NCLEX-RN: Pediatric Nursing

Pediatric Nursing: RENAL SYSTEM

Focus topic: Pediatric Nursing

The genitourinary system the kidneys and their drainage channels is essential for the maintenance of life. This system is responsible for excreting the end products of metabolism as well as regulating water and electrolyte concentrations of body fluids.

Pediatric Nursing: System Assessment

Focus topic: Pediatric Nursing

A. History.

  •  Assess perinatal history, family history of renal disease, and/or deafness.
  •  Normal feeding patterns, diet, number of wet diapers/voidings per day, growth patterns, fever, straining or pain with voiding, irritability.
  • Recent infections (especially streptococcal), and other illnesses (e.g., autoimmune, metabolic, recurrent urinary tract infections).

B. Inspection.

  •  Assess male genitalia for urethral orifice and inspect shaft of penis for abnormalities (hypospadias).
  •  Assess scrotum for edema (normally present for several days after birth).
  •  Assess female urethral orifice for redness, swelling, discharge, normal anatomy.
  •  Observe for edema, evaluate periorbital area, sacral region, hands, and feet in infants. Also evaluate fontanelles.
  • Observe character of urine if cloudy, frothy, with evidence of blood. Evaluate with dipstick test as indicated.
  •  Observe urinary stream.
  •  Evaluate intake and output, daily weights.
  •  Observe general appearance and growth trends on growth charts.

C. Palpation.

  •  Kidneys rarely palpable past the neonatal period.
  •  Bladder often palpable above symphysis pubis.
  •  Palpate infant’s fontanelles for fullness if edema suspected.
  •  Palpate for abdominal masses, which may indicate constipation; constipation often associated with urinary tract infections.
  •  Assess quality of pulses (for fullness and bounding character) and if blood pressure elevated, if decreased perfusion indicated by diminished capillary refill.
  • Palpate for descended testes bilaterally in scrotal sac.
  • Costovertebral tenderness indicates upper urinary tract infection in the older child.

Pediatric Nursing

Pediatric Nursing: Diagnostic Procedures

Focus topic: Pediatric Nursing

Evaluation of Blood
A. CBC with differential.
B. Blood urea nitrogen (BUN).
C. Creatinine.
D. Uric acid (UA).

Evaluation of Urine (Urinalysis)
A. pH.
B. Protein.
C. Specific gravity.
D. Presence of glucose and ketones.

Cystoscopy
A. Direct visualization of bladder and urethra done under general anesthesia.
B. Nursing responsibilities.

  •  Prior to procedure—NPO 6–8 hours.
  •  Following procedure—check I&O, observe for urinary retention and hematuria.
  •  Sedation per institutional protocol.

Intravenous Pyelogram
A. A radiographic study of kidneys, bladder, and other structures via contrast media injection.
B. Nursing responsibilities.

  • Prior to intravenous pyelogram (IVP)—NPO 6–8 hours; bowels cleaned with cathartic; have child void.
  •  Following procedure—evaluate for dye reaction; assess child’s alertness and gag reflex; check for signs of perforation (intense pain in stomach).

Renal/Bladder Ultrasound
A. Transmission of ultrasound through renal parenchyma, along ureters and over bladder.
B. Noninvasive and without radiation.
C. Useful in assessment of structural abnormalities and masses.

Urodynamic Evaluation
A. Includes voiding cystourethrogram, uroflowmetry, cystometrogram, voiding pressure studies.
B. Provides graphic view of bladder, with volume changes.
C. Valuable for assessing ureters and urethra, voiding dysfunction related to urinary infections, retention, or bladder dysfunction.

CT/MRI
A. Accurate views of cross-sections of kidneys from different axes.
B. Most valuable in viewing masses and differentiating tumors and cysts.

Renal Biopsy
A. May be open or via percutaneous technique.
B. Differentiates between types of nephrotic syndromes.

Pediatric Nursing: System Implementation

Focus topic: Pediatric Nursing

A. Monitor laboratory results of serum electrolytes. (Refer to Chapter 11 for major electrolyte disorders.)
B. Provide excellent skin care.
C. Monitor IV solutions for appropriate electrolytes depending on the disorder.
D. Monitor urine.

  •  Utilize urine dipstick testing for each voiding. Check for presence of blood, protein, and ketones.
  •  Describe the appearance of urine: dark, light, cloudy, pink, mucus present.
  •  Evaluate the specific gravity of the urine.
  •  Monitor for possible urinary tract infection.

E. Monitor edema through daily weights and qualitative assessment.
F. Measure intake and output.
G. Monitor vital signs (especially BP) every 4 hours or more frequently if warranted.
H. Administer medications—antihypertensives may be prescribed.
I. Evaluate for rapid respirations associated with acidosis.
J. Separate children who have an increased susceptibility to infection.
K. Control infection, if present, with appropriate medications.
L. Collect urine specimens from children suspected of having urinary tract infections.
M. Provide diet for degree of renal dysfunction.

Monitoring Urine in Renal Disorders
A. Intake and output.

  •  Significant drop in output could signal worsening renal failure.
  •  Output should not drop below 2 mL/kg/hr for infants; 1 mL/kg/hr for children. (1 mL/kg/hr is the most minimal expectation for urinary output.)
  • The child must be catheterized for accurate assessment of output.

B. Measure intake and output and observe for signs of diuresis following the initiation of medical intervention.

  •  Normal output dependent on ages and sizes.
  •  Always evaluate output in relation to input and insensible water losses (through fever, respiration, and diaphoresis).

C. Urine should be clear and yellow with no ketones, protein, blood, or sugar according to dipstick or urinalysis.
D. Specific gravity.

  • Morning specimen usually concentrated around 1.020–1.030 is normal.
  •  Diluted urine around 1.001 may be found in normal infants or in children going through diuresis. Normal values for specific gravity according to age. Under age 2, a specific gravity less than 1.020 is normal.

Monitoring Diet for Renal Conditions
A. If there is a high protein loss in urine, a high protein intake is important.

  •  Restrict foods rich in potassium and sodium as prescribed.
  •  Allow parents to bring in appropriate foods from home.
  •  Sit with child during meals and talk about subjects other than food.
  •  Provide nutritious snacks between meals.

B. Provide appropriate diet for degree of renal dysfunction.

  •  Glomerulonephritis: no added salt regular diet.
    a. Evidence of renal failure: Restrict protein and potassium.
    b. If edema, hypertension, or heart failure: Restrict fluids.
  •  Nephrotic syndrome: Fluids may be restricted if severe edema is present.

Pediatric Nursing: Renal/Urinary Disorders

Focus topic: Pediatric Nursing

Pediatric Nursing: Urinary Tract Infections

Focus topic: Pediatric Nursing

Definition: Urinary tract infection (UTI) is a term that refers to a wide variety of conditions affecting the urinary tract in which the common denominator is the presence of a significant number of microorganisms.

Characteristics
A. Escherichia coli most frequent organism (80% of cases).
B. The most important factor influencing ascending infection is obstruction of free urine flow (vesicoureteral reflux, for example).

  •  Free flow, large urine output, and pH are antibacterial defenses.
  •  If defenses break down, the result may be an invasion of the tract by bacteria.

C. More common in girls than in boys, most common ages 2–6 years. More common in uncircumcised male infants during early infancy. Symptoms in early infancy are subtle and require septic work-up if less than 2 months of age.

Assessment
A. Obtain urine for culture (clean catch midstream specimen). Aseptic catheterization provides most accurate specimen for culture. Specimen should be taken to lab immediately.

B. Assess symptoms of classic urinary tract infection: burning on urination, cloudy, foul-smelling urine, fever.

  •  In children under 2 years of age, symptoms are nonspecific and include vomiting, poor feeding, failure to gain weight, pallor, diaper rash, and excessive thirst.
  •  Incontinence in a toilet-trained child may signal UTI.
  •  More serious infections signaled by jaundice, seizures, dehydration, abdominal or back pain, blood in urine, edema, hypertension, tachycardia, and tachypnea.

C. Determine presence of bacteria in screening for UTI with urinalysis (nitrites, leukocyte esterase).
D. Evaluate microscopic examination for detailed identification of the organism (presence of white blood cells in the  urine diagnostic of UTI with positive culture; may have slightly increased red blood cells).
E. Urine culture: Note that usually a colony count of over 100,000/mL of a single organism from a midstream specimen, or 50,000/mL from a sterile catheterization (according to 2011 American Academy of Pediatrics guidelines), accompanied by pyuria in the urinalysis of a febrile child less than 3 years of age indicate infection.
F. Urosepsis may be present (more commonly in females and young infants), characterized by systemic evidence of bacterial infection with UTI and blood cultures positive for urinary pathogen.
G. Recurrent UTIs should warrant further diagnostic procedures to evaluate structural defects.

Implementation
A. Encourage fluids (after cultures are obtained) to amount appropriate for age.
B. Administer antibiotics as indicated by urine culture and sensitivity results.

  •  Specific for causative bacteria (given 1–2 weeks).
  •  Common drugs—extended spectrum penicillins (Amoxil, Augmentin), sulfonamides, aminoglycosides, Bactrim (trimethoprimsulfamethoxazole), or cephalosporins (Rocephin [ceftriaxone], Claforan [cefotaxime]). Young infants are treated with IV antibiotics while older children may be given PO antibiotics.
  •  Monitor side effects: nausea, vomiting, vertigo, diarrhea, rash, pruritus, urticaria.

C. Teach mother and child to wipe child front to back, especially for females.
D. If stool in diaper, clean immediately, wiping front to back.
E. Teach early signs of UTI and when to seek medical care.

Pediatric Nursing: Vesicoureteral Reflux

Focus topic: Pediatric Nursing

Definition: The retrograde flow of urine from bladder up into ureters.

Assessment
A. Frequently a cause for recurrent UTIs in children.
B. Obtain history of recent illness, previous UTIs.
C. May result from congenital abnormality or from an acquired disorder.

Implementation
A. Prepare family and child for diagnostic procedures (ultrasound, voiding cystourethrogram).
B. Tests will reveal anatomic abnormality in ureteral insertion into bladder (primary reflux).
C. Vesicoureteral reflux (VUR) also results from acquired condition as with recurrent UTI (secondary reflux).
D. Treatment initially may be antibiotics, in lower doses, with follow-up urine cultures.
E. First-line treatment is endoscopic injection of bulking material, Deflux injectable gel, which builds up a protective wall inside the ureter to prevent the backflow of urine.
F. Surgery indicated if anatomic defects are significant, UTIs continue, two to three failed Deflux treatments, and/or the family is noncompliant with treatment and follow-up.
G. Education and family support essential.
H. Routine preoperative care if surgery indicated.
I. Postoperative management: care of wound, possible management of stents, pain management, and discharge planning.

Pediatric Nursing: Acute Glomerulonephritis

Focus topic: Pediatric Nursing

Definition: Acute glomerulonephritis (AGN) is believed to be an antigen–antibody reaction usually secondary to an infection from group A beta-hemolytic streptococci originating elsewhere in the body (for example, strep throat). The disease can range from minimal to severe, even though the preceding infection may be minimal. It is most common in children 4–7 years of age.

Assessment
A. Assess renal system.

  • Protein and blood cells present in urine (painless).
  •  Oliguria and occasional anuria.
  •  Mild edema—facial (periorbital). Worse in mornings.
  • Tea-, cola-colored, or bright red urine.
  •  Elevated BUN and serum creatinine.
  • Serum complement: C3 decreased with C4 normal.
  •  Antistreptolysin O, anti-DNase B, streptozyme +/– positive, reflects previous Streptococcus ninfection.
  •  Throat culture +/– beta hemolytic Streptococcus.

B. Assess cardiovascular system.

  •  Possible hypertension, slowed pulse, and generalized edema.
  •  Possible heart failure or circulatory congestion.

C. Assess for preceding infection and fever, symptoms usually appear approximately 10 days after streptococcal infection.
D. Assess for anorexia and fatigue, irritability, headaches, lethargy.

Implementation
A. Maintain rest during acute stage. Bed rest is not necessarily needed once the gross hematuria, edema, azotemia, and hypertension have subsided.
B. Monitor antibiotic treatment if there are positive bacterial cultures.
C. Monitor diet and fluid intake.

  •  Elevated BUN and oliguria protein moderately restricted only if oliguria is prolonged and azotemia is severe.
  •  Liberal carbohydrates and fats for energy.
  •  Restrict sodium (moderately no added salt) if edema or hypertension present.

D. Give antihypertensive drugs, e.g., Procardia (nifedipine).
E. Prevent fluid overload—may need fluid restriction.

  • Weigh daily, same time, same scale.
  •  Measure intake and output, calculate insensible losses.

F. Prevent complications.

  • Observe for signs of cerebral edema: headache,
    dizziness, vomiting.
  •  Monitor for renal failure: nausea, vomiting, oliguria.
  •  Prevent skin breakdown.
  •  Antibiotics used only if streptococcal infection is indicated.

G. Support of family and discharge teaching.

Pediatric Nursing: Nephrotic Syndrome

Focus topic: Pediatric Nursing

Definition: The most common form of glomerular injury in children. A symptom complex with multiple and varied pathological manifestations; usually massive hyperlipidemia, edema, proteinuria, and hypoalbuminemia, the etiology of which is unknown. Nephrotic syndrome occurs primarily in preschool age groups (2–6 years of age). Overall prognosis is good, but relapses common.

Assessment
A. Assess for generalized edema from fluid overload.

  •  Periorbital and facial (may be severe) edema.
  •  Abdominal edema (ascites); may lead to respiratory distress.
  •  Respiratory difficulty with pleural effusion.
  •  Diarrhea, vomiting, and malabsorption from edema of gastrointestinal tract.

B. Assess for marked proteinuria (3–4+ on dipstick protein). Microscopic hematuria may be present.
C. Serum albumin is markedly decreased (less than 2.5 g/dl).
D. Serum cholesterol, triglycerides, hematocrit, and hemoglobin are elevated.
E. Assess for malnutrition.
F. Assess for potential hypertension (usually normal blood pressure).

Implementation
A. Administer corticosteroid therapy as ordered, generally oral Deltasone 60–80 mg per day, divided into two to three doses.
B. Monitor edema formation through daily weights and abdominal circumferences; accurate recording of intake and output.

  •  Measure abdominal girth at umbilicus.
  •  If ascites present, evaluate for respiratory difficulty from pressure on the diaphragm.
  • Place child in semi-Fowler’s position if massive edema is present.

C. Provide meticulous skin care.

  •  Bathe body surfaces frequently.
  •  Turn and position client frequently to prevent skin breakdown.
  •  Support edematous areas such as the scrotum.

D. Monitor use of diuretics.
E. Monitor use of steroids. Deltasone, which reduces edema and proteinuria, is drug of choice.

  • Diuresis usually occurs in 7–21 days.
  •  Dosage is usually tapered after urine is free of protein and remains normal.
  •  Prepare child and family for side effects: Cushing’s syndrome, weight gain, acne, hirsutism.
  •  Protect from infection.

F. Provide appropriate diet.

  •  Protein not usually restricted; may encourage foods rich in protein.
  •  Moderate sodium restrictions (no added salt)
  •  High-calorie diet.

G. Teaching principles.

  •  Emphasize diagnosis and treatment regimen, skin care, diet, monitoring urine at home.
  •  Support of family and child.

Pediatric Nursing: Hemolytic Uremic Syndrome

Focus topic: Pediatric Nursing

Definition: Among the most frequent causes of acute renal failure in children. Etiology is unclear but most likely bacterial toxins, chemicals, or viruses, particularly the E. coli 0157:h7 serotype.

Characteristics
A. Hemolytic uremic syndrome (HUS) is often associated with E. coli infection that results from improperly cooked meat or contaminated dairy products.
B. HUS produces hemolytic anemia, thrombocytopenia, renal injury, and CNS symptoms. The anemia occurs because of fragmentation of red blood cells, which are damaged as they try to pass through the occluded vessels and are removed from circulation by the spleen. The occlusion of the glomeruli causes renal damage.
C. Occurs mainly in young children (younger than 5 years), predominantly in Caucasians.

Assessment
A. Obtain thorough history.

  •  Possible exposures to known causative organisms.
  •  Prodromal illness—gastroenteritis or upper respiratory infection (URI).
  •  Sudden-onset renal failure.

B. Assess CNS status for seizures, irritability, or lethargy.
C. Assist in obtaining lab tests; triad of anemia, thrombocytopenia, and renal failure is diagnostic.
D. Assess renal function.

  • May be oliguric or anuric.
  •  Elevated BUN and serum creatinine.
  •  Urine has protein, blood, and casts.
  •  Monitor electrolytes.
  •  Renal ultrasound may help with diagnosis of obstruction and postrenal acute renal failure. A renal scan can assess blood flow, kidney function, and obstruction.

E. Evaluate for hypertension or arrhythmias.

Implementation
A. Early diagnosis and management of renal failure most important.
B. Many children managed without dialysis by monitoring fluid, electrolyte, and acid–base status, with recommended nutritional intake (low-sodium, low-potassium, and high-caloric diet).
C. Dialysis (peritoneal or hemo) used if anuric for 24 hours or if seizures or severe hypertension develop.
D. Monitor respiratory status.

  •  Assure airway is protected (CNS status).
  •  Support ventilation and oxygenation as needed.

E. Careful monitoring of cardiovascular status.

  • aintain optimal fluid and electrolyte status.
  •  Monitor blood pressure carefully, administer appropriate medications.
  •  Continuous ECG monitoring if arrhythmias likely.
  •  Treat anemia—packed red blood cells (PRBCs) may be given cautiously.

F. Support family and child.

  •  Long-term sequelae develop in 10–50% of cases (chronic renal failure, hypertension, CNS disorders).
  •  Provide teaching and emotional support teach families to avoid meat cooked < 160°F (71.1°C) (risk of E. coli contamination, especially in ground beef).
  •  Discharge planning.

Pediatric Nursing: Enuresis

Focus topic: Pediatric Nursing

Definition: Involuntary urination in a child who is of age to have bladder control, or previously had control. Frequently occurs at night (nocturnal enuresis), may be due to organic causes and occurs more often in boys after 4–5 years old with a family history of enuresis. Many factors associated with enuresis. Because physical maturation varies, nocturnal enuresis is not a concern unless the child is older than 6 years.

Assessment
A. Obtain accurate history (toilet training, prior habits).
B. Assess for UTI, diabetes, pelvic mass.
C. Assess for signs of child abuse or sexual abuse.
D. Evaluate developmental milestones (delays may occur).
E. Assess family response to enuresis.

Implementation
A. Assist with and help prepare child for additional diagnostic procedures if the child has daytime enuresis and history of UTI (ultrasound, voiding cystourethrogram, UA, developmental assessment).
B. The diagnosis is made based on history and clinical symptoms. Urinalysis can rule out a possible UTI and a urine glucose can rule out diabetes. A pinworm evaluation should also be done.
C. Administer and instruct about appropriate medications.

  •  Antibiotics if UTI is the cause.
  •  DDAVP (desmopressin acetate) given as tablet and taken at bedtime (antidiuretic action as “synthetic” antidiuretic hormone [ADH]) for children over 6 years.
  •  Anticholinergic such as Ditropan (oxybutynin) for diurnal enuresis.

D. Emotional care.

  • Promote child’s self-esteem. Give reassurance that bed-wetting is common.
  •  Support and teaching to family.

E. Teaching.

  •  Limit fluids at bedtime; urinate just before bedtime. Avoid sugar and caffeine after 4:00 pm.
  •  Establish bladder routine. Empty the bladder frequently.
  •  Reward systems—stickers to mark a calendar of “dry” nights.
  •  Behavioral conditioning with a moisture sensitive alarm that goes off when the child starts to void, and awakens the child (must be used consistently for a period of time).

Pediatric Nursing: Structural Defects

Focus topic: Pediatric Nursing

Pediatric Nursing: Exstrophy of the Bladder

Focus topic: Pediatric Nursing

Definition: A rare defect in which the bladder wall fails to close during development and a portion of the bladder wall extrudes through the abdominal wall; the upper urinary tract is normal.

Assessment
A. A mass of bright red tissue in the lower abdomen where the abdominal wall has not closed.
B. Assess for continual leaking from an open urethra.

Treatment and Implementation
A. Surgical reconstruction in several stages; the initial stage is completed shortly after birth.
B. Some children require permanent urinary diversion because it is impossible to reconstruct a functional bladder.
C. Nursing management.

  • Position infant side-lying to promote drainage and help reduce risk of infection.
  • Prevent trauma to exposed bladder; avoid abduction of the legs.
  • Clean exposed area daily using meticulous skin care to protect from urine leakage and infection.
  • Observe for obstruction in drainage tubes (decreased urine output, blood drainage from urethra, bladder spasms).
  •  Complete discharge teaching.
    a. Dressing change protocol.
    b. Prevention of infection.
    c. Observe for changes in urinary function.
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Pediatric Nursing: Hypospadias/Epispadias

Focus topic: Pediatric Nursing

Definition: Hypospadias is the malposition of the external urethral opening behind the glans penis, along the thra is located on the upper surface of the penis. Hypospadias is more common and has familial tendencies.

Assessment
A. Assess location of urethral opening on penis and ability to void in a normal elevated position.
B. Check for presence of fistulas, chordee.
C. Assess child’s understanding of procedure (word for penis, urine).
D. Evaluate parents’ understanding of surgery and fears.

Implementation
A. Preoperative care.

  • Use drawings or dolls to reinforce physician’s
    explanation.
  •  Prepare child for presence of urinary catheter(s).
  • Prepare child for the possibility of postoperative bladder spasms.
  •  Prepare child for nursing and medical personnel looking at his bandages frequently.

B. Postoperative care.

  • Maintain adequate hydration.
    a. Measure urine specific gravity.
    b. Encourage fluid as needed.
  •  Expect a Foley catheter that may be sutured in place; urine should be rose-colored immediately postop, gradually becoming clear.
  • If staged repair, may have a suprapubic catheter for urinary diversion and a Foley catheter.
  •  Tape catheters in place securely. (Do not adjust position or remove catheter.)
  •  Administer analgesics as needed.
  •  Remove Foley and clamp suprapubic intermittently to allow child to void through the meatus.
  •  After Foley is removed, note presence of fistula (should not be present).
  •  Chart when the child voids through the meatus; report to physician:
    a. Character of flow, presence of spray, dribbling, leaking, pain.
    b. Expect pain on the first voids, should decrease in subsequent voids.
  •  Discharge teaching and support of family and child.

Pediatric Nursing: Cryptorchidism (Undescended Testes)

Focus topic: Pediatric Nursing

Definition: The failure of one or both testes to descend into the scrotal sac. Occurs more in premature infants and approximately 80% resolve spontaneously within the first 6 months of life.

Assessment
A. Palpate for presence of testis in scrotal sac, may be unilateral or bilateral.
B. Assess for presence of accompanying hernia (present in 50% of clients).
C. If testes not palpable, the child may be evaluated for their presence with hormonal stimulation.
D. May lead to sterility if persists into adolescence; associated with testicular cancer.

Implementation
A. Support child and family during surgery. Orchiopexy as an outpatient procedure may be performed at 6 months, but usually between 9 and 15 months of age.
B. Provide postoperative care: Maintain traction, which anchors testes to scrotum (5–7 days); prevent contamination of incision.
C. Provide adequate postoperative analgesics.
D. Support family and child.
E. Discharge teaching: Monitor pain levels, swelling, voiding patterns, observing for signs of bleeding and infection.

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