NURS 6541: Primary Care of Adolescents and Children | Week 9

The care of genitourinary (GU) disorders can range from primary care diagnosis and treatment to referral for specialized care, making it essential for you to identify when a patient’s needs fall within your scope of practice. Consider Hannah, who received specialized treatment for a GU disorder. When Hannah was born, her bladder was misshapen and located outside of her body, requiring immediate surgery. Although the surgery was a success, she began to present with complications at age 2. As is common among children with her condition, bladder exstrophy, she suffered from frequent urinary tract infections (Miami Children’s Hospital, 2012). Although you might not treat bladder exstrophy as an advanced practice nurse, you must be able to treat resulting complications that present later in the patient’s life. In your role, you will care for pediatric patients with GU disorders, and like Hannah, some of these patients will have unique needs, requiring long-term treatment and management.

This week you explore genitourinary disorders in pediatric patients. You also examine differential diagnoses for these disorders, as well as the impact of patient culture on treatment, management, and education.

Learning Objectives – Evaluation and Management of Renal and Genitourinary Disorders, NURS 6541 Week 9 Case Study: 3-year old girl complaining of dysuria with frequent episodes of enuresis

By the end of this week, students will:

• Analyze treatment and management plans for pediatric patients with genitourinary disorders
• Analyze strategies for educating patients and families on the treatment and management of genitourinary disorders
• Evaluate the impact of culture on the treatment and management of genitourinary disorders
• Understand and apply key terms, principles, and concepts related to genitourinary disorders in pediatric patients
• Evaluate diagnoses for pediatric patients
• Evaluate treatment and management plans
• Assess pediatric patients with signs of hematologic and metabolic disorders*
• Assess pediatric patients with signs of gastrointestinal disorders*

*These Learning Objectives support assignments that are due this week but were assigned in Weeks 8 and 9.

Discussion: Diagnosis and Management of Genitourinary Disorders

Many genitourinary (GU) disorders such as kidney disease begin developing during childhood and adolescence (Johns Hopkins Children’s Center, 2010). This early onset of disease makes it essential for you, as the advanced practice nurse caring for pediatric patients, to identify potential signs and symptoms. Although some pediatric GU disorders require long-term treatment and management, other disorders such as bedwetting or urinary tract infections are more common and frequently require only minor interventions. In your role with pediatric patients, you must evaluate symptoms and determine whether to treat patients or refer them for specialized care. For this Discussion, consider potential diagnoses, treatment, and/or referral options for the patients in the following three case studies.

Discussion board posting assignments are assigned alphabetically by FIRST NAME to ensure all cases are covered and discussed.

• Case Study 1: A-F
• Case Study 2: G-M
• Case Study 3: N-T
• Case Study 4: U-Z

Case Study 1

HPI: This is a 3 year old girl with a 2-day history of complaints of dysuria with frequent episodes of enuresis despite potty training about 7 months ago. She is afebrile and denies vomiting.

PMH: Last UTI, 6 months ago.
PE: Dipstick voided urine analysis reveals: specific gravity 1.015, Protein 1+ non-hemolyzed blood, 1+ nitrites, 1+ leukocytes, and glucose-negative.

Case Study 2

Jacob is a 1.5 week old brought in by his distressed mother. While changing his diaper last night, she noted that his penis was edematous and erythematous. He has been crying and fussy. Per mom, no other complaints. He’s been breastfeeding every 1-2 hours without any issues.

PE: Stable VS and growth patterns. Essentially a normal examination with the exception of a slightly erythematous and edematous glans penis with retracted prepuce.

Case Study 3

HPI: Mark is a 15-year-old with complaint of acute left scrotal pain with nausea. The pain began approximately 6 hours ago after a wrestling match. He describes the pain as a dull ache and has gradually worsened to where he can no longer stand without doubling over. He is afebrile and in marked pain.

PE: Physical exam is negative except for elevation of the left testicle, diffuse scrotal edema, and the presence of a blue dot sign.

Case Study 4

HPI: Maya is a 5-year-old who presents for a well-child visit. She is a healthy child with no complaints.

PE: VS stable; Height and weight within the 60th percentile. Head to toe examination is normal.
Diagnostics: Routine urinalysis indicates 2+ proteinuria; specific gravity 1.020; negative for glucose, blood, leukocytes, and nitrites. 60th percentile for height and weight.

To prepare:

• Review “Genitourinary Disorders” in the Burns et al. text.
• Review and select one of the three provided case studies. Analyze the patient information.
• Consider a differential diagnosis for the patient in the case study you selected. Think about the most likely diagnosis for the patient.
• Think about a treatment and management plan for the patient. Be sure to consider appropriate dosages for any recommended pharmacologic and/or non-pharmacologic treatments.
• Consider strategies for educating patients and families on the treatment and management of the genitourinary disorder.

ORDER INSTRUCTION-COMPLIANT PAPERSBy Day 3

Post an analysis of your assigned case by responding to the following:

• What additional questions will you ask?
  • Has the case addressed the LOCATES mnemonic? If not, what else do you need to ask? What additional history will you need? (Think FMH, allergies, meds and so forth, that might be pertinent in arriving to your differential diagnoses).
• What additional examinations or diagnostic tests, if any will you conduct?
• What are your differential diagnoses? What historical and physical exam features support your rationales? Provide at least 3 differentials.
• What is your most likely diagnosis and why?
• How will you treat this child?
  • Provide medication treatment and symptomatic care.
  • Provide correct medication dosage. Use the knowledge you learned from this week’s and previous weeks’ readings as well as what you have learned from pharmacology to help you with this area.
• Patient Education, Health Promotion & Anticipatory guidance:
  • Explain strategies for educating parents on their child’s disorder and reducing any concerns/fears presented in the case study.
  • Include any socio-cultural barriers that might impact the treatment and management plans.
  • Health Promotion:
    • What immunizations should this child have had?
    • Based on the child’s age, when is the next well visit?
    • At the next well visit, what are the next set of immunizations?
    • What additional anticipatory guidance should be provided today?

Read a selection of your colleagues’ responses.

By Day 6

Respond to at least two of your colleagues on two different days in both of the ways listed below. Respond to colleagues who selected different case studies than you did.

• Describe how culture might impact the diagnosis, management, and follow-up care of patients with the genitourinary disorders your colleagues discussed.
• Based on your personal and/or professional experiences, expand on your colleagues’ postings by providing additional insights or different perspectives. Case Study: 3-year old girl complaining of dysuria with frequent episodes of enuresis

ADDITIONAL INFORMATION;

Evaluation and Management of Renal and Genitourinary Disorders

Introduction

Renal and genitourinary disorders are common, with approximately 10% of all patients presenting to emergency departments with acute kidney injury (AKI). As such, it is essential for the emergency physician to be familiar with the evaluation and management of these disorders. In addition to a thorough history, physical examination and laboratory testing, the emergency clinician should also consider imaging studies of the kidneys in patients with suspected AKI.

Acute renal failure

Acute renal failure (ARF) is a medical emergency. ARF occurs when the kidneys fail to produce enough urine, or when they cannot excrete waste products or filter out impurities in the blood.

Symptoms of acute renal failure include nausea, vomiting and fatigue. Signs may include confusion and low urine output that can be associated with rapid weight loss as well as dark-colored urine due to dehydration (see below).

The kidneys are a pair of bean-shaped organs located on either side of the spine, just below the rib cage. The kidneys filter blood and remove waste products from the body. They also control levels of electrolytes (such as potassium) in your blood by helping regulate how much fluid you take in. In addition, they produce hormones that help regulate blood pressure and red blood cell production.

Chronic renal failure

Chronic renal failure is a condition in which the kidneys are damaged and can no longer filter blood properly. There are two types of chronic renal failure, chronic glomerulonephritis and chronic interstitial nephritis.

Chronic glomerulonephritis occurs when the filtering mechanism at each pole of your kidneys becomes blocked by protein-containing materials called casts (which form as these materials build up). These casts block the flow of urine through your kidneys, causing them to enlarge. This process leads to swelling and pain in both legs as well as lower back pain because there is no longer enough room for most normal activities such as walking or standing straight up on one leg while resting on another foot so that they appear slightly bent forward at their hips (as opposed to being straight ahead).

Polycystic kidney disease

You may be familiar with polycystic kidney disease (PKD), also known as congenital nephropathy. It is a genetic disorder that involves the formation of small cysts on the kidneys. PKD can cause high blood pressure and kidney failure, but it can be treated with medication if caught early enough.

In addition to the visible symptoms above, some people with PKD may have other health concerns such as:

• Hypertension (high blood pressure)

• Kidney stones

Hematuria

Hematuria is the presence of blood in the urine, typically caused by inflammation or infection. It can result from many different conditions, including:

• Infection (e.g., urinary tract infection)

• Trauma to the bladder, urethra and kidneys

• Cancer

Hematuria (blood in the urine) Enlarged heart Other symptoms of polycystic kidney disease include: Urine that is dark and foul-smelling Frequent urination Pain or pressure in your back or side when you lie dowBladder cancer Genital warts (human papilloma virus)n

Proteinuria

Proteinuria (protein in the urine) is a medical condition in which there is too much protein in your urine. Proteinuria can be caused by many things, including kidney disease, diabetes and high levels of calcium in your blood.

Proteinuria occurs when excessive amounts of protein leak through damaged specialized cells that line the walls of your kidneys or urinary tract. This leakage causes your body to produce excess amounts of proteins in its urine as it tries to cleanse itself from these unwanted substances. The excess proteins build up over time until they flow out with each passing urine sample taken from you (this process takes about one hour).

Proteinuria also affects other organs such as blood vessels and nerves; however, their effects are not noticeable at first glance since they do not cause any symptoms until later on down the road when these areas become damaged due to excessive pressure being applied upon them by chronically elevated levels within our bloodstreams due mainly because we consume too much animal products every day.”

Microscopic hematuria and proteinuria

Microscopic hematuria and proteinuria are two types of renal tract disorders that can occur in children. Microscopic hematuria means that the urine has visible blood, while proteinuria means the amount of protein in your child’s urine has increased.

The difference between microscopic hematuria and proteinuria is that microscopic hematuria occurs as a result of bleeding in the urinary tract while proteinuria occurs as a result of infection or disease within the kidneys. Both conditions require treatment but they differ in how they will be treated. For example, antibiotics may be used to treat microhematuria if it is caused by an infection; however, this does not reduce the amount of blood found in your child’s urine which is what leads us to believe he/she has either microhematuria or possibly even more serious issues such as acute kidney failure (AKF).

Infections of the urinary tract

Urinary tract infections (UTIs) are common in women and children, but they can occur in men as well. UTIs are a type of infection that occurs when bacteria from your bladder enter the ureters (the tubes that carry urine from your kidneys to outside the body). This can happen if you have a urinary catheter or if someone else has inserted something into the urethra to help them urinate.

The symptoms of a UTI include:

• Painful urination

• Burning on passing urine

• Difficulty starting to urinate

Urinary tract obstruction, hydronephrosis, ureteral stones and pyelonephritis

• Urinary tract obstruction, hydronephrosis, ureteral stones and pyelonephritis.

• The kidneys are the chief excretory organs responsible for regulating fluid and electrolytes in the body. However, they also have an important role as a filtration system to remove waste products from the blood stream. The two major functions of these organs are urine formation (Urine) and blood filtration (Blood). Urine formation occurs when dissolved substances like salt ions or glucose molecules pass through barriers called pores that connect tubes called nephrons inside kidney tubules for removal from your body into a chamber called bladder where it can be stored temporarily until you need it later on during urination/defecation phase after which excess liquid will be passed out through another part known as urethra (Male) or vagina(Female).

Urinary stones (nephrolithiasis)

Kidney stones are small, solid masses of minerals that form in the kidneys. They can cause pain and infection. Kidney stones may be broken down into three types:

• Simple kidney stones (uroliths) have a smooth surface and no crystaline structure.

• Complex kidney stones have either a malformed crystal structure or multiple pieces of the stone with different structures embedded in them.

• Urolithiasis is the medical term for any condition where urine has accumulated in one or both kidneys and then crystallized into an uncomfortable formation called nephrolithiasis. Urine that accumulates as crystals (nephrolithiasis) is not considered to be normal growth; it should be treated as quickly as possible by various methods including irrigation through catheterization or surgery if needed

Bladder pain syndrome (interstitial cystitis)

Bladder pain syndrome (interstitial cystitis) is a condition that causes discomfort in the bladder. The pain is usually felt more in the lower abdomen or pelvis, but it can also be felt in your back. Symptoms include frequent urination, painful urination, pelvic pain and pressure in the bladder.

Have a healthy kidney

• Don’t smoke

• Don’t drink too much alcohol

• Don’t take certain medications

• Eat a healthy diet with plenty of fruit and vegetables, and avoid foods high in sugar or salt (like French fries)

Conclusion

Evaluation and management of renal and genitourinary disorders is a complex process that depends on the complete history of symptoms, laboratory tests, imaging studies and special procedures. The same approach should be followed in all cases.