URINARY TRACT INFECTION

Classification of UTI
• Upper tract: involves renal parenchyma,
pelvis, and ureters
– Typically causes fever, chills, flank pain
• Lower tract: involves lower urinary tract
– Usually no systemic manifestations

Mosby items and derived items

© 2009, 2005 by Mosby, Inc.,
an affiliate of Elsevier Inc.
 Classification of UTI (cont’d)
• Lower tract:
– Cystitis
– Urethritis
• Upper tract:
– Pyelonephritis
– Vesicoureteral reflux (VUR)
– Glomerulonephritis

Mosby items and derived items

© 2009, 2005 by Mosby, Inc.,
an affiliate of Elsevier Inc.
 Classification of UTI (cont’d)
• Uncomplicated infection
• Complicated infections:
– Stones
– Obstruction
– Catheters
– Diabetes or neurologic disease
– Recurrent infections

Mosby items and derived items

© 2009, 2005 by Mosby, Inc.,
an affiliate of Elsevier Inc.
 Classification
• Bacteriuria:
• Asymptomatic bacteriuria
• Symptomatic bacteriuria
• Recurrent UTI
• Persistent UTI
• Febrile UTI
• Cystitis
• Urethritis
• Pyelonephritis
• Urosepsis
 Etiology
• Escherichia coli (80% of cases)
• Anatomic and Physical Factors:
• Urethral girls 2cm/ women 4 cm
• male urethra (as long as 20 cm in adult)
• urinary stasis.
• anatomic abnormalities
• Constipation
• Urine PH changes
 Etiology and Pathophysiology of UTI

• Physiologic and mechanical defense

mechanisms maintain sterility:
– Emptying bladder
– Normal antibacterial properties of urine and tract
– Ureterovesical junction competence
– Peristaltic activity

Mosby items and derived items

© 2009, 2005 by Mosby, Inc.,
an affiliate of Elsevier Inc.
 Etiology and Pathophysiology of UTI (cont’d)

• Alteration of defense mechanisms increases

risk of UTI
• Organisms usually introduced via ascending
route from urethra
• Less common routes:
– Bloodstream
– Lymphatic system

Mosby items and derived items

© 2009, 2005 by Mosby, Inc.,
an affiliate of Elsevier Inc.
 Etiology and Pathophysiology of UTI (cont’d)

• Contributing factor: urologic instrumentation

– Allows bacteria present in opening of urethra to
enter urethra or bladder
• Sexual intercourse promotes “milking” of
bacteria from perineum and vagina
– May cause minor urethral trauma

Mosby items and derived items

© 2009, 2005 by Mosby, Inc.,
an affiliate of Elsevier Inc.
 Etiology and Pathophysiology of UTI (cont’d)

• UTIs rarely result from hematogenous route

• For kidney infection to occur from
hematogenous transmission, must have prior
injury to urinary tract:
– Obstruction of ureter
– Damage from stones
– Renal scars

Mosby items and derived items

© 2009, 2005 by Mosby, Inc.,
an affiliate of Elsevier Inc.
 Etiology and Pathophysiology of UTI (cont’d)

• UTI is a common nosocomial infection:

– Often Escherichia coli
– Seldom Pseudomonas organisms
• Urologic instrumentation common
predisposing factor

Mosby items and derived items

© 2009, 2005 by Mosby, Inc.,
an affiliate of Elsevier Inc.
 Clinical Manifestations of UTI
• Symptoms:
– Dysuria
– Frequent urination (>q 2 hr)
– Urgency
– Suprapubic discomfort or pressure

Mosby items and derived items

© 2009, 2005 by Mosby, Inc.,
an affiliate of Elsevier Inc.
 Clinical Manifestations of UTI (cont’d)

• Urine may contain visible blood or sediment

(cloudy appearance)
• Flank pain, chills, and fever indicate infection
of upper tract (pyelonephritis)

Mosby items and derived items

© 2009, 2005 by Mosby, Inc.,
an affiliate of Elsevier Inc.
 Pediatric Manifestations of UTI
• Frequency
• Fever in some cases
• Odiferous urine
• Blood or blood-tinged urine
• Sometimes NO symptoms except generalized
sepsis

Mosby items and derived items

© 2009, 2005 by Mosby, Inc.,
an affiliate of Elsevier Inc.
 Pediatric Manifestations of UTI (cont’d)

• Pediatric patients with significant bacteriuria

may have no symptoms or nonspecific
symptoms like fatigue or anorexia

Mosby items and derived items

© 2009, 2005 by Mosby, Inc.,
an affiliate of Elsevier Inc.
 Diagnostic Studies of UTI
• Dipstick
• Microscopic urinalysis
• Culture
• Sensitivity testing determines susceptibility to
antibiotics
• Imaging studies for suspected obstruction
– IVP or abdominal CT

Mosby items and derived items

© 2009, 2005 by Mosby, Inc.,
an affiliate of Elsevier Inc.
 Diagnostic Studies of UTI (cont’d)
• Clean-catch specimen is preferred
• U-bag for collection from child
• Specimen obtained by catheterization or
suprapubic needle aspiration has more
accurate results
– May be necessary when clean-catch cannot be
obtained

Mosby items and derived items

© 2009, 2005 by Mosby, Inc.,
an affiliate of Elsevier Inc.
 Collaborative Care for UTI Drug Therapy:
Antibiotics
• Uncomplicated cystitis: short-term course of
antibiotics
• Complicated UTIs: long-term treatment

Mosby items and derived items

© 2009, 2005 by Mosby, Inc.,
an affiliate of Elsevier Inc.
 Prevention
• Perineal hygiene: wipe from front to back.
• Avoid tight clothing or diapers; wear cotton
panties rather than nylon.
• Check for vaginitis or pinworms, especially if child
scratches between legs.
• Avoid "holding" urine; encourage child to void
frequently, especially before
• long trip or other circumstances in which toilet
facilities are not available.
 Prevention
• Empty bladder completely with each void.
Have the child "double void"
• (void, wait a few minutes and void again).
Severe cases may require clean,
• intermittent catheterization or biofeedback
instruction.
• Avoid straining during defecation and avoid
constipation.
• Encourage generous fluid intake.
 Vesicoureteral Reflux
abnormal retrograde flow of bladder urine into
the ureters. During voiding, urine is swept up
the ureters and then flows back into the
empty bladder

• Primary reflux
• secondary reflux
• In the presence of reflux, infected urine
(bacteria) from the bladder has access
to the kidney, (pyelonephritis).
high fevers, vomiting, and chills renal
scarring in children
Renal scarring may occur with the first episode
of febrile UTI. Reflux in the presence of sterile
urine does not cause renal damage.
 Therapeutic management
preventing bacteria from reaching the kidneys.
• with daily low-dose antibiotic therapy.
• A urine culture should be done every 2 to 3
months and any time the child has a fever
• annual voiding cystourethrogram
• surgical intervention???????
GLOMERULAR DISEASE

NEPHROTIC SYNDROME
 Nephrotic Syndrome
• Most common presentation of glomerular
injury in children
• Characteristics:
– Proteinuria
– Hypoalbuminemia
– Hyperlipidemia
– Edema
– Massive urinary protein loss

Mosby items and derived items

© 2009, 2005 by Mosby, Inc.,
an affiliate of Elsevier Inc.
(1) a primary disease known as idiopathic
nephrosis, childhood nephrosis, or minimal-
change nephrotic syndrome (MCNS).
(2) a secondary disorder that occurs as a clinical
manifestation after or in association with
glomerular damage of known or presumed
Etiology.
(3) a congenital form inherited as an autosomal
recessive disorder.
 Changes in Nephrotic Syndrome
• Glomerular membrane:
– Normally impermeable to large proteins
– Becomes permeable to proteins, especially
albumin
– Albumin lost in urine (hyperalbuminuria)
– Serum albumin decreased (hypoalbuminemia)
– Fluid shifts from plasma to interstitial spaces:
• Hypovolemia
• Ascites
Mosby items and derived items
© 2009, 2005 by Mosby, Inc.,
an affiliate of Elsevier Inc.
 Nephrotic Syndrome (cont’d)

FIG. 27-2 Sequence of events in nephrotic syndrome. ADH, Antidiuretic hormone.

Mosby items and derived items
© 2009, 2005 by Mosby, Inc.,
an affiliate of Elsevier Inc.
 Management of Nephrotic Syndrome
• Supportive care
• Diet:
– Low to moderate protein
– Sodium restrictions when large amounts of edema
are present
• Steroids:
– 2 mg/kg divided into b.i.d. doses
– Prednisone drug of choice (least expensive and safest)
• Immunosuppressant therapy (cyclophosphamide
[Cytoxan])
• Diuretics
 Nursing Interventions for Nephrotic Syndrome

• Aseptic technique during catheterizations

• Avoid unnecessary catheterization and early
removal of indwelling catheters
– Prevent nosocomial infections:
• Wash hands before and after contact
• Wear gloves for care of urinary system

Mosby items and derived items

© 2009, 2005 by Mosby, Inc.,
an affiliate of Elsevier Inc.
 Nursing Interventions for Nephrotic Syndrome
(cont’d)
• Routine and thorough perineal care for all
hospitalized patients
• Avoid incontinent episodes by answering call
light and offering bedpan at frequent intervals

Mosby items and derived items

© 2009, 2005 by Mosby, Inc.,
an affiliate of Elsevier Inc.
 Nursing Interventions for Nephrotic Syndrome
(cont’d)
• Ensure adequate fluid intake (patient with
urinary problems may think drinking fluids will
be more uncomfortable):
– Dilutes urine, making bladder less irritable
– Flushes out bacteria before they can colonize
– Avoid caffeine, alcohol, citrus juices, chocolate,
and highly spiced foods
• Potential bladder irritants

Mosby items and derived items

© 2009, 2005 by Mosby, Inc.,
an affiliate of Elsevier Inc.
 Nursing Interventions for Nephrotic Syndrome
(cont’d)
• Discharge-to-home instructions
• Follow-up urine culture
– Recurrent symptoms typically occur in 1-2 weeks
after therapy
– Encourage adequate fluids even after infection
– Low-dose, long-term antibiotics to prevent
relapses or reinfections
– Explain rationale to enhance compliance

Mosby items and derived items

© 2009, 2005 by Mosby, Inc.,
an affiliate of Elsevier Inc.
 Glomerulonephritis
• Most are postinfectious:
– Pneumococcal, streptococcal, or viral
• May be distinct entity OR
• May be a manifestation of systemic disorder:
– Systemic lupus erythematosus (SLE)
– Sickle cell disease

Mosby items and derived items

© 2009, 2005 by Mosby, Inc.,
an affiliate of Elsevier Inc.
 ACUTE GLOMERULONEPHRITIS
• Characteristics:
1. Generalized edema due to decreased
glomerular filtration
– Begins with periorbital area
– Progresses to lower extremities and then to ascites
2. Hypertension due to increased extracellular
fluid
3. Oliguria
 Glomerulonephritis Symptoms (cont’d)

4. Hematuria
– Bleeding in upper urinary tract, resulting in smoky
urine
4. Proteinuria
– Increased amount of protein = increased severity
of renal disease

Mosby items and derived items

© 2009, 2005 by Mosby, Inc.,
an affiliate of Elsevier Inc.
 Acute Poststreptococcal
Glomerulonephritis (APSGN)
• A noninfectious renal disease
– Autoimmune
• Onset 10- 21 days after OTHER type of infection
• Often group A β-hemolytic streptococci (winter &
spring),(after impetigo in summer & fall)
• Most common in 6-7 year olds
• Uncommon in children <2 years old
• Can occur at any age

Mosby items and derived items

© 2009, 2005 by Mosby, Inc.,
an affiliate of Elsevier Inc.
 Pathophysiology
• The glomeruli become edematous
infiltrated with leukocytes occlude the
capillary lumen. decrease in plasma
filtration excessive accumulation
of water and retention of sodium that
expands plasma and interstitial fluid volumes
leading to circulatory congestion and edema.
And hypertension
 Diagnostic Evaluation
• History of previous infection
• Urine analysis (protein urea, hematuria, WBC
& RBC casts)
• Kidney function test
• Serum antistreptolysin O
• x-ray examination( cardiac, pulmonary
congestion
• Renal biopsy
 Therapeutic & nursing
Management
• Symptomatic treatment
• Moderate sodium, low potassium diet
• May be restricted fluid
• Body weight, vital signs, intake & output
• If renal failure dialysis
• Bp q 4-6 hrs antihypertensive
• Diuretics
• Antibiotic positive presence of streptococcus
 WILMS TUMOR
 nephroblastoma, is the most common
malignant renal and intraabdominal tumor of
childhood.
 The peak age at diagnosis is approximately 3
years, and occurrence is slightly more
frequent in boys than in girls.
 The majority of patients with Wilms tumor are
diagnosed at younger than 5 years of age
 Etiology

• occurrence slightly favors the left kidney,

• In about 10% of cases both kidneysm are
involved.
• Beckwith-Wiedemann syndrome, and
genitourinary anomalies
 Diagnostic Evaluation
• history and physical examination
• signs of malignancy (e.g., weight loss, size of
liver and spleen, indications of anemia
lymphadenopathy). abdominal swelling or an
abdominal mass
• Abdominal ultrasound, abdominal and chest CT,
hematologic studies, biochemical studies, and
urinalysis.
 Clinical Manifestations
• Abdominal swelling or mass:
• Firm, Nontender, Confined to one side
• Hematuria (less than one fourth of cases)
• Fatigue/malaise
• Hypertension (occasionally)
• Weight loss, Fever
• Manifestations resulting from compression of
tumor mass
• Secondary metabolic alterations from tumor
or metastasis
• If metastasis, symptoms of lung involvement:
• Dyspnea
• Cough
• Shortness of breath
• Chest pain (sometimes)
 Therapeutic Management
• Stage I: Tumor is limited to kidney and completely
resected.
• Stage II: Tumor extends beyond kidney but is
completely resected.
• Stage III: Residual nonhematogenous tumor is
confined to abdomen.
• Stage IV: Hematogenous metastases; deposits are
beyond stage III, namely,to lung, liver, bone, and
brain.
• Stage V: Bilateral renal involvement is present at
diagnosis
 Nursing Considerations
• Preoperative Care
• procedures within 24 to 48 hours of
admission. So????
• explanations should be simple, repetitive, and
focused on the child's actual experiences.
• Observations
• Don’t papate
• radiotherapy and chemotherapy
 RENAL FAILURE
• Renal failure is the inability of the kidneys to
excrete waste material, concentrate urine,
and conserve electrolytes
• Acute renal failur
• Chronic renal failure
• Azotemia
• uremia
 Nursing care of child with renal
failure
• Provide diet low in potassium, sodium, and
phosphorus, if prescribed, to reduce excretory
demand on kidneys
• Daily body weight to assess odema
• Intake and ouput chart
• Keep mouth moist by other means, such as
hard candy, ice chips, fine mist spray of cool
water, to prevent feeling of dryness
 Nursing care of child with renal
failure
• Limit phosphorus, salt, and potassium food
• Encourage intake of carbohydrates and foods
high in calcium
• Assess complication of RF
• Promote self-esteem in child with CRF
• Assess site of dialysis frequently
• Family education