Child Health Nursing Partnering with Children & Families

1. Child HealthNursingPartnering withChildren & Families Jane W. BallRuth C. Bindler Chapter 31 Alterations in Genitourinary Function © 2006 Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, NJ 07458 Child Health Nursing: Partnering with Children & Families By Jane W. Ball and Ruth C. Bindler

2. Urinary System • Maintains balance • Removal of waste products • Functionally immature until puberty

3. Urinary System • Functions: • Excrete wastes • Maintain acid-base and fluid and electrolyte balance • Regulation of Blood pressure • Stimulation of production of erythropoietin • Regulation of calcium metabolism • By activation of vitamin D

4. Review of Urinary A&P • The key structures of the urinary sx are the Kidneys and the Urinary Tract • To produce urine, the various parts of the kidney perform 3 basic functions • Glomerular filtration (the process of filtering blood as it flows through the kidneys) • Tubular resorption (necessary fluids, electrolytes, proteins + blood cells are retained) • Tubular secretion (waste products+ fluids filtered out)

5. FIGURE 31–1The urinary system is comprised of the kidneys, ureters, bladder, and urethra. The kidneys are located between the twelfth thoracic (T12) and third lumbar (L3) vertebrae. Jane W. Ball and Ruth C. BindlerChild Health Nursing: Partnering with Children & Families © 2006 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458All rights reserved.

7. Urinary System • Ureters • Carry waste fluid from kidneys to bladder • Bladder • Stores urine • Bladder capacity in ounces estimated by adding 2 to child’s age • Bladder can hold 1-1 ½ ounces for every year of age • Muscular organ

8. Urinary System • Kidneys: • Nephrons • Perform filtration, reabsorption and secretion • Filtration occurs at the glomerulus, Bowman’s capsule and the basement membrane • Most renal growth occurs during the first 5 years of life. This increase in size is d/t the enlargement of the nephrons.

9. FIGURE 31–2The nephrons are the structural and functional unit of the kidneys. They filter water and wastes across the glomerular capillaries to maintain the body fluid level, electrolyte composition, and pH. A nephron holds six glomeruli, Bowman’s capsule, proximal tubule, loop of Henle, distal tubule, and the collecting duct. Jane W. Ball and Ruth C. BindlerChild Health Nursing: Partnering with Children & Families © 2006 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458All rights reserved.

10. Kidneys • Kidneys are immature at birth. As child grows, concentration of urine becomes more efficient • Refer to Box 31-3 • First 2 years of life: less efficient at regulating f/e and acid/base balance • Urine output per kg body weight is greater in infancy than childhood/ adolescents. • Kidney less able to concentrate urine

11. Urinary System • For the kidneys to function effectively, the following conditions need to be present • Unimpaired renal blood flow • Adequate glomerular ultrafiltration • Normal tubular function • Unobstructed urine flow

12. Urinary System • Diagnostic tests for Urinary System Conditions: • Refer to Table 31-2 p1178 in text • Normal Urinalysis Results: • Refer to Table 31-3 p 1179 in text

13. Structural Defects of the Urinary System • Bladder Exstrophy • Hypospadias and Epispadias • Obstructive Uropathy • Congenital Hydronephrosis • Vesicoureteral Reflux

14. Bladder Exstrophy • Rare congenital defect (1 in 40,000 newborns) • Etiology: failure of abdominal wall to close during fetal development • Leads to eversion of the bladder • Treatment: • Surgical reconstruction in several stages • Nursing care: • Cover w/ wet sterile gauze post-delivery, prepare for surgery

15. FIGURE 31–3 This child has exstrophy of the bladder. Note the extrusion of the posterior bladder wall through the lower abdominal wall and deformity of the penis. Jane W. Ball and Ruth C. BindlerChild Health Nursing: Partnering with Children & Families © 2006 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458All rights reserved.

16. Hypospadias and Epispadias • Congenital anomalies involving and abnormal location of the urethral meatus • Result from failure of the urethra folds to fuse completely over the urethral groove • Familial tendency but exact mechanism unknown • Hypospadias often occurs in conjunction with congenital inguinal hernias, undescended testes, chordee • Epispadias often occurs with bladder exstrophy

17. FIGURE 31–4 Hypospadias and epispadias. A, In hypospadias, the urethral canal is open on the ventral surface of the penis. B, In epispadias the urethral canal is open on the dorsal surface. Jane W. Ball and Ruth C. BindlerChild Health Nursing: Partnering with Children & Families © 2006 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458All rights reserved.

18. The urethral meatus may be located anywhere along the course of the ventral surface of the penile shaft The meatal opening islocated on the dorsal surface of the penile shaft, and may be at the level of the bladder neck. Hypospadias vs epispadias

19. Hyposapdias/ Epispadias Treatment • For mild cases of hypospadias, no intervention is necessary • Surgical correction is the tx of choice • Corrected during the first year of life • DO NOT CIRCUMCISE as foreskin tissue may be used in reconstruction • Goals of Surgery: • Placement of the urethral meatus at the end of the glans penis allowing for good urine stream • Release of chordee to straighten penis • Cosmetic appearance

20. Hypospadias/ Epispadias Nursing Responsibilities • Assist in the identification of defects in complete newborn exam • Prevent potential complications • Promote parental understanding and attachment • Promote normal voiding pattern

21. Obstructive Uropathy • Structural or functional abnormalities of the urinary system that interferes with urine flow and results in urine backflow into the kidneys. • The condition can occur anywhere along the urinary tract. • Pressure caused by urine backup often leads to hydronephrosis

22. FIGURE 31–6Obstruction may occur in either the upper or lower urinary tract. Common sites of obstruction occur at the ureteropelvic valve, the ureterovesicular junction, or the posterior urethral valve. Why would damage from posterior urethral valves potentially be worse than other obstructions? Renal failure is most likely to occur when both kidneys are affected by hydronephrosis. Jane W. Ball and Ruth C. BindlerChild Health Nursing: Partnering with Children & Families © 2006 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458All rights reserved.

23. Hydronephrosis • An accumulation of urine in the renal pelvis as a result of obstructed outflow, and compromises kidney function. • Most children with hydronephrosis are born with the condition although it can develop during childhood. It is the most common urinary tract anomaly (abnormality) and ranges in severity. In mild hydronephrosis, the pelvic (the part of the kidney that collects the urine) dilation is barely noticeable, whereas in severe hydronephrosis the swelling occupies much of the abdomen.

24. Hydronephrosis

25. Pathophysiology of Hydronephrosis • When pressure in the kidney pelvis= the filtration pressure in the glomerular capillary, glomerular filtration stops. In response, Blood pressure increases as the body attempts to increase the glomerular filtration pressure, however increasing pressure usually leads to cell death. • Metabolic acidosis results when the distal nephrons are impaired in their ability to secrete H+ ions. • Impaired ability to concentrate urine results in polydypsia and polyuria. • Obstruction results in urinary stasis, promoting bacterial growth • Chronic renal failure eventually results when hydronephrosis damages the renal parenchyma causing obstructive nephropathy

26. Hydronephrosis • Facts about hydronephrosis • It is four to five times more common in males than females. • It can occur in one or both kidneys. • Most mild cases and even some moderate cases may resolve on their own. • More severe cases may require surgery.

27. Hydronephrosis • What are the symptoms of hydronephrosis? • In mild cases and even some moderate cases of hydronephrosis, children will have no symptoms and the condition may disappear on its own within the first year of life. • In more severe cases, when kidney function is affected, the infant or child can experience pain, bleeding and infections. These symptoms may not develop until months or years after hydronephrosis is first detected. • Tx= surgery to correct blockage

28. Vesicoureteral Reflux • VUR results in backflow of urine from the bladder into the kidneys • Prevents complete emptying of the bladder and creates a reservoir for bacterial growth • The defect results from incomplete development of the ureterovesical junction, or from a structural anomaly.

29. VUR Grades (I-VI)

30. VUR • 70% of children with symptomatic UTI’s have VUR • Diagnosis: • Renal US • VCUG • a voiding cystourethrogram (VCUG) is an x-ray examination of a child's bladder and lower urinary tract that uses fluoroscopy and a contrast material. • Complications • Reflux of infected urine can cause pylonephritis

31. Disorders Affecting Urinary Elimination • Urinary Tract Infections (UTI’s) • Enuresis

32. UTI • A microbial invasion of the kidneys, ureters, bladder, or urethra • In the neonatal period, UTI’s occur most commonly in males, possibly b/c of the higher incidence of congenital abnormalities • By age 4 months, UTIs are more common in females b/c of the placement and size of the urethra

33. UTI • Causes: • Incomplete bladder emptying • Irritation by bubble baths • Poor hygiene • VUR • Urinary tract obstruction • Pathophysiology: • Bacteria enter the urethra and ascend the urinary tract • E.coli (Gram -) causes approximately 75-90% of all UTIs in females

34. UTI • What is the difference b/t these 3 conditions? • Cystitis (bladder) • Urethritis (urethra) • Pyelonephritis (ureters, renal pelvis and renal parenchyma) • Most common disorder of GU tract in children

35. UTI • Complications: • Risk of renal failure: • UTI under age 1 • Delay in diagnosis • Anatomic or neurologic obstruction • Recurrent episodes of upper UTI

36. UTI • Complications: • VUR • Glomerulonephritis • Bacteremia • Sepsis • Septic Shock • Tests: • Clean catch Urine Analysis and urine Cx- results yield large amounts of bacteria • Increased urine pH

37. UTI • Clinical Findings: • Abdominal pain • Enuresis • Frequency and Urgency • Pain/ burning w/ urination (dysuria) • Hematuria • Lethargy or irritability • Poor feeding patterns • Cloudy, foul-smelling urine

38. UTI • What is the most common clinical presentation of UTI in the child under 2? • Fever with associated s/sx including: • V/D • Irritability • Poor PO intake • Malodorous urine • Oliguria • Constipation • Please Refer to Table on page 1187 for other clinical manifestations of UTIs

39. Normal Urinalysis Results • Normal values used in many laboratories are given below: • Glucose: negative (quantitative less than 130 mg/day or 30 mg/dL). • Bilirubin: negative (quantitative less than 0.02 mg/dL). • Ketones: negative (quantitative 0.5–3.0 mg/dL). • pH: 5.0–8.0. • Protein: negative (quantitative 15–150 mg/day, less than 10 mg/dL). • Blood: negative. • Nitrite: negative. • Specific gravity: 1.015–1.025. • Urobilinogen: 0–2 Ehrlich units (quantitative 0.3–1.0 Ehrlich units). • Leukocyte esterase: negative. • Red blood cells: 0–2 per high power field. • White blood cells: 0–5 per high power field (0–10 per high power field for some standardized systems). • Also note color and odor of urine

40. Urine Culture • A urine culture is a diagnostic laboratory test performed to detect the presence of bacteria in the urine (bacteriuria). • Usually takes 24-48 hours for results • If symptomatic, treat empirically

41. Nursing care of UTI’s • Administer abx as Rx’d; instruct parents to complete entire course of abx • Encourage fluids to help to flush infection from the urinary tract • Teach proper toileting hygeine • Encourage child to use toilet every 2 hours • Discourage bubble baths • Teach parents about s/sx of UTIs

42. Enuresis • Repeated involuntary voiding by a child who has reached an age which bladder control is expected (5-6 y.o) • Enuresis at night= nocturnal enuresis • 50% of cases • More common in boys • Enuresis during day= diurnal enuresis • More common in girls • Further categorized as primary, intermittent and secondary

43. Enuresis • Primary: • Child has never had a dry night; attributed to maturational delay and small functional bladder • Intermittent: • Child has occasional nights or periods of dryness • Secondary: • Child begins bedwetting who has been reliably dry for 6-12 months; associated with stress, infections and sleep disorders

44. Enuresis • Clinical manifestations for diurnal enuresis: • Frequency • Urgency • Constant dribbling • Involuntary loss of control after voiding • Clinical manifestations for nocturnal enuresis: • bedwetting

45. Enuresis • A thorough hx is obtained. See Box 31-3 • Clinical therapy: • Spontaneous cure rate in 15% of cases/year • Multitreatment approach most efficient • 1/3 of nocturnal enuresis tx’d w/ meds • See page 1191 for meds used to tx enuresis • Behavioral interventions • Fluid intake programs, bladder alarms, and bladder training

46. Enuresis • Nursing management: • Thorough hx • Evaluate if parents and child are equally motivated to resolve problem • Teaching

47. Kidney Disorders • Nephrotic Syndrome • Renal Failure • Glomerulonephritis • Hemolytic Uremic Syndrome • Polycystic Kidney Disease

48. Nephrotic Syndrome • Condition in which the kidneys lose a significant amount of protein in the urine, resulting in low blood levels of protein. • Nephrotic syndrome refers not to a specific disease but to a clinical state characterized by: • Proteinuria • Hypoalbuminemai • Hyperlipidemia • edema

49. Nephrotic Syndrome • If nephron’s allow increased protein to escape from the blood what does this lead to?

50. Nephrotic Syndrome