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
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-Structural
Abnormalities of the Urinary Tract p.1300, Infections of the Urinary System p.1303

STRUCTURAL ABNORMALITIES OF THE URINARY TRACT

PATENT URACHUS EXSTROPHY OF THE BLADDER
 A narrow tube(urachus) that connects bladder and  a midline closure defect that occurs during the
umbilicus fails to close during embryonic 10th week of pregnancy. As a result, at birth, the
development. bladder lies exposed on the anterior abdominal
 Occurs more commonly in males than females. wall
 same cases on both sexes
ASSESSMENT
 Nitrazine paper test for pH will identify the clear ASSESSMENT
fluid as urine on the umbilical cord while changing  detected by fetal ultrasound
the diaper of the newborn.  pelvic bone defects, particularly a wide pubic
 Ultrasound will confirm the patent connection diastasis
 Urethral defects in males, such as epispadias—
THERAPEUTIC MANAGEMENT the opening of the urinary meatus on the dorsal or
 A few patent urachus abnormalities heal superior surface of the penis—are also common.
spontaneously, but most require surgical  The skin around the bladder quickly becomes
correction to prevent pathogens from entering the excoriated because of constant exposure to acid
fistula site and causing persistent bladder urine.
infection.  Kidney infection can occur from ascending
 This is done in the immediate neonatal period organisms from the open bladder.
using only a small sub-umbilical incision  When children with this disorder begin to walk,
they may demonstrate a “waddling” gait caused
by the wide pubic diastasis.

HYPOSPADIAS THERAPEUTIC MANAGEMENT

 a urethral defect in which the urethral opening is  Surgical closure of the bladder and the anterior
not at the end of the penis but on the ventral abdominal wall, and construction of a urethra
(lower) aspect of the penis  bladder mucosa should be kept moist and
 tends to be familial or may occur from a

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 Care of Mother and Child at Risk or with
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multifactorial genetic focus covered with plastic wrap to prevent the bladder
 The most extreme cases in males result in a surface both from drying out and from adhering to
penopubic location of the meatus and complete bedclothes or diapers and being injured
incontinence  To prevent the skin of the abdomen from
excoriation, consult a wound, ostomy, and
ASSESSMENT continence nurse for the best approach, which
 to inspect all male newborns at birth for usually involves a protective topical application
hypospadias or epispadias as part of a routine such as A&D Ointment, Karaya Gum, or Maalox.
physical examination  Sponge bathe rather than tub bathe the infant to
 degree of hypospadias may be minimal (on the prevent water from entering the ureters and
glans but inferior in site) or maximal (at the becoming a source of infection.
midshaft or at the penal-scrotal junction)
 Many newborns with hypospadias have an POSTOPERATIVE
accompanying short chordee—a fibrous band that  After bladder closure, a suprapubic tube is placed
causes the penis to curve downward for urine drainage and will typically remain in
place for 4 to 6 weeks to allow the bladder to drain
THERAPEUTIC MANAGEMENT continuously and the surgical anastomoses to
 Children with hypospadias should not be heal.
circumcised because, at the time of the repair, the  The infant should be positioned on the back with
surgeon may wish to use a portion of the foreskin the legs raised in traction at 90 degrees is
for the repair. maintained for 4 to 6 weeks after surgery and is
 Chordee repair is a surgery to straighten the essential to prevent failure of the closure
penis. It is done for a condition of the penis called For children who have a successful initial closure,
chordee. Chordee causes the penis to be curved, adequate bladder capacity, pelvic floor function,
which is most obvious during an erection. A and bladder contractility, an alternate continence
chordee repair is done by a specialized doctor procedure, called a bladder neck reconstruction
called a pediatric urologist (BNR), may be an option
 Meatotomy—a procedure in which the urethra is  A BNR reconstructs the bladder neck and urethra
extended to a usual position—to establish better and allows the child to void via the urethra and
urinary function achieve continence.
 If the repair will be extensive, all surgery may be
delayed until the child is 3 to 4 years of age
 After surgical repair, a urethral urinary drainage
catheter will be inserted to allow urine output
without putting tension against the urethral
sutures.
 Analgesic such as acetaminophen (Tylenol) and
an anticholinergic medication such as oxybutynin
(Ditropan) may be prescribed for pain relief.
 After hypospadias repair, children can be
expected to have usual urinary and reproductive
function unless accompanying anomalies of the
penis are present.
INFECTIONS OF THE URINARY SYSTEM AND RELATED DISORDERS
HYDRONEPHROSIS  Elevated blood pressure caused by increasing
 enlargement of the pelvis of the kidney with urine tubular pressure (which activates the renin–
as a result of back-pressure is generally caused angiotensin system) may be detected on a routine
by obstruction, either of the ureter or of the point health assessment
where the ureter joins the bladder, as with  With severe back pressure, the infant will
vesicoureteral reflux. eventually experience flank or abdominal pain.
 may occur at any age, it occurs most often in the  An IVP or ultrasound will reveal the enlarged
first 6 months of life and is often diagnosed by pelvis and the point of obstruction.
ultrasound during intrauterine life

ASSESSMENT MANAGEMENT
 usually asymptomatic.  The treatment is surgical correction of the

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 Care of Mother and Child at Risk or with
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 The infant may have repeated UTIs caused by obstruction before glomerular or tubular
urinary stasis (difficult to detect in a young child destruction occurs.
except as general irritability or crying on voiding).
 although blood pressure is not taken routinely in
infants.
 Abdominal palpation may reveal an abdominal
mass (the dilated kidney pelvis).

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. Enlargement of the pelvis of the kidney with urine as a result of back-pressure is generally caused by obstruction, either
of the ureter or of the point where the ureter joins the bladder, as with vesicoureteral reflux.
A. Patent Urachus
B. Hydronephrosis
C. Hypospadias
D. Epispadias

2. A urethral defect in which the urethral opening is not at the end of the penis but on the ventral (lower) aspect of the
penis:
A. Patent Urachus
B. Hydronephrosis
C. Hypospadias
D. Epispadias

3. A narrow tube that connects bladder and umbilicus fails to close during embryonic development.
A. Patent Urachus
B. Hydronephrosis
C. Hypospadias
D. Epispadias

4. You care for a 3-year-old with hypospadias. After a surgical repair, he has a urethral urinary catheter inserted. You
would want to teach his parents that:
A. the catheter insertion site will leave only a minimal scar.
B. back pressure from such drainage may result in nephrotic syndrome.
C. He must be reevaluated at puberty for testicular function.
D. He will always have tenderness on penile erection.

5. A child is administered oxybutynin (Ditropan) following surgical repair of a hypospadias. The purpose of this drug is to:
A. prevent nausea and vomiting.
B. stimulate kidney function.
C. acidify urine.
D. relieve bladder spasms.

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 Care of Mother and Child at Risk or with
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6. A procedure in which the urethra is extended to a usual position to establish better urinary function:
A. Chordee Procedure
B. Meatotomy
C. Bladder Neck Reconstruction
D. Vagotomy

7. A surgery to straighten the penis. It is done for a condition of the penis:

A. Chordee Procedure
B. Meatotomy
C. Bladder Neck Reconstruction
D. Vagotomy

8. An alternate continence procedure that reconstruct bladder capacity, pelvic floor function, and bladder contractility:
A. Chordee Procedure
B. Meatotomy
C. Bladder Neck Reconstruction
D. Vagotomy

9. All of the following are management of Exstrophy of the Bladder, EXCEPT:

A. Surgical closure of the bladder and the anterior abdominal wall, and construction of a urethra
B. Bladder mucosa should be kept moist and covered with plastic wrap to prevent the bladder surface both from drying
out and from adhering to bedclothes
C. Sponge bathe rather than tub bathe the infant to prevent water from entering the ureters and becoming a source of
infection.
D. The treatment is surgical correction of the obstruction before glomerular or tubular destruction occurs.

10. The following are postoperative management of Exstrophy of the Bladder, EXCEPT:
A. After surgical repair, a urethral urinary drainage catheter will be inserted to allow urine output without putting tension
against the urethral sutures.
B. After bladder closure, a suprapubic tube is placed for urine drainage and will typically remain in place for 4 to 6 weeks
to allow the bladder to drain continuously and the surgical anastomoses to heal.
C. The infant should be positioned on the back with the legs raised in traction at 90 degrees is maintained for 4 to 6 weeks
after surgery and is essential to prevent failure of the closure
D. A Bladder Neck Resection reconstructs the bladder neck and urethra and allows the child to void via the urethra and
achieve continence.

C. LESSON WRAP-UP

AL Activity: CAT: 3-2-1 This strategy provides a structure for students to record their own comprehension and
summarize their learning. It also gives the teacher an opportunity to identify areas that need re-teaching, and areas of

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 Care of Mother and Child at Risk or with
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student interest

Instructions:

1. As an exit ticket at the end of the class period

2. After the lesson, have each student record three things he or she learned from the lesson.
3. Next, have them record two things that they found interesting and that they’d like to learn more about.
4. Then, have students record one question they still have about the material.
5. Review the students’ responses. You can use this information to help develop future lessons and determine if some
of the material needs to be taught again.

Three things you learned:

1.

3.

Two things that you’d like to learn more about:

1.

2.

One question you still have:

1.

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