Chapter 43 Nursing Care of the Child with an Alteration in Urinary Elimination/Genitourinary Disorder Flashcards
Urinary Elimination
Refers to the secretion & excretion of body waste through the urinary/renal system
Structural GU Differences in Children
Kidneys: The kidney is large in relation to the size of the abdomen until the child reaches adolescence
- Kidneys are less well-protected from injury by the ribs and fat padding than they are in the adult
Urethra: Shorter urethra in boys & girls promotes risk for infection (increased risk for entrance of bacteria into bladder via urethra)
- Girls are at an elevated risk: Risk is compounded by the physical proximity of the urethral opening to the rectum
- Boys: Shorter than a man’s-> higher elevated risk for UTI than men
Urinary Concentration in Children
GFR is slower in the infant and young toddler compared with the adult.
- The kidney is less able to concentrate urine and reabsorb amino acids, placing the infant and young toddler at increased risk for dehydration during times when fluid loss or decreased fluid intake occurs.
Normal range for serum blood urea nitrogen (BUN) and creatinine of the healthy infant or young toddler is usually less than the older child’s or adult’s
Renal system usually reaches functional maturity at around 2 years of age
Urine Output in Children
Bladder capacity is about 30 mL in the newborn
- Increases to the usual adult capacity of about 270 mL by 1 year of age.
Expected urine output in the infant and child is 0.5 to 2 mL/kg/hr, with the average 1-year-old voiding about 400 to 500 mL per day.
The average urine output for a teenager is about 800 to 1,400 mL per day.
The infant and toddler may void as often as nine or 10 times per day.
By age 3 the average number of voids per day is the same as an adult (3 to 8)
Hypospadias
A urethral defect in which the opening is on the ventral surface of the penis rather than at the end of the penis
Epispadias
A urethral defect in which the opening is on the dorsal surface of the penis. In either case, the opening may be near the glans of the penis, midway along the penis, or near the bas
Consequences of Untreated Hypospadias/Epispadias
Boy may not be capable of appropriately aiming a urinary stream from a standing position
May result in ED or interfere with the deposition of sperm during intercourse, leaving the man infertile
Surgical Correction of Hypospadias/Epispadias
The defect is usually repaired at 6 months and 1 year of age
Surgical correction goal: Provide for an appropriately placed meatus that allows for normal voiding and ejaculation.
The meatus is moved to the glans penis and the urethra is reconstructed as needed
Most repairs are accomplished in one surgery
- More extensive reconstructions may require two stage
Nursing Assessment: Hypospadias/Epispadias
Note history of an unusual urine stream
Inspect the penis for placement of the urethral meatus: it may be slightly off center of the glans or may be present somewhere along the shaft of the penis
Inspect for chordee, a fibrous band causing the penis to curve downward
Palpate for the presence or absence of testicles in the scrotal sac, because cryptorchidism (undescended testicles) often occurs with hypospadias, as do hydrocele and inguinal hernia
Nursing Management: Hypospadias/Epispadias Post-OP
Newborn with hypospadias or epispadias should NOT undergo circumcision until after surgical repair of the urethral meatus
- In more extreme cases, the surgeon may need to use some of the excess foreskin while reconstructing the meatus.
Assess urinary drainage from the urethral stent or drainage tube, which allows for discharge of urine without stress along the surgical site.
Ensure that the urinary drainage tube remains carefully taped with the penis in an upright position to prevent stress on the urethral incision.
The penile dressing is usually a compression type, used to decrease edema and bruising.
Administer antibiotics if prescribed
Assess for pain, which is usually not extensive, and administer analgesics or antispasmodics (oral oxybutynin or B&O suppository) as needed for bladder spasm
Double Diapering
A method used to protect the urethra and stent or catheter after surgery
- Also helps keep the area clean and free from infection
The inner diaper contains stool and the outer diaper contains urine, allowing separation between the bowel and bladder output
Change the outside (larger) diaper when the child is wet
- Change both diapers when the child has a bowel movement
Steps for Double-Diapering
1) Cut a hole or a cross-shaped slit in the front of the smaller diaper.
2) Unfold both diapers and place the smaller diaper (with the hole) inside the larger one.
3) Place both diapers under the child.
4) Carefully bring the penis (if applicable) and catheter/stent through the hole in the smaller diaper and close the diaper.
5) Close the larger diaper, making sure the tip of the catheter/stent is inside the larger diaper
Nursing Education: Hypospadias/Epispadias Post-Op
If the child is to be discharged with the urinary catheter in place (which is common), teach the parents how to care for the catheter and drainage system
Have parents demonstrate their ability to irrigate the catheter should a mucus plug occur
Tub baths are generally prohibited until it is time to remove the penile dressing
Roughhousing, ride-on toys, or any activity involving straddling is NOT ALLOWED for 4 WEEKS!
Obstructive Uropathy
An obstruction at any level along the upper or lower urinary tract
Common Sites: Junction of the upper ureter w/ pelvis of the kidney, lower ureter w/bladder, ureter swells into bladder, flaps of tissue in proximal urethra
Defect may be unilateral or bilateral and can cause partial or complete obstruction of urine flow, resulting in dilation of the affected kidney (hydronephrosis)
Complications: Recurrent UTI, renal insufficiency, and progressive damage to the kidney resulting in renal failure
Obstructive Uropathy: Assessment–Health History
Recurrent UTI
Incontinence
Fever
Foul-smelling urine
Flank pain
Abdominal pain
Urinary frequency
Urinary urgency
Dysuria
Hematuria
Explore the child’s current and past medical history for risk factors such as:
“Prune belly” syndrome
Chromosome abnormalities
Anorectal malformations
Ear defects
