RENAL / URINARY TRACT DISORDER

I. DEFINITION OF TERMS
1. Alport Syndrome : causes blood in urine
2. Azotemia : excess of nitrogenous waste products in blood
3. Dialysis : used to separate macromolecules from micro using
semipermeable membrane
4. Dysfunctional Elimination Syndrome (DES) : cby urine & bowel
incontinence
5. Enuresis : involuntary discharge of urine at night or during sleep
6. Epispadias : urethra opens on dorsum of penis
7. Exstrophy of bladder : exposure of bladder d/t congenital gap in
anterior wall of abdomen
8. Glomerular filtration rate (GFR) : expression of quantity of
glomerular filtrate / min
9. Glomerulonephritis : cby inflammation of capillary loops in
glomeruli of kidney
10. Hydronephrosis : swelling of kidneys d/t obstruction of urine
flow in urinary tract
11. Nephrosis : disease of kidneys cby degenerative lesions
12. Hypospadias : urethra opens on ventral of penis

II. INTRODUCTION
A. Urinary Tract Disorder : condition which bacteria invade & grow
in urinary tract
B. Renal Disorder : condition which kidneys stop working; not able to
remove waste & extra water from blood; not able to keep body
chemicals in balance

III. NURSING PROCESS

 ASSESSMENT
- Symptoms:
1. Mild abdominal pain
2. Slowly increasing edema
3. Low grade fever
- Assess for: (before giving analgesic or antispasmodic)
1. Degree of pain
2. Location of pain
3. Intensity of pain
 NURSING DIAGNOSIS
- Pain r/t bladder irritation from UTI
- Excess fluid volume r/t decreased kidney function and fluid
accumulation
- Fear r/t renal transplantation
- Imbalanced nutrition, less than body requirement, r/t to effects of
dietary restrictions
 - Social isolation r/t immunosuppressant therapy
- Interrupted family processes r/t the stress of child’s chronic illness
- Compromised family coping r/t the chronic nature of child’s illness
 OUTCOME IDENTIFICATION AND PLANNING
- Involves helping parents develop a reliable system to remember
giving medicine.
- Assist parents in scheduling times for hemodialysis or peritoneal
dialysis.
 OUTCOME EVALUATION
- Pain is at a tolerable level and decreasing in intensity after
treatment
- Family members state they are able to cope with long-term illness
in their child
- States the purpose of a low-sodium diet and lists ingredients of
low-sodium meal
- States he or she can accept the need for kidney transplantation

IV. ANATOMY AND PHYSIOLOGY OF KIDNEYS

 Glomeruli
- Filter water & solutes from blood
 Urine
a. Oliguria (low urine output)
b. Anuria (no urine output)
c. Hematuria (blood in urine)

V. ASSESSMENT OF RENAL AND URINARY TRACT DYSFUNCTION

 Lab / diagnostic tests

1. Urinalysis : most revealing & simplest; detect glucose, protein,
occult blood, pH
2. Urine culture : presence of bacteria in urine
o techniques (midstream clean-catch, catheterization, or
sterile suprapubic aspiration)
3. Radioisotope scanning : administration of radioisotopes ( a
technetium scan)
4. Blood studies
o BUN (5-20 mg/100ml)
o creatinine clearance rate (100ml/min)
o urine creatinine level (0.7-1.5 mg/100ml)
o creatinine in blood serum (rarely >1mg/dl)
5. Ultrasonography & MRI : show diff sizes of kidneys or ureters;
show diff between solid or cystic kidney masses
6. X-ray studies : show size & contour of kidneys;
o CT scans show size & density
 o Intravenous Pyelogram (IVP) is x-ray study of upper urinary
tract
o Voiding Cystourethrogram (VCUG) study of lower urinary
tract
7. Cystoscopy : cystoscope introduced into bladder thru urethra;
done to eval for possible vesicoureteral reflux or urethral stenosis
8. Renal biopsy : used to diagnose extent of renal disease

VI. STRUCTURAL ABNORMALITIES OF URINARY TRACT

1. Patent urachus
2. Exstrophy of the bladder
3. hypospadias

4. PATENT URACHUS
- If Urachus (joined to the umbilicus when bladder first forms in
utero), fails to close during embryologic development, a fistula
is left between the bladder and umbilicus.
- Commonly in males than females
- Lab test: Ultrasound (confirm patent connection)
- Intervention: mostly require surgical correction

5. EXSTROPHY OF THE BLADDER

- Midline closure defect
- Bladder lies exposed on anterior abdominal wall
- Genital defect is more severe in males
- Require vaginoplasty after puberty to allow sexual intercourse
- “waddline” gait caused by wide pubic diastasis
- Lab test: Fetal ultrasound
- Therapeutic management:
o surgical closure (suitable size and quality: first 24-72 hrs of
life; too small bladder: 3-6 months)
o construction of urethra
o cover bladder mucosa with plastic wrap to prevent from
drying out
o protective topical application to prevent skin of abdomen
from excoriation
o do not separate infant’s legs
o position infant on back
o sponge bath rather than tub bathe
- postoperative management:
o suprapubic tube for urine drainage (4-6 weeks)
 o position on back with legs raised (90 degrees)

6. HYPOSPADIAS
- Urethral opening is on ventral aspect of penis
- 1 in 300 male newborns
- Assessment:
o Degree of hypospadias:
a. Minimal – on the glans but inferior in site
b. Maximal – at the midshaft or at the penal-scrotal junction
o Short chordee : a fibrous band that causes penis to curve
downward (cobra-head appearance)
- Therapeutic management:
o No circumcision
o Meatotomy (newborn) : procedure which the urethra is
extended to a usual position to establish better urinary
function
o Urethral urinary drainage catheter

VII. INFECTIONS OF THE URINARY SYSTEM AND RELATED

DISORDERS
1. Urinary tract infection
2. Honeymoon cystitis
3. Vesicoureteral reflux
4. Hydronephrosis

1. URINARY TRACT INFECTION

- More in females (F: 8% M: 2%)
- Gram negative rods: Escherichia coli
- Prevention:
o Encourage drinking fluids
o Urinate every 2-3 hrs
o Avoid bubble bath
o Teach wiping from front to back
o Wear cotton underwear
o Wash vulva daily
o Change sanitary pads q 4 hrs during menstruation
o Complete prescribed antibiotic course if UTI symptoms occur
o Urinate immediately after intercourse
- Assessment:
o Suspected in children with unexplained fever
o Symptoms in bladder infection (cystitis):
a. Low-grade fever
b. Mild abdominal pain
c. Day or nighttime enuresis
o Symptoms in pyelonephritis:
 a. High fever
b. Abdominal or flank pain
c. Vomiting
d. Malaise
- Collect urine for culture using any of 3 techniques
o Positive for bacteriuria if colony count is >100,000/ml;
negative if <10,000/ml
- Microscopic examination of urine may show presence of RBC
d/t bacterial irritation
- Presence of RBC or WBC or bacteria tends to make urine more
alkaline (>7pH)
- Therapeutic management:
o Oral administration of broad-spectrum antibiotics
o Nitrofurantoin
o Drinking plenty of fluids to flush the infection out
o Cranberry juice; but water is best choice
o Avoid fluids with artificial coloring and carbonation
o Warm water baths
o Acetaminophen for pain relief and voiding
o Complete full antibiotic course
o Repeat clean-catch urine sample after 7 days
o Prophylactic antibiotics

2. HONEYMOON CYSTITIS
- UTIs in young women after initiating a first sexual
relationship
- Caused by local irritation and inflammation from
intercourse
- Voiding after intercourse may help flush pathogens
- Initial cystitis may indicate sexual activity

3. VESICOURETERAL REFLUX
- Refers to retrograde flow of urine from the bladder into the
ureters
- Occurs during micturition (voiding)
- Happens due to defective valve guarding entrance of
bladder to ureter (either from birth or d/t scarring)
- Assessment:
o History of repeated UTIs
o Lab / diagnostic tests:
1. VCUG
2. CT scan
3. MRI
4. Cystoscopy
5. Cystography
 o Reflux is graded from I to V (V being most serious)
- Therapeutic management:
o Double voiding
o Cystoscopy (if antibiotic or prophylactic antibiotics are
ineffective)
o Suprapubic catheter & ureteral catheters (post-op) for urine
drainage
o Antispasmodics for bladder spasms
o Follow up care: repeat VCUG and/or ultrasound

4. HYDRONEPHROSIS
- Enlargement of pelvis of kidney due to back pressure in
ureter (often caused by obstruction)
- Obstruction is most common in first 6 months of life
- Assessment:
o Elevated BP
o Severe back pressure
o Abdominal mass (dilated kidney pelvis) detected with
palpation
o Imaging tests like IVP or ultrasound
- Treatment:
o Surgical correction of obstruction

VIII. DISORDERS AFFECTING NORMAL URINARY ELIMINATION

1. Enuresis
2. Postural (orthostatic) proteinuria
3. Kidney agenesis
4. Polycystic kidney
5. Renal hypoplasia
6. Prune belly syndrome
7. Acute post-streptococcal glomerulonephritis
8. Chronic glomerulonephritis
9. Nephrotic syndrome (nephrosis)
10. Henoch-Scholein syndrome nephritis
11. Systemic lupus erythematosus
12. Hemolytic-uremic syndrome
13. Acute renal failure
14. Chronic kidney disease (end-stage kidney disease)

1. ENURESIS
- Involuntary passage of urine (past age when bladder control
should be attained)
- May be nocturnal (only at night), diurnal (day), or both
 - Primary if bladder training was never achieved; Acquired or
Secondary if control was established but now been lost.
- More in boys than girls
- Management should include multimodal approach
o Bowel management
o Timed voiding
o Hydration management
o Improved fiber intake
o Behavioral management
o Biofeedback
o Drug therapy (when necessary)
- Assessment:
o Ask for symptoms other than bed wetting (abdominal pain,
burning, or frequency; UTI is suggested)
- Therapeutic management:
o Bladder-stretching exercises
o Synthetic antidiuretic hormone [ desmopressin acetate
(DDAVP) ]

2. POSTURAL (ORTHOSTATIC) PROTENURIA

- Spill albumin into the urine when they stand upright for an
extended period (postural albuminuria)
- an MRI of kidneys and ureters may be prescribed

3. KIDNEY AGENESIS
- Agenesis means (lack of growth) or that no organ formed in utero
- Assessment:
o Potter syndrome or accompanying misshapen (not having
the normal shape or form)
o Low-set ears and hypoplastic (stiff, inflexible) lungs from
compression caused by lack of amniotic fluid
o Bilateral absence of kidneys

4. POLYCYSTIC KIDNEY
- Large, fluid-filled cysts have formed in place of normal kidney
tissue
- Most frequent type: autosomal recessive trait
- More rare form: autosomal dominant trait
- Assessment:
o Flattened nose or micrognathia (small jaw)
o Symptoms of Potter syndrome (unusual facial appearance
i.e. widely separated eyes, abnormal limbs, oligohydramnios)
o Oliguria (low urine output) present if condition is unilateral
o Liver is filled with identical cysts, if condition is associated
w/ cerebral aneurysm
 o Increased difficulty with portal circulation
- Treatment:
o Sonogram reveals fluid-filled cysts
o Surgical removal if diseased kidney (if only is cystic)

5. RENAL HYPOPLASIA
- Reduced growth
- Hypoplastic kidneys are small and underdeveloped (fewer lobes
than usual)
- May need kidney transplant

6. PRUNE BELLY SYNDROME

- Has broad spectrum of severity
- Most common abnormalities associated with PBS
o Cardiac
o Pulmonary
o Orthopedic
o Urologic : 3 Main urologic symptoms
1. Bilateral undescended testes
2. Dilated faulty development of bladder and upper urinary
tract
3. Renal dysplasia
- Assessment:
o Affects boys
o Back pressure and kidney damage (result of severe
dilatation of ureters and bladder)
o Infant’s abdomen has wrinkled appearance (resembling a
prune)
o Needs surgical remodeling to prevent recurrent UTIs
- Therapeutic management:
o Surgical therapy – repair of abdominal wall and urinary
tract abnormalities
o Abdominal wall reconstruction – to improve respiratory
function and cosmesis
o Medical therapy – maintenance suppressive antibiotics

7. ACUTE POST-STREPTOCOCCAL GLOMERULONEPHRITIS

- Inflammation of glomeruli of kidney
- Immunoglobulin G (IgB) antibodies can be detected in blood with
such condition
o Intravascular coagulation – minute renal vessels
 o Ischemic damage – scarring and decreased glomerular
function
o Decreased GFR – leads to accumulation of sodium and water
in blood
o Inflammation of glomeruli – allows protein to escape into
urine

8. CHRONIC GLUMERONEPHRITIS
- A secondary disease
- May follow acute glumeronephritis or nephrotic syndrome
- Symptoms:
o Edema
o Hematuria
o Hypertension
o Oliguria
- Therapeutic management:
o Symptom relief
o Antihypertensive therapy (diastolic reaches above 90mmHg)
o Corticosteroid therapy
o Kidney transplantation
o Peritoneal dialysis
9. NEPHROTIC SYNDROME (NEPHROSIS)
- Altered glomerular permeability (an increase leads to protein loss
in urine)
- 3 forms:
1. Congenital
2. Secondary
3. Idiopathic (primary)
- Classification according to membrane destruction:
1. MCNS – Minimal Change Nephrotic Syndrome (most frequently
observed)
2. FGS – Focal Glomerulosclerosis
3. MPGN – Membranoproliferative Glomerulonephritis
- Symptoms:
o Proteinuria (protein loss in urine)
o Edema (fluid shift from blood to interstitial tissue)
o Hypoalbuminemia (low serum albumin levels)
o Hyperlipidemia (liver’s increased production of lipoproteins
to compensate for protein loss)
- Diagnostic procedure:
o MRI or renal biopsy
- Therapeutic management
o Corticosteroid therapy
o Diuretic therapy
 o IV albumin administration
o Cytotoxic or immunosuppressant therapy
o Adequate protein intake

10. HENOCH-SCHOLEIN SYNDROME NEPHRITIS

- Symptoms:
o Urinary abnormalities
o Rapidly progressing glumeronephritis

11. SYSTEMIC LUPUS ERYTHEMATOSUS

- Autoimmune diease
- Causes deposits of complement in the kidney glomerulus
- Some children with SLE develop symptoms of:
o Acute glomerulonephritis
o Chronic glomerulonephritis
- Therapy:
o Corticosteroids
o Cytotoxic agents
o Kidney transplantation

12. HEMOLYTIC-UREMIC SYNDROME

- Lining of glomerular arterioles is inflamed, swollen, and occluded
- 90% of children who develop this syndrome have
recently experienced an E coli gastrointestinal infection
- Therapy:
o Renal replacement therapy

13. ACUTE RENAL FAILURE

- Occurs in:
1. Acute form – sudden body insult
2. Chronic form – extensive kidney disease
- Can occur in people exposed to industrial wastes like mercury
- Symptoms:
o Oliguria
o Azotemia
o Uremia
o Hyperkalemia

14. CHRONIC KIDNEY DISEASE (ENG-STAGE KIDNEY DISEASE)

- Results from developmental abnormalities
- Assessment:
o Polyuria
o Erythropoietin
IX. KIDNEY TRANSPLANTATION
- May be done for children who have extensive hypertension

A. PREOPERATIVE CARE
- most effective when kidney is taken from living twin, parent, or
sibling (rejection rates are lower)
- transplanted kidney are placed in abdomen rather than usual
place of kidney
- tests that donors undergo:
1. HLA Typing (antibodies)
2. Electrolyte blood analysis
3. CBC
4. u/a
5. urine culture
6. 24-hr urine sample for protein
7. Renal arteriogram
8. IV pyelography
9. Dialysis

B. POSTOPERATIVE CARE
- After renal transplantation, children are placed on
immunosuppressive therapy to reduce the risk of kidney rejection
- Hemodialysis may be continued initially until the transplanted
kidney fully functions
- Some may experience a “honeymoon” period

- TRANSPLANTATION REJECTION
o First 3 months
o symptoms such as fever, proteinuria, oliguria, weight gain,
hypertension, and kidney tenderness
- CHRONIC REJECTION
o First 6 months
o the rejected kidney is removed, and the child may need to
return to hemodialysis

X. THERAPEUTIC MEASURES FOR THE MANAGEMENT OF RENAL

DISEASE

A. PERITONEAL DIALYSIS
- Dialysis – separation and removal of solutes from body
 - Peritoneal dialysis – uses peritoneal cavity membrane; can be
temporary for sudden renal failure
B. CONTINUOUS CYCLING PERITONEAL DIALYSIS (CCPD)

XI. HEMODIALYSIS