Care of Mother and Child at Risk or with

Problems (Acute and Chronic)

LESSON TITLE: NURSING CARE OF A FAMILY WHEN A CHILD Materials:

HAS A RENAL OR URINARY TRACT DISORDERS 2
Pen, paper, index card, book, and class List
Learning Targets:
At the end of the module, students will be able to:
1. Define the common renal and urinary disorders that occur in References:
children and describe these common illnesses that occur in
these children. Pilliteri, Adele and Silbert-Flagg, JoAnne
2. Integrate the knowledge of common renal and urinary (2018) Maternal and Child Health Nursing, 8th
disorders that occur in children and describe these common Edition. USA: Lippincott Williams and Wilkins
illnesses that occur in these classifications of children in
formulating nursing care plan in giving quality maternal and
child health nursing care.

A. LESSON PREVIEW/REVIEW

To the students: Review of past lessons regarding disorders affecting oxygenation.

B. MAIN LESSON
The instructor should discuss the following topics. Instruct students to take down notes.

(Please refer to Chapter 46: Nursing Care of a Family when a Child Has a Renal or Urinary Tract Disorder- Disorders
Affecting Normal Urinary Elimination p. 1306)
DISORDERS AFFECTING NORMAL URINARY ELIMINATION
ENURESIS
 involuntary passage of urine past the age when a child should be expected to have attained bladder control
 may be nocturnal (occurs only at night), diurnal (occurs during the day), or both.
 It is primary if bladder training was never achieved and is considered acquired or secondary if control was
established but has now been lost.

ASSESSMENT
 Children with enuresis who are older than 5 years of age need an evaluation to determine whether there is an
organic cause for the disorder.
 history taking
 Assess whether there are stresses in the family
 If children wet only on nights when they are exceptionally tired or troubled, a functional rather than an organic
cause is suggested.
 If children wet only when they are engrossed in an interesting activity, they may simply need more reminders to
empty their bladder.
 If children have symptoms other than bed-wetting, such as abdominal pain, burning, or frequency, UTI is
suggested.
 may be associated with small bladder capacity (which would explain why the condition is familial).

DIAGNOSIS
 an ultrasound
 pre–post bladder scan, or urodynamic testing
 clean-catch urine specimen may be prescribed to rule out bacteriuria if other possible symptoms are present.
 Assess specific gravity, protein, and glucose of urine to rule out a defect in urine concentration or reveal
evidence of nephron disease.

THERAPEUTIC MANAGEMENT
 The treatment of enuresis can be complex because the cause is often unknown.
 Help limit fluids during the 2 hours before bed.
 Bladder-stretching exercises—drinking a large quantity of water and then refraining from voiding as long as

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 Care of Mother and Child at Risk or with
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possible—to increase the functional size of the bladder are contraindicated and can cause both dysfunctional
voiding and renal damage.
 antidiuretic hormone (desmopressin [DDAVP]) administered orally is the drug of choice to reduce urinary output
and nocturnal enuresis in cases of primary nocturnal enuresis
 Children should be evaluated and treated in a clinic focused on DES and voiding dysfunction

POLYCYSTIC KIDNEY PRUNE BELLY SYNDROME

 large, fluid-filled cysts have formed in place of  a syndrome with a broad spectrum of severity.
normal kidney tissue.  The most common abnormalities associated with
 The most frequent type of polycystic kidney seen PBS are cardiac, pulmonary, orthopedic, and
in children is inherited as an autosomal recessive urologic.
trait.  Occurring mainly in boys, the severe dilation of
 A more rare form is inherited as an autosomal ureters and the bladder causes back pressure and
dominant trait. destruction of kidneys.
 With either type, there is abnormal development  The condition is typically marked by the presence
of the collecting tubules. of three main urologic symptoms: bilateral
 The kidneys grow large and feel soft and spongy. undescended testes, the dilated faulty
 The newborn can have a flattened nose or development of the bladder and upper urinary
micrognathia (small jaw), findings of Potter tract, and renal dysplasia.
syndrome.  The infant’s abdomen appears wrinkled (like a
 A sonogram during pregnancy or at birth will prune) because of the poorly developed
reveal the fluid-filled cysts. abdominal muscles Without surgical remodeling,
the infant will develop repeated UTIs, leading
MANAGEMENT eventually to end-stage renal disease.
 treatment for polycystic formation is surgical  Teach parents to protect their child’s abdomen
removal of the diseased kidney if only one is from trauma, such as can happen from lap belts
cystic. or baby walkers because their child lacks
 If both kidneys are cystic, treatment is renal abdominal support, while waiting for muscle
transplantation (difficult in the young child transplant procedures to create more abdominal
because few infant kidneys are available for support.
transplantation and because of the technical  Some children need kidney transplants as they
challenge presented by such small blood vessels). reach school age because of destruction of
 Because this kidney disease is inherited, parents glomeruli from continual back pressure of urine on
and children at adolescence need genetic nephrons.
counseling to inform them that future children may
have this problem.
ACUTE POSTSTREPTOCOCCAL CHRONIC GLUMERULONEPHRITIS
GLOMERULONEPHRITIS  Follows acute glomerulonephritis or nephrotic
 inflammation of the glomeruli of the kidney syndrome, it also occurs as a primary disease
 usually occurs in children as an immune complex  The disorder may result in either diffuse or local
disease after infection with nephritogenic nephron damage.
streptococci (most commonly subtypes of group A  Alport syndrome, which also includes hearing
beta-hemolytic streptococci) where complement, a loss and ocular changes, is progressive chronic
cascade of proteins activated by antigen–antibody glomerulonephritis inherited as an X-linked or
reactions, plugs or obstructs glomeruli. autosomal recessive disorder
 Immunoglobulin G (IgG) antibodies against
streptococci can be detected in the bloodstream ASSESSMENT
of children with acute glomerulonephritis, proof  proteinuria at a routine health assessment
the illness follows a streptococcal infection  hypertension
 presence of red cell or white cell casts
ASSESSMENT  occult blood in urine with low specific gravity
 Acute glomerulonephritis is most common in (below 1.003)
children between the ages of 5 and 10 years, the
age group most susceptible to streptococcal THERAPEUTIC MANAGEMENT
infections.  antihypertensive drugs such as hydralazine
 Boys appear to develop the disease more often (Apresoline) or with diuretics to increase urine

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 Care of Mother and Child at Risk or with
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than girls output such as ethacrynic acid (Edecrin) can be

 Child typically has a history of a recent respiratory helpful.
infection (within 7 to 14 days) or impetigo (within 3  Corticosteroid therapy may reduce or halt the
weeks). progress of the disorder by reducing inflammation.
 All children who have had a “strep” throat,  Children have difficulty accepting long-term
tonsillitis, otitis media, or impetigo caused by a corticosteroid therapy because of the side effects,
streptococcal infection in particular the typical “moon face” and extra
 hematuria is usually so extreme that the child’s body hair (Cushing syndrome) that develop.
urine appears tea-colored, reddish-brown, or  Kidney transplantation is a possibility to replace a
smoky diseased kidney.
 child develops oliguria  Children can be maintained for long periods by
 Specific gravity of urine becomes elevated peritoneal dialysis or hemodialysis while waiting
 Hypertension for a transplant.
 Blood analysis will indicate a lowered blood
protein level (hypoalbuminemia) caused by the
massive proteinuria. SYSTEMIC LUPUS ERYTHEMATOSUS
 is an autoimmune disease in which, when
THERAPEUTIC MANAGEMENT autoantibodies and antigens meet, they cause
 course of antibiotics may be prescribed to be deposits of complement in the kidney glomerulus.
certain all streptococci are removed from the  As a result, some children with SLE develop
child’s system. symptoms of acute or chronic glomerulonephritis;
 Diuretics are of little value because obstructed glomerulonephritis or heart disease is the ultimate
glomeruli cannot be made to function, although a cause of death in many adults with SLE.
course of ethacrynic acid or furosemide (Lasix)  Therapy with corticosteroids or cytotoxic agents
may be tried. may be effective to stop the renal destruction. If
 If heart failure occurs, keeping the child in a semi- kidney transplantation is required, the transplant
Fowler’s position, digitalization, and oxygen should be successful because the same damage
administration are helpful. rarely occurs in the transplanted kidney.
 If diastolic blood pressure rises to more than 90
mmHg, antihypertensive therapy with an
antihypertensive such as labetalol will be
prescribed.
 Phosphate binders, such as aluminum hydroxide
to reduce phosphate absorption in the
gastrointestinal tract, or a potassium-removing
resin agent, such as sodium polystyrene sulfonate
(Kayexalate), may be necessary in children who
have rising phosphate and potassium levels
because the kidneys are unable to clear these
from the circulation.
 Weighing the child every day and calculating
intake and output are important assessments to
follow the course and extent of the disease.
NEPHROTIC SYNDROME (NEPHROSIS) HEMOLYTIC-UREMIC SYNDROME
 Nephrosis is altered glomerular permeability  the lining of glomerular arterioles becomes
apparently due to an autoimmune process or a T- inflamed, swollen, and occluded with particles of
lymphocyte dysfunction that results in fusion of platelets and fibrin.
the glomeruli membrane surfaces, which, in turn,  The child’s red blood cells and platelets become
leads to abnormal loss of protein in urine. damaged as they flow through the partially
 The highest incidence is at 3 years of age, and it occluded blood vessels.
occurs more often in boys than in girls  As the damaged cells reach the spleen, they are
 Nephrotic syndrome occurs in three forms: destroyed by the spleen and removed from
(a) congenital, as an autosomal recessive circulation, leading to a hemolytic anemia.
disorder  Ninety percent of children who develop this
(b) secondary, as a progression of syndrome have recently experienced an E. coli
glomerulonephritis or in connection with systemic gastrointestinal infection from a source such as

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 Care of Mother and Child at Risk or with
Problems (Acute and Chronic)

diseases such as sickle-cell anemia or systemic undercooked hamburger (E. coli is found in the
lupus erythematosus (SLE) intestine of beef cattle).
(c) idiopathic (primary).  Whether to treat E. coli infections with antibiotics
 The congenital form is rare; the idiopathic form is is controversial because some children who have
most common their initial E. coli infection treated with an
antibiotic appear to have a more serious form of
ASSESSMENT anemia than those not treated
 The four characteristic symptoms of nephrotic
syndrome are proteinuria, edema, ASSESSMENT
hypoalbuminemia (low serum albumin level), and  Children usually develop only a transient diarrhea
hyperlipidemia (increased blood lipid level) from the E. coli infection, although this can
 Edema tends to be dependent or occur in the progress to severe fluid loss and bowel wall
lower parts of the body necrosis.
 periorbital edema  Fever may become so elevated that the child
 Ascites may become so extensive that the experiences stupor and hallucinations.
resultant pressure on the stomach and intestine  Oliguria accompanied by proteinuria, hematuria,
leads to anorexia, vomiting, or diarrhea. and urinary casts in urine follows.
 Laboratory studies will reveal marked proteinuria.  The oliguria will lead to increased serum
 A single test will show a 1+ to 4+ protein; a 24- creatinine and BUN and extensive edema.
hour total urine test will show up to 15 g of protein  Children appear pale from anemia; easy bruising
(normally, urine contains no protein) or petechiae may be present from
 The ESR is elevated thrombocytopenia (reduced platelet level).
 An MRI or renal biopsy may be done to determine  Laboratory studies will show fibrin split products in
whether there is scarring of the glomerular the serum as the fibrin deposits in glomerular
membrane and to document the type of nephrotic vessels are degraded.
syndrome present.  Thrombocytopenia will be present because
platelets are damaged by the irregular blood
vessels.
THERAPEUTIC MANAGEMENT
 Therapy for nephrotic syndrome is directed toward THERAPEUTIC MANAGEMENT
reducing the proteinuria and subsequent edema.  The child needs renal replacement therapy
 a course of corticosteroids, such as IV (supportive therapy) to maintain kidney and heart
methylprednisolone or oral prednisone, and function.
keeping the child free of infection while the  The extreme oliguria can be treated with
immune system is suppressed by these drugs. peritoneal dialysis; anemia can be corrected by
 initial dose of prednisone is given until diuresis careful transfusion of packed red cells.
without protein loss is accomplished; the dosage  Ensure that parents understand the importance of
is then reduced for maintenance and continued for follow-up care and have an appointment for this.
as long as 1 to 2 months.  Help them begin to view the child as well again so
 long-term administration of prednisone will cause they do not continue to shelter the child
a cushingoid appearance or a “moon face,” extra unnecessarily but allow for normal growth and
fat at the base of the neck, and increased body development.
hair.  Despite the extent of the illness, most infants with
 Be certain also that parents know to plan ahead hemolytic-uremic syndrome recover completely.
for pharmacy refills so prednisone therapy is not
stopped abruptly because an abrupt stop can lead
to adrenal insufficiency.
 Diuretics are not commonly used to reduce the
edema of nephrosis because they tend to
decrease blood volume, which is already
decreased, possibly leading to acute renal failure.
 They may need supplemental potassium and
should eat foods high in potassium such as
bananas and milk.
 IV albumin may be administered to temporarily
correct hypoalbuminemia.

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 Care of Mother and Child at Risk or with
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 This causes edema to lessen because, as the

serum albumin level rises, fluid shifts from
subcutaneous spaces into the bloodstream.
 cyclophosphamide (Cytoxan) or cyclosporine
(Sandimmune), or a stronger immunosuppressant
agent, such as mycophenolate mofetil, may be
effective in reducing symptoms or preventing
further relapses of the disease

CHECK FOR UNDERSTANDING

The instructor will prepare 10 questions that can enhance critical thinking skills. Students will work by themselves to
answer these questions and write the rationale for each question.

1. To determine if ascites is increasing in amount in a child with nephrotic syndrome, which measurements would be most
appropriate?
A. Abdominal Circumference
B. Urine for protein
C. Blood pressure
D. Bowel sounds

2. You care for a 6-year-old boy with acute glomerulonephritis. When planning care for him, you should be aware that
glomerulonephritis usually follows an infection of what organism?
A. Group B Streptococci
B. Staphylococcus viridans
C. A Beta-hemolytic Streptococcus
D. One of the rhinoviruses

3. A 6-year-old male is diagnosed with nephrotic syndrome. In your nursing care plan, you will include which of the
following as a nursing diagnosis for this patient?
A. Risk for infection
B. Deficient fluid volume
C. Constipation
D. Overflow urinary incontinence

4. 2. Which patient below is NOT at risk for developing nephrotic syndrome?

A. An 8-year-old male with diabetes mellitus.
B. A 5-year-old female diagnosed with minimal change disease.
C. A 10-year-old male with Lupus.
D. A 7-year-old male recently diagnosed with Alport’s Syndrome.

5. You’re providing education to a group of nursing students about nephrotic syndrome. A student describes the signs and
symptoms of this condition. Which signs and symptoms verbalized by the student require you to re-educate the student
about this topic?

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 Care of Mother and Child at Risk or with
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A. Slight proteinuria
B. Hypoalbuminemia
C. Edema
D. Hyperlipidemia

6. You’re providing care to a 6-year-old male patient who is receiving treatment for nephrotic syndrome. Which
assessment finding below requires you to notify the physician immediately?
A. Frothy, dark urine
B. Redden area on the patient’s left leg that is swollen and warm
C. Elevated lipid level on morning labs
D. Urine test results that show proteinuria
7. As the nurse, you know that it is important to implement a low sodium diet for a patient with nephrotic syndrome.
However, it is important to implement what other type of diet due to another complication associated with this syndrome?
A. Low-phosphate
B. Low-fat
C. High-carbohydrate
D. Low-potassium

8. A client has been admitted to the hospital with a diagnosis of acute glomerulonephritis. During history-taking the nurse
first asks the client about a recent history of:
A. bleeding ulcer
B. deep vein thrombosis
C. myocardial infarction
D. streptococcal infection
9. A nurse is assigned to care for a patient with nephrotic syndrome. The nurse assesses which important parameter on a
daily basis?
A. weight
B. albumin levels
C. activity tolerance
D. blood urea nitrogen (BUN) level

10. A child with minimal change nephrotic syndrome (MCNS) has generalized edema. The skin appears stretched, and
areas of breakdown are noted over the bony prominences. The child has been receiving Lasix twice daily for several
days. Which does the nurse expect to be included in the treatment plan to reduce edema?
A. An increase in the amount and frequency of Lasix.
B. Addition of a second diuretic, such as mannitol.

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 Care of Mother and Child at Risk or with
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C. Administration of intravenous albumin.

D. Elimination of all fluids and sodium from the child’s diet.

C. LESSON WRAP-UP

AL Activity: Minute Paper

Instruction:
1. Reserve a few minutes at the end of class session. Leave enough time to ask the questions, to allow students to
respond, and to collect their responses.
2. Pass out slips of paper on index cards for students to write on. You may also ask students to bring out and write on a
half sheet of paper instead.
3. Collect the responses as or before students leave. One way is to station yourself at the door and collecting “minute
papers” as student file out.
4. Respond to students’ feedback during the next class meeting or as soon as possible.

1) What was the most useful or the most meaningful thing you have learned this session?

2) What question(s) do you have as we end this session?

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