Nocturnal Enuresis (Bed Wetting)

Bed Wetting

• Nocturnal enuresis is also referred to as daytime or diurnal enuresis
• Full bladder control is typically gained between ages 4-6
• Bed wetting is not considered normal after age 5
• 2 times per week for 3 months is the threshold for diagnosis
• Primary bedwetting means the child has never been free from bedwetting
• Secondary bedwetting means the child began bedwetting again after demonstrating previous bladder control
• Family history, being male, bladder disorders, emotional factors, and constipation can increase the risk of bedwetting

Medications for Bed Wetting

• Medications are usually titrated
• Desmopressin Acetate (DDMP) is an antidiuretic hormone
• DDMP reduces urine volume; the goal is at least 5 dry nights per week
• Administer DDMP at bedtime and avoid fluids in the evening
• Nasal spray should be kept refrigerated
• Imipramine hydrochloride is a tricyclic antidepressant which inhibits urination
• Administer Imipramine hydrochloride 1 hour before bedtime with food
• Avoid sun exposure and OTC medications when administering Imipramine hydrochloride
• Monitor for suicidality and only administer for 6-8 weeks
• Oxybutynin chloride is an anticholinergic that reduces bladder contraction
• Wean patients off Oxybutynin chloride and monitor effectiveness

Discharge Teaching for UTIs

• Teach females to wipe front to back to prevent UTIs
• "Double voiding” helps ensure adequate emptying of the bladder
• Wearing cotton, nonrestrictive underwear and not staying in wet clothes is important
• Demonstrate how to retract and clean foreskin if uncircumcised
• Avoid bubble baths, whirlpools, and hot tubs
• Adequate fluid intake and voiding after sex are important
• Completing the total antibiotic regimen when prescribed is key

Glomerulonephritis

• Glomerulonephritis is most common in children aged 5-8 years
• Glomerulonephritis can be acute or chronic
• Glomerulonephritis is the inflammation of the glomeruli, or bundles of tiny vessels, inside the kidneys
• Glomeruli damage causes ineffective filtering of waste products and excess urine water from the bloodstream
• This can result in tea-colored urine, increased blood pressure, periorbital edema, and sudden onset
• Glomerulonephritis is a post-infectious disorder associated with an overreacting immune system
• Pneumococcal, streptococcal, and viral infections can cause glomerulonephritis

Nephrotic Syndrome

• Minimal change nephrotic syndrome causes kidneys to leak protein into the urine
• Leaking protein causes swelling of body tissues and greater chances of infection
• Diagnosis occurs when kidneys appear normal (or nearly normal) under a microscope
• Administering 25% albumin increases plasma and decreases edema

Hemolytic Uremic Syndrome (HUS)

• HUS occurs when damaged red blood cells block the kidney's filtering system
• Kidney failure can occur due to the blockages
• HUS develops after infection with a toxic strain of E. Coli bacteria
• E. Coli bacteria found in contaminated foods like meats and dairy/undercooked meat
• Hemorrhagic enterocolitis begins 2–12 days after initial infection
• E. Coli outbreaks can occur in fast food locations with undercooked meats, daycare centers, and water parks, common in the summer and spring
• The unknown etiology presents as a triad of symptoms
• Microangiopathic hemolytic anemia, thrombocytopenia, and AKI (acute kidney injury)
• Children aged 6 months-3 years are at risk of HUS
• Ingestion of shiga toxin that creates E. Coli, genetic disorders, and toxins in blood stream killing red blood cells can cause HUS

Hydrocephalus

• Hydrocephalus, can be congenital or acquired, causes accumulation of fluid in the ventricles
• Hydrocephalus is caused by the imbalance between the production and absorption of cerebral spinal fluid
• Infant manifestations include a shrill, high-pitched cry and increased head circumference
• Other infant manifestations include a full or tight fontanel, lethargy, seizures, sun set eyes, irritability, and a sluggish/unresponsive demeanor
• Bradycardia, hypertension, apnea, and opisthotonos posturing are also infant manifestations
• Child manifestations include early morning headache relieved by vomiting, swelling of the optic disc (papilledema, blurred/double vision, and urinary incontinence
• Increased vomiting that becomes projectile, irritability, trouble walking/uncoordinated movement, hypertension, and bradycardia can occur
• In children, as ICP worsens, tachycardia can develop

Hypospadias and Epispadias

• Hypospadias means the urethral opening is on the ventral (lower) aspect of the penis, near the scrotum
• The urethral opening in epispadias is on the dorsal (top) aspect of the penis

Nephrotic Syndrome Complications

• Complications include sepsis and infection, circulation insufficiency, and thromboembolism

Hirschsprung Disease

• Hirschsprung disease is diagnosed when parasympathetic ganglion cells in the wall of the large intestine (colon) do not develop before birth
• Newborns may experience a delayed or absent meconium stool in the neonatal period of 24-48 hours
• This sign is a cardinal sign, and newborns may also experience vomiting of bile, refusal to eat, and abdominal distension
• Infant manifestations include failure to thrive, constipation, vomiting, and episodes of vomiting/diarrhea
• Child manifestations include foul-smelling ribbon-like or pellet-like stool
• Being undernourished/anemic-like in appearance, abdominal distension, visible peristalsis, palpable fecal mass, and constipation are other child symptoms

Pyloric Stenosis

• Hypertrophic Pyloric Stenosis usually presents in children aged 3 weeks-3 months
• Non-bilious vomiting and an olive-shaped mass in the RUQ of the abdomen occur
• A peristaltic wave that moves from left to right while lying supine can be observed
• Failure to gain weight and signs of dehydration, and hunger are other manifestations
• Diagnosis done through ultrasound
• Surgical procedure: pyloromyotomy

Necrotizing Enterocolitis (NEC)

• NEC is an infection most commonly affecting the lower portion of the small intestine (ileum)
• Stop ALL feeds and administer IV or TPN
• Use NG to decompress the abdomen and administer IV antibiotics
• Measure abdominal girth above the umbilicus every 4-8 hours
• Abdominal X-rays are done every 4-6 hours; monitor vital signs and facilitate bonding
• Possible surgery to remove necrotized portion of bowel or a temporary colostomy

Burns

• Burns care priority is ABC's
• Provide oxygen and fluids quickly to prevent shock
• For minor burns, soak the burn in tepid water, and do NOT apply greasy lotions, ice, or butter
• With partial-thickness burns, do NOT break blisters
• Major burn patients need airway maintenance and ventilation
• Provide 100% oxygen, monitor vital signs, and administer IV fluids
• Fluid replacement with Lactated Ringer's within the first 24 hours
• Maintain urine output at 0.5 mL/kg/hr to 1 mL/kg/hr if