21 terms

Vesicoureteral reflux, pediatric

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Overview
A genitourinary condition in which urine flows from the bladder back into the ureters and eventually into the renal pelvis or parenchyma
Two groups identified: Those detected prenatally without any history of urinary tract infection (UTI) and those detected after a UTI
Results in poor bladder emptying, possibly leading to UTI renal scarring, and acute or chronic renal failure
Also called VUR
Overview-Pathophysiology
Primary VUR (most common form) can result from incompetence of the valve at the ureterovesical junction between the ureter and bladder, which normally keeps urine from backing up into the ureter, or from a shortened ureter, which also affects valve function. This type of VUR may resolve with age, as the ureter lengthens.
Secondary VUR results from abnormally high pressure most likely due to a blockage in the system that causes urine reflux into the kidneys, commonly due to infection.
Overview-Causes
Acquired diverticulum (from outlet obstruction)
Congenital anomalies of the ureters or bladder
Cystitis
Flaccid neurogenic bladder
High intravesical pressure from outlet obstruction
Inadequate detrusor muscle buttress in the bladder, stemming from congenital paraureteral bladder diverticulum
Sometimes unknown
Overview-Incidence
VUR occurs in approximately 1% of children.
It's detected prenatally three times more often in boys than in girls.
Detection of VUR after a UTI is more common in girls.
Overview-Complications
Renal impairment (reflux nephropathy)
UTIs
Urosepsis
Ureteral obstruction (after surgery)
Anuria
Renal failure (acute and chronic)
Assessment-History
Typically asymptomatic unless UTI occurs
Urinary frequency and urgency
Burning on urination
Failure to thrive
Nausea
Vomiting
Abdominal or flank pain
Assessment-Physical Findings
Hematuria
Strong-smelling urine
In male infants, a hard, thickened bladder (a hard mass deep in the pelvis) if the posterior urethral valves are causing an obstruction
Diagnostic Test Results-Laboratory
A clean-catch urinalysis may show a bacterial count greater than 100,000/μL with or without leukocytes or nitrates.
A microscopic examination may reveal white blood cells, red blood cells, and an increased urine pH in the presence of infection. Specific gravity less than 1.010 demonstrates an inability to concentrate urine.
An elevated creatinine level (more than 1.2 mg/dL) and an elevated blood urea nitrogen level (more than 18 mg/dL) may indicate advanced renal dysfunction.
Diagnostic Test Results-Imaging
Renal and bladder ultrasonography reveal the degree and amount of hydronephrosis.
I.V. pyelography may reveal an obstruction in the urinary tract.
Diagnostic Test Results-Diagnostic Procedures
Excretory urography may show a dilated lower ureter, a ureter visible for its entire length, hydronephrosis, calyceal distortion, and renal scarring.
Voiding cystourethrography (either fluoroscopic or radionuclide) identifies and determines the degree of reflux and shows when reflux occurs. It may also pinpoint the causative anomaly.
Nuclear cystography and renal ultrasound may detect reflux.
Diagnostic Test Results-Other
Catheterization of the bladder after the child voids determines the amount of residual urine.
Treatment-General
Behavior modification program for regular voiding schedules and bladder retraining
Treatment-Diet
Increased fluid intake
Treatment-Medications
Prophylactic antibiotics, such as co-trimoxazole and nitrofurantoin
Anticholinergics, such as oxybutynin and tolterodine to control detrusor muscle overactivity
Treatment-Surgery
Ureteral re-implantation (open or robotic assisted laparoscopy) or valve repair
Endoscopic injection of bulking agent
Nursing Considerations-Nursing Diagnoses
Acute pain
Excess fluid volume
Impaired urinary elimination
Risk for infection
Risk for injury
Nursing Considerations-Expected Outcomes
report increased comfort
maintain fluid balance
demonstrate skill in managing the urinary elimination problem
remain free from signs and symptoms of infection
avoid or minimize complications.
Nursing Considerations-Nursing Interventions
Allow the child and family to verbalize concerns and ask questions. Provide support and guidance, and offer clear explanations.
Ensure that the child has readily available access to bathroom facilities or a bedpan, urinal, or commode, if appropriate. Assist with a bladder retraining program; encourage the child to empty his bladder completely every 2 to 3 hours.
Obtain a daily weight.
Explain all procedures to the parents and child, if he's old enough to understand.
Administer the prescribed antibiotic therapy.
Make sure catheters are patent and draining well. Maintain sterile technique during catheter care.
Assist with applying a heating pad (on low setting) to the abdomen to promote comfort.
Prepare the child and family physically and psychologically for surgery.
Provide postoperative care, including surgical site care.
Nursing Considerations-Monitoring
Vital signs
Pain level and management
Fluid balance
Daily weight
Urinary elimination
Signs and symptoms of complications, such as postoperative infection
Nursing Considerations-Associated Nursing Procedures
Bladder ultrasonography
Blood pressure assessment, pediatric
Clean-catch (midstream) urine collection, pediatric female
Clean-catch (midstream) urine collection, pediatric male
General guidelines for performing a procedure on a child
Health history interview and physical assessment, pediatric
Heat application
Indwelling urinary catheter (Foley) insertion, pediatric female
Indwelling urinary catheter (Foley) insertion, pediatric male
Intake and output assessment
Oral drug administration, older child
Pain assessment, pediatric
Pain management
Postanesthesia care, pediatric
Preoperative care, pediatric
Preparing a patient for urologic surgery, OR
Pulse assessment, pediatric
Respiratory assessment, pediatric
Temperature assessment
Urine pH
Venipuncture, pediatric
Weight measurement
Patient Teaching-General
the disorder, diagnosis, and treatment, including the possible need for surgery
the prescribed drug therapy, including drug names, dosages, and frequency and schedule of administration
that nitrofurantoin, if prescribed, may change the color of urine to dark yellow or brown
the need to encourage complete emptying of the bladder, for example, by using the double-void technique (void once and then try to void again in a few minutes)
the importance of voiding every 2 to 3 hours regardless of whether the urge exists
the importance of recognizing and reporting recurring signs of UTI (painful, frequent, burning urination; foul-smelling urine)
the importance of completing the prescribed therapy or maintaining low-dose antibiotic prophylaxis and of discontinuing antibiotic therapy once resolution is confirmed
the importance of follow-up care, including diagnostic testing, such as a voiding cystourethrogram between 18 months and 2 years (for children with VUR detected in infancy), annual nuclear voiding cystourethrograms (for children receiving antibiotic therapy), and renal ultrasounds to evaluate renal growth and check for scarring; and renal ultrasound in 1 to 2 months after surgery and nuclear cystography in 3 months
the need for annual blood pressure evaluation and urinalysis for proteinuria, if the child has renal scarring.