Chapter 43
Caring for the Child with a Renal,
Urinary Tract,
or Reproductive Condition
Student Learning Outcomes:
*Compare anatomic and physiologic differences of the
genitourinary system in infants and children versus adults.
*Understand the factors that make infants and children at risk for
dehydration and describe nursing care related to dehydration in
children.
*Identify appropriate nursing assessments and interventions
related to UTI, VUR, Acute Post Streptococcal Glomerulonephritis,
and renal failure.
*Compare and contrast hemodialysis and peritoneal dialysis and
the benefits for children.
*Develop child/family teaching plans for the child with an
alteration in genitourinary or reproductive disorder.
A & P Review
Outer cortex
Composed of the
glomeruli and
convoluted tubules of
the nephron and blood
vessels
Inner medulla
Composed of the renal
pyramid
Differences in Anatomy and Physiology
of Children Affecting Renal System
Kidney: large in relation to Bladder capacity: 30
stomach; prone to injury
ml in newborn
Kidneys are immature and
Reproductive organs:
less efficient. Renal
system does not reach immature until
maturity until 2 years of adolescence
age.
Glomerular filtration rate:
slower, risk for
dehydration
Urethra is shorter;
Increased risk for UTI
Fluid and Electrolyte
Balance
Compared to adults, children are at a greater risk for fluid and electrolyte
imbalance. Children have:
A proportionately greater amount of body water
Require more fluid intake and subsequently excrete more fluid
A greater body surface area and a higher percentage of total body
water
A greater potential for fluid loss via the gastrointestinal tract and skin
An increased incidence of FEVER, upper respiratory infections, and
gastroenteritis
A greater metabolic rate
Immature kidneys that are inefficient at excreting waste products
Kidneys that have a decreased ability to concentrate urine
Increased risk for developing hypernatremia based on their inability to
verbalize thirst
Role of the Kidneys in Acid Base Balance
Acidic Normal Alkaline
pH < 7.35 7.35-7.45 >7.45
PCO2 > 45 35-45 <35
HCO3 <22 22-26 >26
Kidneys: HCO3- base (bicarb)
Kidneys remove excess acid and base through the
body through the urine.
Lungs: regulate the amount of carbon dioxide in
the blood
PCO2- carbon dioxide- lungs
S/S of dehydration
Weight loss
Decreased skin turgor
Depressed fontanels
Increased HR
Decreased BP
Increased Cap refill
Respiratory pattern changes
Irritability or lethargy
Sunken eyes (infants)
*Based on Seattle study of children 2 and under,
1st 3 changes they saw in a dehydrated child
include increased cap refill, decreased skin turgor,
& repiratory changes
Loss of Skin Elasticity Due to
Dehydration
Slide 8
Nursing Care
Obtain daily weights
Measure intake and output
Assess hydration status
Laboratorytests include specific gravity, hematocrit, blood urea
nitrogen (BUN), creatinine, Na+, K+ and CA++
Assess type of acid-base disturbance
Administer oral clear liquids as ordered
Start an IV for fluid and electrolyte replacement as ordered
You may give 10-20 ml/kg bolus for dehydration
Encourage parents to be involved in the care of child
Educateparents about signs and symptoms of dehydration, re-
hydration, and when to call the doctor
Defining Dehydration
Mild – 0-5%
Moderate – 6-10%
Severe – Greater than 10%
Calculation for fluid loss
*Take the current weight and divide by the previous weight to get a percentile of weight that the child kept. Subtract that
percentile from 100.
Calculate % of weight loss for infant who one week ago weighed 10.2 kg and today weighs 8.9 kg. Then identify loss as
mild, moderate or severe.
Disorders of the
Renal and
Urinary
Systems
Urinary Tract Infections
A microbial invasion of the urinary tract
Lower urinary tract (cystitis)
UTIspreads to infect upper urinary tract
(Pyelonephritis) kidney infection
UTI’s
Escherichia coli most common pathogen
(80%)
Streptococci
Staphylococcus
Klebsiella pneumoniae
Psudeomonas aeurginosa
Slide 14
UTI: S/S
Typical s/s: dysuria, urgency,
frequency, flank pain, abdominal
pain, fever, concentrated urine,
strong-smelling urine, personality
changes, hematuria
Infant s/s can also include: irritability,
vomiting, failure to thrive, jaundice
Toddlers & preschoolers: Could start
having accidents again if they are
already potty trained (enuresis)
Slide 15
UTI: Diagnostic Studies
Clean-catch
U-bag for collection from child
Specimen obtained by
catheterization has more
accurate results
Slide 16
UTI Collaborative Care:
Drug Therapy—Antibiotics
Uncomplicated cystitis: short-term
course of antibiotics
Complicated UTIs: long-term
treatment
Trimethoprim-sulfamethoxazole (TMP-
SMX) or nitrofurantoin
Amoxicillin
*Augmentin (amoxicillin-clavulanate)
*Cefdenir
Slide 17
Risk Factors for UTI
Urinary stasis
Constipation
Hot tubs
Pinworms
Sexual abuse
Bubble baths
Age (less than 12 months)
Girls (proximity of urethra to the anus)
Normal Urinalysis
pH 4.6 to 8
Sp gr 1.001 to 1.030
Protein <20 mg/dl – trace
WBC’s – 0-4 (occ)
RBC’s – 0-2 (occ)
There should be almost no WBC, RBC, no proteins. No albumin,
glucose, ketones, and nitrates.
Slide 19
Practice Question
Which of the following urine tests
would be considered abnormal?
A. pH of 4.9
B. WBC: 15 cells/ml
C. Glucose: 0
D. Specific gravity of 1.020
Practice Question
A nurse in an emergency department is
assessing an infant who is dehydrated.
Which of the following findings should
the nurse expect?
a. Irritability
b. Slow, bounding pulse
c. Decreased temperature
d. Tetany
Vesicoureteral Reflux
(VUR)
Vesicoureteral reflux (VUR) occurs
when the valve between the ureters
and the bladder is not working
properly (ureterovesical junction). It
should operate as a one-way valve.
Instead, it operates as a two-way
valve and can allow urine in the
bladder to flow backward (reflux) into Slide 22
one or both ureters and kidneys.
Vesicoureteral Reflux (VUR)
Signs and symptoms
Recurrent UTI, flank pain, abdominal pain, and
enuresis
Nursing care
Surgery (reimplanting the ureter)
Medical management (antibiotics and
anticholinergic agents)
Educate the parents about signs and symptoms
of UTI and the importance of medication
Postsurgical—manage intake and output, pain
control and infection
*Goal of management
with VUR is to prevent
pyelonephritis and renal
scarring!
*Best way to diagnose
VUR is a voiding
cystourethrogram (VCUG)
Acute Poststreptococcal
glomerulonephritis
Most common type of glomerulonephritis in
children
Glomerulonephritis: Inflammation of the glomeruli
in the kidneys)
APSG occurs about 1-2 weeks after a
streptococcal infection like strep throat, impetigo,
or scarlet fever
S/S Gross hematuria, either tea- or coffee-colored
urine, periorbital edema & edema around the
face, hypertension, proteinuria, increased BUN &
Creatinine, oliguria, headache
Nursing Management of
APSG
Manage edema
Daily weights
Accurate I&O
Daily abdominal girth
Nutrition
Low-sodium, low to moderate protein
Administer diuretics, antibiotics, antihypertensive
drugs and corticosteroids during the acute phase. Help
protect the kidneys from further damage.
Slide 27
Nephrotic Syndrome
A kidney disorder that allows massive amounts of
protein loss through the urine.
S/S: massive proteinuria > 3 grams
Hypoalbuminemia
Hyperlipidemia
Edema (especially face, eyes, extremities)
Fatigue
Glomeruli are damaged and allow protein to pass
through the glomerular membrane. Massive loss
of protein occurs into the urine.
Most common cause of
nephrotic syndrome in
children is Minimal
Change Disease. It is
idiopathic.
Dialysis in
Pediatric
Nursing
Peritoneal Dialysis
Peritonealdialysis (this process of dialysis uses the
peritoneal membrane to filter blood and purify it)
Nursing care
Assist parents in learning peritoneal dialysis
Monitor for peritonitis (antibiotics, hospitalization, and follow-
up)
Monitorabdominal catheter site for signs of infection or
malfunctioning equipment
Make certain that the returning dialysate solution remains clear
Peritoneal Dialysis
Hemodialysis
Hemodialysis is dialysis through the blood, using a special
machine. Children must be hemodialyzed three times a week at
a dialysis center
Signs and symptoms
At the onset, a child may experience several side effects—
hypotension, dizziness, nausea, or muscle cramps.
Nursing care
Educate parents on how to keep the AV fistula site clean and
safe
No jewelry near access site
No blood pressure on that arm
Avoid carrying heavy objects, sleeping with arm under head
or body
Check pulse at the site daily
Promote lifelong coping skills
Functional
Disorders of the
Urinary Tract
Exostrophy of the Bladder
Signs and symptoms
Visualization that the bladder is open on the abdominal wall
Nursing care
Surgery necessary within the first 48 hours of life
Presurgical psychological and medical preparation
Postsurgical care
Keep area clean
Teach caregiver that diaper should be loose fitted and changed
frequently
Bladder
Exstrophy
Picture by Mayo
Clinic
Reproductive
Disorders
Affecting Girls
Vulvovaginitis
Signs and symptoms
Vulvar itching
Vaginal candidiasis has thick curdy
white discharge and is pruritic and
foul-smelling
Nursing care
Teach young girls to avoid
predisposing factors
Teach young girls about over-the-
counter antifungal remedies; applied
topically
Instruct young girls to wipe from the
front to the back after voiding
Educate patients about decreasing
bubble baths and artificial bath
bombs in bathtub
Amenorrhea
Signsand symptoms
Primary amenorrhea—delayed puberty
Secondary amenorrhea— Could be caused by hypothyroidism,
hyperthyroidism, polycystic ovarian syndrome, corpus luteum
cysts
Nursing care
Educate about risk for pregnancy
Assist with constructing a calendar depicting abnormal menstrual
pattern
Assess eating disorders and excessive exercise
Assess family members who experienced amenorrhea
Reproductive
Disorders
Affecting Boys
Testicular Tumors
Usually malignant
Testicular cancer is the most common
solid tumor in males ages 15 to 34
Testicular self-examination
Slide 43
Undescended Testes
Orchiopexy: Surgery for undescended testes
should be performed before 2 years of age
Varicocele
Signs and symptoms
Feel like a “bag of worms”
Distended veins in the scrotum on standing
Accentuation of the veins with the Valsalva maneuver
Decrease in visibility of the varicocele when in the supine
position
Small testes
Nursing care
Surgical ligation
Postsurgical nursing care
Cryptorchidism
Signs and symptoms
A retractile testis has descended but retracts with exam and
physical stimulation
An ectopic testes is outside of the normal pathway
Nursing care
Surgical repair; orchiopexy done between ages 1 and 2
Instruct caregiver to have the child wear loose clothing and use
analgesics as ordered
Instruct caregiver to observe for erythema, purulent discharge,
fever, and increased pain at the incision site (indicative of
infection)
Instruct caregiver to change diapers more frequently and avoid
having the older child engage in sports or straddle riding toys that
might injure the surgical site
Hypospadias and Epispadias
Signs and symptoms
Hypospadias—opening of urethra below the tip on the bottom side of the penis
Epispadias—opening of the urethra above the tip of the penis
Nursing care
Surgeryperformed before 18 months and before toilet training (urethral stent,
Foley catheter in place, and compression dressing applied)
Instructparents to have the child soak in warm water for 20 minutes before the
surgical follow-up appointment (loosen the dressing)
Assess for postsurgical complications
Monitor for signs of infection
Watch for evidence of UTI
Assess pain (oxybutynin chloride relieves bladder spasms)
Assess parent’s knowledge deficit and feelings
