdominal or

flank painFever and chillsFatigueSmall amount of

urine while micturating despite feeling of urgency

Central pyrexia but peripherally coldPoor colourPale, grey mottled skinQuiet and lethargic childPoor toneTachycardic and hypertensive

Obtaining a urine specimen:-- Urine bag

- Clean catch urine- Mid-stream urine- Catheterisation

- Supra-pubic aspiration-draining the bladder by inserting a sterile needle through the skin above the pubic arch and into the bladder.

Ultrasound Plain x-ray Micturating Cystourethrogram (MCUG)

Obtain urine specimen before antibiotics started, sent for ME/CS

Blood tests Strict I/O chartMonitor vital signs esp. body temperatureAdminister antibiotics as prescribed (5

days course)Administer anti-pyretic drugs to reduce

fever and painAdvised to take plenty of fluids to prevent

dehydration and to flush the urinary tractIf the child is unable (vomiting) or refuse to

take fluids, administer IV fluids as prescribed

1. Fever due to increased body temperature related to urinary tract infection.

2. Alteration in urination (frequency, pain, burning, dribbling and enuresis) related to infection.

3. Pain related to inflammatory changes in the urinary tract.

4. Lack of knowledge about UTI and health prevention

Nursing interventions Rationales

• monitor body temperature every 4º • encourage plenty of fluid intake• administer anti-pyrexial medications as prescribed• maintain bed rest• wear thin loose clothing

• give tepid-sponging with luke-warm water

• baseline obs.• to maintain hydration• to maintain an optimum body temp.

• to reduce the body heat• to reduce body heat

Goal: to reduce fever and maintain normal body temperature

Nursing interventions Rationales

• assess the urinary frequency, pain or burning sensation during micturation • assess the colour & odour of urine• strict I/O chart

• administer antibiotics as prescribed

• observe for signs & symptoms of serious infection

• as baseline obs.

• as baseline obs.• to observe urinary frequency• to prevent spread of infection• to prevent complications

Problem 2: Alteration in urination (frequency, pain, burning, dribbling and enuresis) related to infection

Goal: to ensure that the child is comfortable during urination

Ensure the child to pass urine regularly (every 2-3 hours) and take the time to completely empty the bladder

Avoid holding urine for prolonged period of time

Perineal hygiene - wipe from front to backAvoid tight fitting clothing or diapers; wear

cotton pantiesAvoid constipationEncourage fluid intakeAvoid bubble baths

You are required to do the nursing care plan for problem no. 3 & 4, including nursing

interventions and rationales

Alteration of glomerular membrane permeability with massive proteinuria, hypoalbuminaemia, hyperlipidaemia and oedema

It occurs when the filters in the kidney leak an excessive amount of protein. The level of protein in the blood ↓ and this allows fluid to leak across the blood vessels into the tissues – causing oedema

Nephrotic syndrome are caused by changes in the immune system

For unknown reason, the glomerular membrane, usually impermeable to large proteins becomes permeable.

Protein, especially albumin, leaks through the membrane and is lost in the urine.

Plasma proteins decrease as proteinuria increase.

The colloidal osmotic pressure which holds water in the vascular compartments is reduced owing to decrease amount of serum albumin. This allows fluid to flow from the capillaries into the extracellular space, producing oedema.

Accumulation of fluid in the interstitial spaces and peritoneal cavity is also increased by an overproduction of aldosterone, which causes retention of sodium.

There is increased susceptibility to infection due to decreased gamma-globulin.

Causing generalised oedema

1 : 50 000 childrenMales > femalesCommon age of onset is between 2 to 6 years,

but can occur at any age

Oedema- initially noted in the periorbital area- ascites- intense scrotal oedema- striae may appear due to skin overstretching- pitting oedema

↑ weight

↓ urine outputProteinuria (foamy urine

indicates proteinuria)FatigueIrritable and depressionSevere recurrent

infectionsAnorexiaWasting of skeletal

muscles

Urinalysis- protein 3+ - 4+ on dipstick- haematuria may be absent or microscopic

Blood test- total serum protein – low- serum albumin – low- cholesterol and lipoproteins – high

Renal function test – often normalBlood pressure – often normal but 25%

hypertensionRenal biopsy

1. Generalised oedema due to fluid volume excess related to glomerular dysfunction

2. Impaired skin integrity related to oedema3. Altered urinary pattern related to

glomerular dysfunction4. Increased susceptibility to infection related

to disease process and steroid therapy

5. Altered body image (round face) due to side-effects of medication

6. Inadequate nutritional intake related to large loss of protein from the urine

7. Knowledge deficit of the disease process and treatment

8. Anxiety and depression due to the up and down of the course of disease

Goal : to relieve oedemaNursing interventionsAdminister steroids – prednisolone 2-4mg/kg

to control oedemaObserve for side-effects of steroids –

Cushing’s syndrome (moon face, abdominal distension, striae, ↑ appetite, ↑ weight, aggravation of adolescent acne)

Administer diuretic – frusemide. Diuretics can cause loss of electrolytes esp. potassium, encourage ↑ potassium food e.g. citrus fruits, date, apricot, banana

Keep the child CRIB during periods of severe oedema

Strict I/O chart – restrict intake of fluid – offer small amount of measured fluid during severe oedema, for infant measure the diaper’s wt.

Measure daily weight and abdominal girth – to check any weight gain due to water retention

Goal : to protect the child from skin breakdown Nursing interventionPosition the child comfortably in bed so that

oedematous skin is well-support with a pillowElevate the child’s head to reduce peri-

orbital oedemaProvide good skin care – give bath and

maintain hygiene esp. genitals and moist area

Change bedding daily and free from creases and sharp objects – to avoid cut

For problems 3 – 9, you are required to look for the nursing interventions yourself.

Admission to wardExplain to parents nature of illnessBlood for FBC/DC, U +E, Creat., Serum lipid,

C&S, LFT, serum albuminFor CXR and EchoDaily urine dipstick for protein, ME and C&S –

every morningDaily BP, weight and abdominal girthStart on IV infusion

Administration of IV albuminStart on steroid therapy – prednisolone given

at a dose of 2mg/kg/day divided into 2-3 doses. This regimen is continued until remission is achieved

Remission is achieved when the urine is 0 or trace for protein for 5 to 7 consecutive days

Administer prophylactic antibiotics to reduce infections

Start on diuretic therapy – frusemide (lasix)Dietary restriction – provide ↑ protein, high

carbohydrate, ↑ potassium diet & no salt dietStrict I/O chartProvide careful skin careGood hygieneCRIB

Question and Answer

DEFINITION

The backflow or reflux of urine from the bladder into the ureters and possibly the kidneys. The urine returns to the bladder after passing urine.

Fever >39ºCIrritabilityPoor feedingVomitingDysuria as evidenced by crying when passing

urineChange in urine colour or odor

Abdominal or suprapubic painFrequency in passing urineUrgency in passing urineDysuriaNew or increased incidence of enuresis

In normal functioning urinary tract, there is a valve-like mechanism at the junction of the ureter and bladder that prevents urine from refluxing in the ureters

As urine fills the bladder or the bladder contracts during micturating, pressure in the bladder occludes the opening to the ureter

When a defect occur at the vesioco-ureteral junction, VUR occur

MCUG – to visualise the urethra, evaluate degree of reflux and define any abnormalities

Renal scan – to assess renal scarring and function

Urodynamic studies – this is done when there is micturating dysfunction (frequency, urgency, or incontinence) is present

CystogramsUrine cultureBlood test – serum creatinine

GRADE I: reflux into ureter only – no dilatation

GRADE II: reflux into ureter, pelvis and calyces with no dilaltation and normal calyceal fornices

GRADE III: mild dilatation of ureter and renal pelvis

GRADE IV: moderate dilatation of ureter, pelvis and calyces

GRADE V: gross dilatation of ureter, pelvis and calyces

GRADE IVGRADE IV: : moderate dilatation moderate dilatation of ureter, of ureter, pelvis and calycespelvis and calyces

GRADE VGRADE V: : gross dilatation gross dilatation of ureter, of ureter, pelvis and calycespelvis and calyces

Reflux can be divided into 2 categories :-

1. PRIMARY REFLUX - caused by abnormal position of the ureteral bud on the wolffian duct during development of the urinary tract, resulting in smaller, tunneled segment of the ureter

2. SECONDARY REFLUX- occurs as a result of acquired bladder dysfunction

Daily low dose of prophylactic antibiotic to prevent UTI

Urinalysis and urine ME/CS – every 3 to 4 months to evaluate for UTI

Monitor ↑BP

Surgery – reimplantation of the ureter into the bladder

Indicated due to recurrent UTI despite antibiotics, Grade 5 reflux or progressive renal injury

Definition

Hypospadias is a congenital anomaly in which the actual opening of the urethral meatus is “below” the normal placement on the glans of penis

Occurs from incomplete development of the urethra in utero

Exact causes unknown – may be genetic, environmental or hormonal factor

Stenosis of the opening could occur – may lead to UTI or hydronephrosis

May interfere with fertility if left uncorrectedThe location of the meatus may make it

difficult for the child to urinate standing up

The choice of surgical correction is affected primarily by the severity of the defect

Surgery is done when the child’s age is less than 18 months

Reconstruction of the meatal opening is done – Meatal advancement granuloplasty (MAGPI)

The goal for surgical correction:-To enhance the child’s ability to pass urine in

the standing position with a straight streamTo improve the physical appearance of the

genitalia for psychological reasonsTo preserve a sexually adequate organ

1. Ashwill, J.W. and Droske, S. C. 1997. Nursing Care of Children. Principles and Practice. USA: W.B. Saunders.

2. Brunner, L.S. and Suddarth, D.S. 1986. The Lippincott Manual of Peadiatric Nursing. (3rd ed.) UK: Chapman & Hall.

The End