Johnson J., Keogh J. Pediatric Nursing Demystified: A Self-Teaching Guide
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Treatment
䊋 Acute:
• Administer antibiotics for 10 days.
• Administer diuretics to reduce edema.
• Administer corticosteroids to reduce the inflammatory response.
• Administer antihypertensive medication to reduce blood pressure.
• Low-sodium, low-protein diet to prevent fluid retention.
• Fluid restriction.
• Dialysis if the patient experiences renal failure.
䊋 Chronic:
• Administer corticosteroids to reduce the inflammatory response.
• Administer antihypertensive medication to reduce blood pressure.
• Low-sodium, low-protein diet to prevent fluid retention.
• Fluid restriction.
• Dialysis or kidney transplant if the patient experiences renal
failure.
• For hyperkalemia:
䊊
For emergency reduction of potassium, administer insulin, hypertonic
glucose, and calcium gluconate.
䊊
To remove potassium, administer sodium polystyrene sulfonate
(Kayexalate).
Nursing Intervention
䊋 Strict intake and output
䊋 Daily weights
䊋 Acute:
• Provide a quiet environment.
• Monitor vital signs and report changes to the health-care provider.
• Explain to the family the importance of a low-salt, low-protein, and
fluid-restricted diet, and teach the family not to stop administering
antibiotics when the child’s condition improves.
䊋 Chronic:
• Monitor for signs of hyperkalemia (muscle weakness, paresthesia,
anorexia, and malaise).
• Explain to the family the importance of a low-salt, low-protein, low-
potassium, and fluid-restricted diet and the importance of ongoing
monitoring of the child by their health-care provider.
Nursing alert Monitor for renal failure where urine output <1 mL/kg per hour
in infants and <0.5 mL/kg per hour in children, and creatinine, BUN, and urine
creatinine clearance are elevated.
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URINARY TRACT CONGENITAL ANOMALIES
What Went Wrong?
Urinary tract congenital anomalies consist of abnormal ureter, bladder or
urethra whose cause is unknown. The most common urinary tract congenital
anomalies are
䊋 Duplicated ureter: Either a complete duplication of the ureter or incom-
plete duplication where two duplicate ureters are joined together prior to
entering the bladder.
䊋 Ureter stenosis: Narrowing of the ureter.
䊋 Exstrophy bladder: The bladder is inside out and exposed on the out-
side of the abdomen.
䊋 Ureterocele: The ureter balloons into the bladder to form a pouch.
䊋 Hypospadia: Abnormal position of the urinary meatus in boys.
Signs and Symptoms
䊋 Signs and symptoms depend on the nature of the anomaly but might
include
• Fever
• Chills
• Reduced urine output
• Flank pain
• Burning on urination
• Recurrent infection
• Abnormal voiding pattern
• Dark color urine
Test Results
䊋 Urography: Shows anomaly
䊋 Retrograde pyelography: Shows anomaly
䊋 Cystoureterography: Shows anomaly
Treatment
䊋 Administer antibiotic if there is a bacterial infection.
䊋 Surgical repair of the anomaly.
Nursing Intervention
䊋 Daily weights.
䊋 Strict intake and output.
䊋 Insert indwelling urinary catheter if ordered.
䊋 Cover the exposed area (i.e., exstrophy bladder) with sterile saline
dressing.
䊋 Teach the family how to care for the child at home.
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HEMOLYTIC UREMIC SYNDROME
What Went Wrong?
Hemolytic uremic syndrome is a common cause of renal failure in children
and is a result of damage to the glomerular arterioles secondary to a bacterial
infection. Glomerular arterioles become blocked by lesions and thrombi caus-
ing enlargement of the kidneys and decreased filtering.
Signs and Symptoms
䊋 Pallor
䊋 Irritability
䊋 Petechiae
䊋 Decreased urination
䊋 Hypertension
䊋 Diarrhea
Test Results
䊋 Urine analysis: Presence of protein and blood
䊋 Serum: Decreased red blood cells (RBC), decreased platelet count,
increased prothrombin time (PT) and partial thromboplastin time (PTT),
elevated white blood cells (WBC), elevated BUN and creatinine
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1. A parent of a child who is diagnosed with acute glomerulonephritis asks why her
child hasn’t improved following 20 days of treatment. What is the best response?
a. Explain that the health-care provider is likely to order another round of antibiotic
treatment.
b. Tell the parent to bring the child to see the health-care provider immediately.
c. Tell the parent to give the child increased fluids to help flush the kidneys.
d. Tell the parent to decrease fluids to protect the kidneys until the infection resolves.
Answer:
2. Your patient has an exstrophy bladder. Which of the following is the most important
intervention to perform?
a. Cover the exposed area with sterile saline dressing.
b. Strict intake and output.
c. Daily weights.
d. Teach the family how to care for the child at home.
Answer:
✔ ROUTINE CHECKUP 1
䊋 Coombs test: Negative
䊋 Stool culture: Positive for Escherichia coli
Treatment
䊋 Administer corticosteroids to reduce inflammation.
䊋 Maintain fluid and electrolyte balance to prevent seizures.
䊋 Administer antihypertensive if patient has hypertension.
䊋 Reduce fluid and salt intake if patient has hypertension.
䊋 Dialysis if patient is in renal failure.
Nursing Intervention
䊋 Daily weights.
䊋 Strict intake and output.
䊋 Maintain hydration.
䊋 Monitor vital signs every 4 hours.
䊋 Monitor for renal failure.
䊋 Explain the disorder and treatment to the family.
Nursing alert Antibiotics are administered only if the underlying infection is
caused by Shigella dysenteriae.
NEPHROTIC SYNDROME
What Went Wrong?
Nephrotic syndrome occurs when albumin is released by the kidneys into the
urine, resulting in decreased albumin in blood because the glomerular filtra-
tion membrane is injured, thus causing a fluid switch and edema because of
the decreased albumin in the blood.
A number of disorders can cause nephritic syndrome, including glomeru-
lonephritis, diabetes mellitus, allergic reactions, toxins, and circulatory dis-
ease. Nephrotic syndrome occurs in children of preschool age.
Signs and Symptoms
䊋 Weight gain
䊋 Decreased urination
䊋 Dark color urine
䊋 Lethargy
䊋 Irritability
䊋 Activity intolerance
䊋 Edema
Test Results
䊋 Urine analysis: Presence of protein and blood and elevated specific
gravity
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䊋 Serum: Elevated cholesterol, decreased albumin, and elevated platelet count
䊋 Renal biopsy: Identifies type of nephritic syndrome
Treatment
䊋 Administer prednisone (Deltasone) to reduce inflammation.
䊋 Administer albumin (Albuminar) intravenously (IV) to replace serum
albumin and return to normal fluid balance.
䊋 Administer furosemide (Lasix) IV to increase urination.
䊋 Administer antihypertensive medication if the child has hypertension.
䊋 Administer antibiotics to prevent infection due to the administration of
prednisone (Deltasone).
䊋 Restrict dietary salt.
Nursing Intervention
䊋 Daily weights.
䊋 Strict intake and output.
䊋 Monitor for pulmonary congestion.
䊋 Monitor for signs of infection.
䊋 Take precautions to avoid infection.
䊋 Maintain adequate nutrition.
䊋 Monitor for electrolyte imbalance.
䊋 Explain the disorder and treatment to the family.
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1. A parent of a child who was diagnosed with hemolytic uremic syndrome asks you
why the child must be weighed every day. What is the best response?
a. To measure the child’s daily fluid intake
b. To assess if the condition has negatively influenced the child’s growth
c. To assess if the child is retaining fluid
d. To determine if the child is adhering to dietary restrictions
Answer:
2. What should you alert to if the patient is being given corticosteroids to reduce
inflammation?
a. Renal failure
b. Infection because the immune system is surprised
c. Hypertension
d. Elevated sodium levels
Answer:
✔
ROUTINE CHECKUP 2
RENAL FAILURE
What Went Wrong?
Renal failure is the sudden or progressive decrease in renal function. The two
types of renal failure are acute and chronic.
Acute renal failure is the sudden decrease in renal function. It is reversible
following intensive treatment of the underlying condition. Acute renal failure
is divided into three categories:
䊋 Prerenal stage: Diminished renal perfusion is caused by a disorder
occurring before blood reaches the kidneys such as fluid loss, third-spacing
of fluids, congestive heart failure, or medication such as diuretics.
䊋 Renal stage: Diminished renal perfusion is caused by tubular necrosis
within the kidney related to pyelonephritis, glomerulonephritis, medica-
tion, or allergic reaction.
䊋 Postrenal stage: Diminished renal perfusion is caused by a urinary tract
obstruction due to a stone, tissue growth, or compressed ureter.
Chronic renal failure is the progressive decrease in renal function second-
ary to diabetes mellitus, hypertension, glomerulonephritis, HIV infection,
polycystic kidney disease, or ischemic nephropathy. Chronic renal failure is
an irreversible, permanent loss of kidney function.
Signs and Symptoms
䊋 Abdominal bruit with ischemic nephropathy
䊋 Peripheral edema with third spacing of fluids
䊋 Decreased urinary output
䊋 Uremic pruritus
䊋 Prerenal stage:
• Tachycardia
• Orthostatic hypotension
• Dry skin
• Mucous membranes
䊋 Chronic renal failure:
• Anemia related to kidneys production of erythropoietin
• Weight loss
Test Results
䊋 Serum: Elevated BUN, creatinine, and BUN-to-creatinine ratio
䊋 Urinalysis: Casts, RBC, WBC, proteinuria, glomerular filtration rate
decreased in chronic disease, creatinine clearance decreased
䊋 Renal ultrasound: Decrease in renal size in chronic renal failure; dilation
and fluid buildup in postrenal failure
Treatment
䊋 Resolve underlying cause.
䊋 Administer IV fluids to replace hypovolemia (acute renal failure prerenal
stage).
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䊋 Administer inotropic agents for patients with congestive heart failure
(CHF) to enhance cardiac output.
䊋 Administer antibiotics for pyelonephritis.
䊋 Insert a stent or catheter (urethral, suprapubic, nephrostomy) to drain
urine if there is a blockage.
䊋 Dialysis.
䊋 Administer erythropoietin to treat anemia.
䊋 Restrict dietary potassium, phosphate, sodium, and protein.
䊋 Administer phosphate binders to reduce phosphate levels.
䊋 Administer sodium polystyrene sulfonate to reduce potassium levels.
䊋 Monitor electrolyte levels.
䊋 Administer antihypertensive medication to control blood pressure.
䊋 Monitor and control blood glucose levels.
Nursing alert Chronic renal failure is asymptomatic until kidney function
declines 20% at which time the child becomes lethargic and fatigued.
Nursing Intervention
䊋 Monitor vital signs for changes in heart rate or blood pressure.
䊋 Strict intake and output.
䊋 Check dialysis access site for signs of infection.
䊋 Check arteriovenous (AV) shunt for thrill and bruit.
䊋 No contrast dye tests.
䊋 No nephrotoxic medication.
WILMS TUMOR
What Went Wrong?
Wilms tumor, also referred to as nephroblastoma, is cancer of the kidney
that begins in the womb that is linked to abnormal chromosomal and congen-
ital renal abnormalities. The Wilms tumor is encapsulated but may begin to
metastasize to the renal vein, vena cava, lymph nodes, lungs, and other organs
when the child is 4 years of age. Prognosis is good if the tumor is removed
before it metastasizes. The five stages of the Wilms tumor are
䊋 Stage I: The tumor is contained in one kidney.
䊋 Stage II: The tumor metastasized beyond the kidney; however, the tumor
can be completely removed.
䊋 Stage III: The tumor metastasized to lymph nodes and the abdomen.
䊋 Stage IV: The tumor metastasized to the bone, liver, lung, and brain.
䊋 Stage V: The tumor metastasized to both kidneys.
Signs and Symptoms
䊋 Nontender abdominal mass confined to one side
䊋 Enlarged abdomen
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䊋 Blood in urine
䊋 Hypertension
䊋 Vomiting
䊋 Constipation
䊋 Anemia
Test Results
䊋 Ultrasound: Identifies the size of the mass and if the mass is solid
䊋 CT scan: Identifies the location of the mass
䊋 Magnetic resonance imaging (MRI): Identifies the location of the mass
䊋 Chest radiograph: Identifies the location of the mass
䊋 Urograph: Assesses kidney function
Treatment
䊋 Biopsy to determine the type of tumor
䊋 Surgical removal of the tumor and the kidney if necessary
䊋 Chemotherapy (dactinomycin [Cosmegen], vincristine) to reduce the
size of the tumor
䊋 Radiation to reduce the size of the tumor
Nursing Intervention
䊋 Handle the child carefully during transportation and repositioning to
avoid rupturing the tumor capsule.
䊋 Explain the disorder and treatment to the family.
Nursing alert Don’t palpate the site of the tumor. Palpation can rupture the
tumor capsule resulting in the tumor metastasizing quickly.
PYELONEPHRITIS
What Went Wrong?
Pyelonephritis is a kidney infection typically following a urinary tract
infection commonly caused by E. coli, Klebsiella, Enterobacter, Proteus,
Pseudomonas, and Staphylococcus saprophyticus. Inflammation may impair
renal function.
Signs and Symptoms
䊋 Flank pain
䊋 Fever due to infection
䊋 Chills
䊋 Frequency, urgency, dysuria due to urinary tract infection
䊋 Nausea, vomiting, and diarrhea due to infection
䊋 Increased heart rate due to fever
䊋 Costovertebral angle (CVA) tenderness
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Test Results
䊋 Urinalysis: Presence of bacteria, nitrites, RBC, and WBC.
䊋 Urine culture and sensitivity: Identifies microorganism that causes the
infection and the antibiotic that kills the microorganism.
䊋 Complete blood count: Elevated WBC (leukocytosis).
Treatment
䊋 Administer antibiotics to treat infection:
• Nitrofurantoin
• Ciprofloxacin
• Levofloxacin
• Ofloxacin
• Trimethoprim-sulfamethoxazole
• Ampicillin
• Amoxicillin
䊋 Administer antipyretics for fever.
䊋 Administer fluids for dehydration due to vomiting and diarrhea.
䊋 Administer phenazopyridine for relief of dysuria symptoms.
䊋 Repeat urine culture after completion of antibiotic course.
Nursing Intervention
䊋 Monitor vital signs.
䊋 Monitor intake and output.
䊋 Assess for side effects of medication.
䊋 Teach patient that phenazopyridine will cause orange-colored urine.
URINARY TRACT INFECTION
What Went Wrong?
Urinary tract infection occurs when a microorganism, typically a gram-nega-
tive bacteria such as E. coli, enters the urinary tract. The microorganism is
present in the genital area and enters through the urethral opening or during
sexual contact. A nosocomial urinary tract infection can also develop in
patients who have a urinary catheter in place or who have undergone proce-
dures such as a cystoscopy where an instrument is placed in the urinary tract.
Nursing alert Urinary tract infections must be treated immediately to prevent
pyelonephritis.
Signs and Symptoms
䊋 Dysuria due to irritation of mucosal lining
䊋 Feeling of fullness in suprapubic area
䊋 Low back pain
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Test Results
䊋 Urinalysis: Presence of WBC, RBC, and nitrites.
䊋 Urine culture and sensitivity: Identifies microorganism and the antibiotic
that kills the microorganism.
Treatment
䊋 Administer antibiotics:
• Nitrofurantoin
• Ciprofloxacin
• Levofloxacin
• Ofloxacin
• Trimethoprim-sulfamethoxazole
• Ampicillin
• Amoxicillin
䊋 Encourage fluids, to make urine less concentrated.
䊋 Administer phenazopyridine for symptoms of dysuria.
䊋 Repeat urine testing after antibiotics are completed.
Nursing Intervention
䊋 Monitor intake and output.
䊋 Monitor vital signs for changes, signs of fever.
䊋 Encourage fluid intake.
䊋 Encourage cranberry juice to acidify urine.
䊋 Teach patient that phenazopyridine will cause orange-colored urine.
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CASE STUDY
Judy Miller, age 6, arrived at the Emergency Department with her mother
at 5
PM. Her mother reported that she had become lethargic in recent days.
Her mother became concerned when she felt warm to the touch and had-
n’t urinated as much as she normally would. The mother reports that Judy
had a strep throat 4 weeks ago, but she recovered and she was fine up to
a few days ago.
Assessment data: Temperature 101.3°F +1 pitting edema bilaterally arms
and legs. Slight edema around the eyes. Urine analysis showed hema-
turia, proteinuria, and specific gravity is 1.034 g/mL. Blood serum shows
elevated creatinine and BUN. Urine culture and sensitivity is positive for
streptococcal bacteria.