Nursing Care for Children with Genitourinary Dysfunction I 1
Assessment of renal function Clinical manifestations Laboratory tests Urinalysis Urine culture and sensitivity Renal/bladder ultrasound Testicular ultrasound Voiding cystourethrography Radionuclide cystogram Radioisotope imaging studies Intravenous pyelography (IVP)(Intravenous urogram) Computed tomography Cystoscopy Retrograde pyelography Renal angiography Renal biopsy Urodynamics 2
Urine tests of renal function Test Normal range deviations Significance of deviations volume Specific gravity Age-related Newborn: 30-60 ml Children: bladder capacity( oz)=age+2 With normal fluid intake: 1.016-1.022 Newborn: 1.001-1.020 Ohers: 1.001-1.030 Clear pale yellow to deep gold Polyuria Oliguria Anuria High Low Dehydration Excessive fluid intake appearance Cloudy Cloudy reddish pink t o reddish brown Light Dark red Protein level absent present Abnormal glomerular permeability Glucose level absent present Diabetes mellitus glomerulonephritis Leukocyte esterase absent present Both lysed and intact WBCs via enzy me detection Nitrites absent present Most species of bacteria convert nitr ates to nitrites in the urine 3
Blood tests of renal function test Blood urea nitrogen(bun) Normal range(mg/dl) Newborn: 4-18 Infant, child: 5-18 deviations elevated Significance of deviations Renal disease Increased protein catabolism Dehydration Hemorrhage High protein intake Corticosteroid therapy Uric acid Child 2.0-5.5 increased Severe renal disease creatinine Infant: 0.2-0.4 Child: 0.3-0.7 Adolescent: 0.5-1.0 increased Severe renal impairment 4
Nursing considerations Preparing infants, children, and parents for tests and for collection of urine and blood specimens Maintaining of careful intake and output measurements and blood pressure 5
Genitourinary tract disorders Urinary tract infections Obstructive uropathy External defects 6
Urinary tract infection 10% of children during the first 2 years of life 7
Classification Bacterinuria Asymptomatic bacteriuria Symptomatic bacteriuria Recurrent UTI Persistent UTI Febrile UTI Cystitis Urethritis Pyelonephritis Urosepsis 8
Etiology Anatomic and physical factors Short urethra in females 2cm in young girls to 4cm in mature women Male: 20cm in adults + antibacterial properties of prostatic secretions Urinary stasis Reflux Anatomic abnormalities Dysfunction of the voiding mechanism Extrinsic ureteral or bladder compression by constipation Altered urine and bladder chemistry Fluid intake & diuresis: beneficial Bacteriostatic to E.coli at a ph of 5.0 9
Clinical manifestations of UTI Neonatal period Poor feeding Vomiting Failure to gain weight Frequent urination Dehydration Enlarged kidneys or bladder Infancy Foul-smelling urine Fever Persistent diaper rash Childhood Poor appetite Vomiting Growth failure Excessive thirst Enuresis, incontinence, frequent urination Painful urination Swelling of face Pallor Fatigue Abdominal or back pain Edema Hypertension tetany 10
Diagnostic evaluation Urine culture Suprapubic aspiration in children younger than 2 years of age Bladder catheterization Dipstick tests Leykocyte esterase or nitrite Percutaneous kidney taps Ultrasonography voiding cystourethrogram (VCUG) Intravenous pyelogram (IVP) DMSA (dimercaptosuccinic acid) scan 11
Objectives Therapeutic management To eliminate current infection To identify contributing factors to reduce the risk of recurrence To prevent systematic spread of the infection To preserve renal function 12
Antibiotic therapy Penicillins, sulfonamide (trimethoprim and sulfisoxazole in combination), cephalosporins, nitrofurantoin Surgical correction Careful follow-up High rate of recurrent infection To reduce the chance of renal scarring 13
Vesicoureteral reflux Most common cause of renal scarring in children Mild-moderate VUR Daily low-dose antibiotic therapy 2-3 months urine culture Annual voiding cystourethrogram
Vesicoureteral reflux Indications for surgical intervention Significant anatomic abnormality Recurrent UTIs Sever forms of VUR Noncompliance with medical therapy Intolerance to antibiotics VUR after puberty in females 15
Nursing considerations Careful history in infants and young children Voiding habits Stooling pattern Episodes of unexplained irritability Urine specimen collection Preparation for procedures according to pt s age and developmental status Explanation of the procedure, its purpose, and what the children will experience Anticipatory instruction on distraction techniques Antibacterial drug use Parent education for long-term use of nitrofurantoin Fluid intake 16
Prevention of urinary tract infection Factors predisposing to development Short female urethra close to vagina and anus Incomplete emptying (reflux) and overdistention of bladder Concentrated urine Measures of prevention Perineal hygiene: wipe from front to back Avoid tight clothing or diapers Check for vaginitis or pinworms Avoid holding urine; encourage child to void frequently Empty bladder completely with each void Avoid straining during defecation and avoid constipation Encourage generous fluid intake 17