TUBERCULOSIS

Tuberculosis is a contagious disease caused by an acid-fast bacillus, Mycobacterium tuberculosis. The transmission of tuberculosis is through inhalation of droplets from a person with active tuberculosis.

Children are more common infected than adult in family. They can be infected from family member or by another individual with whom they have frequent contact such as babysitter.

Sign and Symptoms:

• May be asymptomatic
• Malaise
• Fever
• Cough
• Weigh loss
• Anorexia
• Lymphadenopathy

Diagnose:

1. Mantoux Test
2. Sputum Culture

Medical Interventions:

1. Isoniazid (INH), rifampin (rifadin), and pyrazinamide
2. A 9 month course of INH is prescribed to prevent a latent infection from progressing to clinically active tuberculosis and to prevent initial infection in children in high risk situations
3. A 12 month course is prescribed to the HIV infected child
4. For child with active tuberculosis: INH, rifampin, and pyrazinamide daily for 2 months and then INH and rifampin twice weekly for 4 months

Nursing Interventions:

1. Wear a mask if the child is coughing and does not cover his or her mouth
2. Place children on airborne precautions until medications have been initiated, sputum cultures demonstrate a diminished number of organisms, and cough is improving
3. Maintain airborne precaution with family members
4. Adequate rest and diet
5. Advice the child and family to prevent transmission of tuberculosis

Mantoux Test:

• Positive reaction to the mantoux test will appear 2-10 weeks after the initial infections
• The test is done to determine whether the child has been infected and has developed a sensitivity to the protein of the tubercle bacillus
• A positive reaction does not confirm the presence of active disease
• Once the child reacts a positively, the child will always react positively
• A positive reaction in a previously negative test indicates that the child has been infected since the last test
• The test should not be done at the same time as measles immunization since it may cause false-negative reaction

Measuring of Mantoux Test:

• The result of the test is measured by indurations:
• 15 cm or more = positive in child 4 years or older who do not have any risk factor
• 10 cm or more = positive in children younger than 4 years and in those with chronic illness or at high risk for exposure to tuberculosis
• 5 cm or more = positive for the highest risk groups such as children with immunusuppressive conditions or human immunodeficiency virus

Sputum Culture:

• The test is positive if it demonstrates the presence of mycobacteria in a culture
• Gastric washing (aspiration of lavaged contents from the fasting stomach) is done to obtain specimen from an infant or young child since they often swallow sputum rather than expectorate it
• The specimen is obtained in the early morning before breakfast

Pneumonia

Pneumonia is an inflammation of the alveoli. It can be cause by a virus, mycoplasmal agents, bacteria, or the foreign substances aspiration. The causative agents are usually come to the lung through inhalation or from the bloodstream.

There are types of pneumonia:

1. Viral pneumonia
2. Primary atypical pneumonia (Mycoplasma pneumonia)
3. Bacterial pneumonia
4. Aspiration pneumonia

Aspiration Pneumonia

Aspiration pneumonia may occur when food, secretions, liquids, or other materials enter the lung and cause inflammation and a chemical pneumonitis.

Signs and Symptoms of Aspiration Pneumonia:

• Cough or fever with foul-smelling sputum
• Deteriorating results on chest x-rays

Bacterial Pneumonia

Bacterial pneumonia is a serious infection that sometimes need for hospitalization when pleural effusion or empyema accompanies the disease and is mandatory for children with staphylococcal pneumonia.

Signs and Symptoms of Bacterial Pneumonia:

• Acute onset, fever, toxic appearance
• In infant: irritability, poor feeding, lethargy, abrupt fever, respiratory distress
• In older child: chills, headache, abdominal pain, chest pain, and meningeal symptoms
• Diminished breath sound or scattered crackles
• Hacking, nonproductive cough
• Coarse crackles and wheezing are heard as the infections resolves

Nursing Interventions for Bacterial Pneumonia:

• Administer oxygen as prescribed
• Place the child in a mist tent as prescribed
• Administer antimicrobial, antipyretic, antitussives as prescribed
• Suction mucus if the infant is unable to handle secretions
• Chest physiotherapy and postural drainage every 4 hours as prescribed
• Encourage child to lie on the affected side to splint the chest and reduce the discomfort caused by pleural rubbing
• Provide fluid intake and take caution to prevent aspiration
• Institute isolation precautions according to the agency policy
• Continuous closed chest drainage may be instituted if purulent fluid is present
• Thoracentesis may be done to remove fluid accumulation in the pleural cavity

Primary Atypical Pneumonia

Primary atypical pneumonia is the most common cause of pneumonia in children between 5-12 years of age. Primarily it occurs in the fall and winter season and in crowded living conditions.

Signs and Symptoms of Primary Atypical

• Anorexia, headache, fever, chills, muscle pain, and malaise
• Rhinitis, sore throat, and dry-hacking cough
• Initially non productive cough, then production of seromucoid sputum that becomes mucopurulent or blood streaked

Nursing Intervention:

• Nursing interventions for patient with primary atypical pneumonia are symptomatic.

Viral Pneumonia

Viral pneumonia occurs more frequently than bacterial pneumonia. It is also associated with upper respiratory infection caused by viruses.

Signs and Symptoms of Viral Pneumonia:

• Slight cough, malaise, and mild fever, to severe cough, prostration, and high fever
• Non productive or productive cough with small amounts of whitish sputum
• Wheezing or fine crackles

Nursing Interventions for Patient with Viral Pneumonia:

1. Oxygenation with cool mist as prescribed
2. Encourage to increase fluid intake
3. Administer antipyretics and antimicrobials as prescribed
4. Chest physiotherapy and postural drainage as prescribed

Bronchiolitis / Respiratory Syncytial Virus (RSV)

Bronchiolitis is defined as an inflammation of the bronchioles. It causes production of tick mucus that occludes bronchiole tubes and small bronchi. The common cause of bronchiolitis is respiratory syncytial virus that is higly communicable and usually transferred by the hands.

Signs and Symptoms:

• Upper respiratory infection symptoms: rhinorrhea and low-grad fever
• Tachypnea
• Lethargy, poor feeding and irritability
• Increased difficulty in breathing
• Expiratory wheeze and grunt
• Nasal flaring and retractions
• Diminished breath sounds

Nursing Interventions:

1. Maintain patent airway
2. Place child at a 30-50 degree angle with the neck is slightly extended to maintain an open airway as well as decrease pressure on diaphragm
3. Provide cool and humidified oxygen
4. Assess for any signs of dehydration
5. Encourage fluid intakes

Special Consideration in Giving Care Child with RSV:

• Isolate the child in a single room or in a room with another child with RSV
• Good hand washing procedures
• The nurses who care for these children do not care for other high-risk children
• Wear gowns when soiling of clothing may occur during care
• Administer ribavirin (Virazole) as prescribed
• Prepare for the administration of respiratory syncitial virus immune globulin ((RSV-IGIV or RespiGam or palivizumav)

Key Concept in Administration of Ribavirin (Virazole)

• Administer Ribavirin via aerosol by hood, tent, mask, or through ventilator tubing
• Pregnant health care providers should not care for a child receiving ribavirin
• The nurse who wear contact lenses should wear goggles when coming in contact with ribavirin since the mist may dissolve soft lenses

Respiratory Syncytial Virus Immune Globulin

• The immune globulin is used prophylactically to prevent respiratory syncytial virus infection in high-risk child
• The immune globulin is not administered to infants or children with congenital heart disease or with cyanotic congenital heart disease

Bronchitis

Bronchitis is an infection of the major bronchi that may be referred to as tracheobronchitis.

Signs and Symptoms:

• Fever
• Dry, hacking, and nonproductive cough that is worse at night and becomes productive in 2-3 days

Nursing Interventions:

1. Monitor for respiratory distress
2. Provide cool and humidified air
3. Monitor for any signs of dehydration
4. Increased fluid intake
5. Administer acetaminophen (Tylenol) for fever as prescribed

Laryngotracheobronchitis

Laryngotracheobronchitis is gradual inflammation of the larynx, trachea and bronchi. It is a most common type of croup and may be caused by virus or bacteria.

Sign and Symptoms:

• Irritability and restlessness
• Fever at low to high grade
• Hoarse voice
• Inspiratory striddor and suprasternal retraction
• Seal bark and brassy cough
• Crackles and wheezing
• Use of accessory muscles for breathing
• Anorexia, nausea, and vomiting
• Signs of anoxia and carbon dioxide retention
• Cyanosis

Nursing Interventions:

1. Keep a paten airway
2. Assess respiratory status (nasal flaring, inspiratory stridor, sternal retraction)
3. Monitor for pallor or cyanosis
4. Elevate the head of the bed and provide bed rest
5. Provide humidified oxygen
6. Encourage fluid intake
7. Administer medication as prescribed (antibiotics, analgetics, bronchodilators, corticosteroids)
8. Epinephrine nebulizer may be given for children with severe disease, stridor at rest, retractions, or difficulty breathing
9. Have resuscitation equipment available

Epiglottitis

Epiglottitis is an inflammation on the epiglottitis. It mah be caused by Haemophilus influenzae type B or Streptococcus pneumoniae.

Epiglottitis most frequently occurs in winter in child between age 2 and 5 years. If it is happened, it is consideres as an emergency situation.

Signs and Symptoms:

• High fever
• Sore, red, and inflamed throat
• Drooling
• Absence of spontaneous cough
• Muffled voice
• Difficulty swallowing
• Inspiratory stridor
• Agitation
• Tripod positioning

Nursing Interventions:

1. Maintain a patent airway
2. Assess respiratory status and breath sounds (nasal flaring, stridor, using accessory muscles)
3. Avoid assess body temperature by oral route
4. To prevent spasm of the epiglottis and airway occlusion, no attempts should be made to visualize the posterior pharynx or to obtain a throat culture
5. Prepare for lateral neck films to confirm the diagnosis
6. Keep NPO
7. Do not restrain the child
8. Do not leave the child unattended
9. Do not force the child to lie down
10. Administer fluids and antibiotic intravenously as prescribed
11. Administer analgesics and antipyretics as prescribed
12. Provide high humidification to cool the airway and decrease swelling
13. Provide cool-mist oxygen therapy as prescribed
14. Have resuscitation equipment available
15. Prepare for endotracheal intubation or tracheotomy if there is severe respiratory distress
16. Ensure that the child has up-to-date immunization schedule

Tonsilitis and Adenoiditis

Tonsillitis is an inflammation and infection of the tonsils, while adenoiditis is inflammation and infection of the adenoids. Both of them are usually manage by tonsillectomy and adenoidectomy.

Signs and Symptoms:

• Enlarged, bright red tonsils (may be covered by white exudates)
• Persistent or recurrent sore throat
• Swallowing difficulties
• Fever
• Cough
• Mouth breathing and unpleasant mouth odor
• Enlarge adenoids lead to nasal quality of speech, mouth breathing, hearing difficulties, snoring, or obstructive sleep apnea

Pre-operative Interventions:

• Observe for sign of active infection
• Assess bleeding and clotting studies
• Assess for any loose teeth to decrease the risk of aspiration during surgery

Post-operative Interventions:

• Place patient in prone or side-lying position to facilitate drainage
• Keep suction equipment in reach, however do not suction unless if there is any airway obstruction


• Discourage coughing or clearing the throat
• Avoid milk products initially
• Provide clear, cool, noncitrus and noncarbonated fluid
• Avoid red liquids since will stimulate the appearance of blood if the child vomits
• Do not give child any straws, forks, or sharp objects that can be put in the mouth
• Administer acetaminophen (Tylenol) for sore throat as prescribed
• Notify physician if bleeding, persistent earache, or fever occur
• Instruct parent to keep child away from crowds until heal

Otitis Media

Otitis media is an infection in the middle ear as a result of a blocked Eustachian tube which prevent normal drainage. It is more prone to infants and children because their Eustachian tubes are shorter, wider and straighter. Otitis media also is common complication from an acute respiratory infections.

Signs and Symptoms of Otitis Media:

• Fever
• Irritability and restlessness
• Loss of appetite
• Rolling of head from side to side
• Earache or pain
• Puling on or rubbing the ear
• Signs of hearing loss
• Red, opaque, bulging, or retracting tympanic membrane
• Purulent ear drainage

Nursing Interventions:

1. Encourage fluid intake
2. Teach parent to feed infants in upright position
3. Teach parent about administering ear medication. In a child younger than age 3, pull the pinna down and back, while in a child older than 3 years, pull the pinna up and back
4. Instruct child not to chew during acute episode since it increases pain
5. Provide local heat and have the child lie with the affected ear down
6. Instruct and teach the parent how to clean drainage from the ear with sterile cotton swabs
7. Instruct the parents that screening for hearing loss may be necessary

Myringotomy:
Myringotomy is in insertion of tympanoplasty tubes into the middle ear to equalize pressure and keep the ear aerated.

Post-operative Nursing Intervention for Child with Myringotomy:

• Keep the ear dry
• Instruct patient to wear earplugs when bathing, shampooing, and swimming
• Avoid diving and submerging under water

Conjunctivitis

Conjunctivitis is an inflammation of the conjunctiva and it is usually caused by allergy, infection, or trauma. Conjunctivitis that is caused by bacteria or virus is extremely contagious.

Signs and Symptoms of Conjunctivitis:

• Redness
• Itching, burning, or scratchy eyelids
• Edema
• Discharge

Nursing Interventions:

1. Instruct patient in infection control: good hand washing, not sharing towels, and washcloth
2. Administer antibiotic, antiviral eye drops or ointments or antihistamines as prescribed
3. The child should be kept home from school or day care until antibiotic eye drops have been given for 24 hours
4. Cool compresses can be used to lessen irritation and dark glasses can be worn for photophobia
5. Discontinue wearing contact lenses (if any) and obtain new lenses to eliminate the reinfection
6. Discharge eye makeup (if any)

Strabismus

Strabismus is defined as a condition when the eyes are not aligned because of lack of coordination of the extraocular muscles. It is sometimes called as "squint" or "lazy eyes". Strabismus is normal in the young infant but should disappear after around age 4 months.

The most cause of strabismus come from the muscle imbalance or paralysis of extraocular muscles, however it also may result from brain tumor, myasthenia gravis, or infection.

Signs and Symptoms of Strabismus:
Amblyopia (it comes if not treated early)
Loss of binocular vision
Permanent loss of vision if not treated early
Impairment of depth perception
Squinting or tilting of the head to see
Frequent headaches

Nursing Interventions:
Instruct the parents regarding occlusion therapy (patching) of the good eye to strengthen the weak eye
Corrective lenses may be indicated
Inform the parent that the injection of botulinum toxin wears off in about 2 months, and if successful, the correction will occur
Prepare for surgery. The surgery is performed to realign the weak muscles if non-surgical interventions are unsuccessful. It is performed usually before 2 years
Instruct and encourage parents in regarding the need of follow-up visits

Child Abuse

The term of child abuse is involved emotional or physical abuse or neglect, sexual exploitation or molestation by caretakers or other individuals.

Signs and Symptoms of Physical Abuse:

• Bald spots on the scalp
• Unexplained bruises, burns, or fracture
• Apprehensive child
• Fear of parent
• Extreme aggressiveness or withdrawal
• Lack of crying when approached by a stranger

Signs and Symptoms of Physical Neglect:

• Poor hygiene
• Consistent hunger
• Inadequate weight gain
• Constant fatigue
• Inconsistent school attendance
• Delinquency
• Reports of lack of child supervision

Signs and Symptoms of Emotional Abuse:

• Speech disorders
• Psychoneurotic reactions
• Learning disorder
• Suicide attempts
• Habit disorders: sucking, biting, and rocking

Signs and Symptoms of Sexual Abuse:

• Difficulty walking or sitting
• Torn, stained or bloody under-clothing
• Pain swelling or itching of the genitalia
• Poor peer relations
• Bruises, bleeding, or lacerations in the genital or anal area
• Unwillingness to change clothes

Shaken Baby Syndrome:

• Intracranial hemorrhage
• Full bulging fontanelles and head circumference greater than expected

Nursing Interventions:

1. Assess any possible injuries
2. Support the child during a physical assessment
3. Report case of suspected abuse
4. Place the child in an environment that is safe
5. Document the objective manner information
6. Assess parent's strength and weakness in dealing with stress
7. Assist the family in identifying stressor, support systems, and resources
8. Refer the family to appropriate support groups

Tourette's Disorder

Tourette's Disorder is a disorder that is characterized by recurrent involuntary and rapid movement affecting various parts of the body, accompanied by vocal noises such as barks, grunts, or profanities. It appears between ages 2 and 5.

Nursing Interventions:

• One-to-one relationship
• Protect the child from harm
• Allow the child to have a favorite toy or other object
• Maintain eye contact
• Provide positive reinforcement for appropriate behaviors
• Assess suicide potential
• Remove dangerous objects from the environment
• Limit on socially inappropriate or manipulative behaviors
• Provide non-competitive group situations.

Attention-Deficit Hyperactivity Disorder

Attention-Deficit Hyperactivity Disorder (ADHD) is a disorder in child that is characterized by developmentally inappropriate degrees of inattention, overactivity, and impulsivity. The diagnosis is established base on self-reports, parent, and teacher report, and psychological assessments.

The child with Attention-Deficit Hyperactivity Disorder may probably has childhood problems such as lowered intellectual development, some minor physical abnormalities, sleeping disturbances, behavioral or emotional disorders, and difficulty in social relationships.

Signs and Symptoms:

• Easily distracted with external or internal stimuli
• Difficulty with following the instructions
• Poor attention span
• Talking excessively
• Shifting from one uncompleted activity to another
• Interrupting or intruding on others
• Engaging in physically dangerous activities

Nursing Interventions:

1. Encourage support group for parent
2. Provide environmental and physical safety measures
3. Enhance capabilities and self-esteem
4. Administer medications as prescribed such as methylphenidate hydrochloride (Ritalin), pemoline (Cylert), and dextroamphetamine sulfate (Dexedrine)
5. Inform the child and parent that the effects medication may come with in 1-2 weeks if taken as prescribed

Autism

Autism is a severe mental disorder begins in infancy or toddler-hood. It is characterized by impairment of reciprocal social interaction and in verbal and non-verbal communication. The cause of autism is unknown and the prognosis is poor, however, the diagnosis can be established through the symptoms and specialized autism assessment tools

Signs and Symptoms of Autism:

• Abnormal responses of body sensations
• Disturbance in the rate ad appearance of physical, social, and language skills
• Abnormal ways in relating to persons, objects, and events
• Self-absorbed and unable to relate to others
• The child may play happily alone for hours but have temper tantrums if interrupted
• Repetition of previously heard speech meaninglessly and reversal of the pronouns "I" and "you"
• Unusual attachment to a significant object and display frequent rocking, spinning, twirling, or other bizarre behaviors

Nursing Interventions:

1. Identify the child routines, habits, and preferences, and maintain consistency as much as possible
2. Observe the specific ways in which the child communicates
3. Encourage communication through the use of picture boards
4. Provide safety environment and safety precautions
5. Observe for stress and anxiety
6. Avoid placing demands on child
7. Initiate referrals to special programs as required
8. Provide support for child's parents

Mental Retardation

Mental retardation is a condition that is characterized by a below-average score on a test of mental ability or intelligence and limitations in the ability to function in daily life, such as communication, self-care, and getting along in social situations and school activities.


Signs and Symptoms of Mental Retardation:

• Cognitive skills and level of adaptive functioning are in under level of normal
• Speech delays
• Fine-motor and gross-motor are delayed
• Decreased spontaneous activity
• Irritability
• Non-responsiveness
• Poor eye contact during feeding

Nursing Interventions:

1. Promote care skills as much as possible
2. Facilitate appropriate playtime
3. Assist the child in communication and socialization skills
4. Provide safety precaution as necessary
5. Assist the family with decisions in relation to care
6. Provide information about support services and community agencies

Cerebral Palsy

Cerebral palsy is a condition that is characterized by impaired movement and posture due to an abnormality in the extra-pyramidal or pyramidal motor system.

Signs and Symptoms of Cerebral Palsy:

• Feeding difficulties
• Extreme irritability and crying
• Stiff and rigid arms or legs
• Abnormal motor performance
• Delayed gross development
• Muscles tones alterations
• Abnormal posturing (such as episthotonic)
• Persistent of primitive infantile reflexes

Nursing Interventions:

1. Assess the child's developmental level and intelligence
2. Encourage the child in early intervention and participation in school programs
3. Communicate and interact with the child on his/her developmental level
4. Prepare for using mobilizing devices
5. Provide a safe environmental
6. Provide safe and appropriate toys for age and developmental levels
7. Place the child upright after meals
8. Administer medication as prescribed

Seizure Disorder

Seizure is defined as a sudden, transient alteration in brain function due to excessive levels of electrical activity in the brain. It can be classified as partial or generalized, or unclassified, that is depended on the area of the brain involved.

Nursing Assessment of Seizure in Child

• Obtain information from the parent about the onset time, precipitating events, and behavior before and after the seizure.
• Assess the child's history in relation to seizures.

Seizure Precautions:

• Raise the side rails when the child is sleeping or resting
• Place a waterproof mattress or pad on the bed or crib
• Pad the side rails and other hard object
• Instruct child to wear medical identification
• Instruct the child about precaution during potentially hazardous activities
• Instruct the child not to swim without a companion
• Instruct the child to wear a helmet and padding during bicycle riding, skateboarding, and inline skating
• Alert caregivers to the need for any special precautions

Emergency Treatment for Seizures:

1. Ensure airway patency
2. Identify time of seizure episode
3. If the child is in sitting or standing position, ease the child down to the floor, placing the child in a side-lying position
4. Place a pillow or folded blanket under the child's head, or place your own hands under the child's head, or place the child's head in your own lap
5. Loose the child's clothes
6. Remove eye glasses if present
7. Clear area from any hazard or hard objects
8. Allow seizure to proceed and end without interference
9. Turn child to one side (as a unit) if vomiting
10. Do not restrain the child, place anything in the child's mouth or give any food or liquid to the child
11. Remain with the child until the child fully recovers
12. Prepare to administration some medication as prescribed
13. Observe for incontinence
14. Document the occurrence

Bladder Exstrophy

Bladder exstrophy is a congenital anomaly characterized by extrusion of the urinary bladder to the outside of the body through a defect in the lower abdominal wall. The cause of bladder exstrophy is unknown.

Bladder exstrophy needs a surgical management and a series of staged reconstructions. The initial surgery is to close the abdominal defect, and it should be done within the first few day of life. However, the subsequent operation is done to reconstruct the bladder and genitalia and enable child to achieve urinary continence.

Signs and Symptoms of Bladder Exstrophy:

• Esposed bladder mucose
• Widened symphysis pubis
• Defects of the external genitalia

Nursing Interventions:

• Monitor urinary output
• Monitor for signs of urinary tract or wound infections
• Maintain the integrity of the exposed bladder mucose
• Prevent the bladder tissue from drying, while allowing the drainage of urine until surgical closure is done.
• Cover the bladder with sterile, nonadherent clear plastic wrap or a sterile thin film dressing without adhesive
• Petroleum jelly is avoided because it tends to dry out, adhere to the bladder mucose, and damage the delicate tissues when the dressing is remove
• Administer antibiotics as prescribed
• Emotional support to the parents and encourage verbalization of their fears and concerns

Epispadias and Hypospadias

Epispadias is a condition in which the urethral orifice is located on the dorsal surface of the penis (often occurs with exstrophy or the bladder). In hypospadias the urethral orifice is located below the glans penis along the ventral surface.

Surgical intervention is done before the age of toilet training (preferably between 16 and 18 months of age) and the child should not be circumcised because the foreskin may be used in surgical reconstructions.

After surgery, the child will have a pressure dressing and may have some type of urinary diversion or a urinary stent that is used to maintain patency of the urethral opening while healing of the meatus occurs.

Postoperative Nursing Interventions:

• Monitor vital signs
• Encourage child fluid intake to maintain urine output and to maintain patency of the stent
• Monitor intake and output and the urine for cloudiness or a foul odor
• Notify the physician if there is no urinary drainage for 1 hour because it may indicate kinks in the system or obstruction by sediment
• Administer pain killer, anticholinergic and antibiotic as prescribed
• Instruct the parent to avoid giving the child a tub bath until the stent is removed (if any)

Cryptorchidism

Cryptorchidism is a condition in which one or both testes fail to descent through the inguinal canal into the scrotal sac.

Sign of cyptorchidism:
Testes are not palpable or easily guided into the scrotum

Nursing Interventions:

• Observe during the first 12 month of life to determine whether spontaneous descent occurs.
• After age of one year, medical or surgical treatment may be instituted
• Human chorionic gonadotropin may be prescribed
• Surgical corrections (if needed) is done by orchiopexy between 1 and 2 years of age

Enuresis

Enuresis is a condition in which the child is unable to control bladder function even though the child has reached an age at which control of bladder is expected. There are two types of enuresis: primary and secondary (acquired)

Primary Nocturnal Enuresis

• Bed wetting in a child who has never been dry for extended periods
• The child is unable to sense a full bladder and does not awaken to void
• The child may have delayed maturation of the central nervous system

Secondary or Acquired Enuresis

• Bed wetting occurs after a period of established urinary continence
• It may occur during nighttime sleep (nocturnal), only during the waking hours (diurnal), or during both times of the day

Nursing Interventions:

• Obtain urinalysis and urine culture as prescribed
• Limit fluid intake at night, and encourage the child to void just before going to bed
• Involve the child in caring for the wet sheets and changing the bed to assist the child to take ownership of the problems
• Give child rewards as appropriate

Nephrotic Syndrome in Children

Nephrotic syndrome is a kidney disorder that characterized by massive proteinuria, hypoalbuminemia, and edema. The primary treatments are to reduce the excretion of urinary and maintain protein-free urine.

Signs and Symptoms:

• Child body weight is increased
• Periorbital and facial edema (mostly in the morning)
• Urine output is decreased
• Urine is dark and frothy
• Leg, ankle, labial or scrotal edema
• Abdominal swelling
• Blood pressure is normal or slightly decreased

Nursing Interventions:

• Monitor vital signs, intake and output, and daily weights
• Monitor urine for specific gravity and albumin
• Monitor for edema
• A regular diet without added salt is prescribed during remission
• A sodium restriction diet is prescribed during massive edema
• Administer corticosteroid and immunosuppressant as prescribed
• Administer diuretics as prescribed

Glomerulonephritis in Children

Glomerulonephritis is an inflammation of the internal kidney structures (glomeruli). Glomeruli itself has functions to help filter waste and fluids from the blood. This disease leads to proliferative and inflammatory changes within glomerular structure, as well as, destruction, inflammation and sclerosis of the glomeruli of both kidneys.

Inflammation in glumeruli due to an antigen-antibody reaction produced by an infection elsewhere in the body.

Casuse of glomerulonephritis:

• Autoimmune disease
• Immunological disease
• Streptococcal infection, group A beta-hemolytic
• History of pharyngitis or tonsillitis 2-3 week before the symptoms

Complication of Glomerulonephritis:

• Hypertensive encephalopathy
• Renal failure
• Heart failure
• Pulmonary edema

Signs and Symptoms:

• Periorbital and facial edema (more prominent in the morning)
• Decreased urinary output
• Cloudy, smoky, and brown-colored urine
• Anorexia
• Pallor, irritability and lethargy


• Headaches, abdominal or flank pain, dysuria
• Hypertension
• Proteinuria
• Azotemia
• Blood urea nitrogen and creatinine levels are increased
• Antistreptolysin O titer is increase

Nursing Intervention:

1. Monitor vital signs, weight, intake and output, and observe characteristic of urine
2. Limit activity and provide safety
3. In uncomplicated disease, a regular diet is permitted but sodium is restricted
4. For child with hypertension or edema, moderate sodium restriction is prescribed
5. During oliguria period, foods high in potassium are restricted
6. If child has severe azotemia, protein restricted is prescribed
7. Observe the complication of glumerulonephritis
8. Administer diuretics, antihypertensives, and antibiotics as prescribed
9. Initiate seizure precaution and administer anticonvulsant as prescribed
10. Instruct parent to report signs of bloody urine, headache, or edema
11. Inform parent that child needs to obtain treatment for infection