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Running Head: Case Study#2 RHenson

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NURS 6045 Practicum II

Case Study #2

Robin Henson

March 8, 2010

Texas Woman’s University


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Subjective

Case Selection

Choice of Patient. I chose this patient because I wanted to review the current

evidence based treatments for primary nocturnal enuresis.

Type/# of encounters. This patient was scheduled as a sick visit. It was his

first time to visit the clinic. The DNP student had one encounter with him.

Site. Cook Children’s Physician Network, Mansfield, Texas. This clinic is an

outpatient pediatric clinic that services infants, children, and adolescents for acute and

health maintenance examinations.

Insurance. This patient is enrolled in the Traditional Medicaid insurance

program.

Patient Profile

Identifying factors. K.H. is a nine-year-old Caucasian male who presents to the

clinic today for bedwetting.

Date of birth. November 13, 2000.

Date of first encounter. January 23, 2010.

Accompanied by. K.H. is accompanied by his biologic mother, S.H.

Background Information

Chief complaint (CC). S.H. states, “K.H. has never been able to sleep through

the night without wetting his bed.” K.H. states, “I try not to wake up wet, but it just keeps

happening.”

History of presenting illness (HPI). K.H. was daytime potty trained since he

was three year old. He has been unable to achieve dry nights and wears a disposable


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Pull-up© each night. When he chooses to sleep in his underwear, his bed is saturated

with urine when he awakens in the morning. He is a Cub Scout and wants to go to an

overnight camping trip this spring with his den. K.H. is afraid to go on this trip because

he does not want to wear a Pull-up© in front of his friends. His mother reports that until

this camping trip K.H. did not seem bothered by his wet nights. He has never been

treated for this condition. S.H. admits that she is “frustrated” with K.H.s bedwetting.

She notes that K.H.s three year old sister has been potty trained for a “few months and

she does not wet the bed.” S.H. reports that her husband is not concerned about the

bedwetting and feels that K.H. “will eventually outgrow it, like my brother did.”

Past Medical History (PMI). K.H. denies loss or change in appetite, recent

weight change, stress, or fatigue. K.H. has been a patient of the same pediatrician

since his birth. His current pediatrician is retiring, so his mother has chosen Dr. M to be

his new primary care provider (PCP). Past records from his previous healthcare

provider have not been received and could not be reviewed at this visit. His mother

reports that K.H. is in good health. “He had roseola when he was two years old and he

had a few colds, sore throats, and ear infections” over the years, however, he has not

had any illness this past year. He currently is being treated for allergic rhinitis. He has

not had any surgeries and denies any chronic conditions.

Health Maintenance. His mother reports that he has had all of his required

health maintenance examinations with his past PCP. His last reported exam was

around his birthday last November (2009).

Immunizations. He has no reported adverse reactions from any immunizations.

His mother brought a copy of K.H.s immunizations:


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Immunization Dates Hepatitis B 01/14/01 03/22/01 08/05/01 Diphtheria/Tetanus Pertussis

01/14/01 03/22/01 05/19/01 02/20/02 11/12/04

Haemophilus Influenza Type B

01/14/01 03/22/01 05/19/01 02/20/02

Inactivated Poliovirus

01/14/01 03/22/01 05/19/01 11/12/04

Measles, Mumps, Rubella

11/15/01 11/12/04

Varicella 11/15/01 11/12/04

Pneumococcal Conjugate

01/14/01 03/22/01 05/19/01 02/20/02

Hepatitis A 11/17/02 12/03/03 Influenza seasonal TIV

11/12/04 12/14/04 12/15/06 11/30/08 11/23/09

Illnesses. S.H. reports that K.H. has had a few minor colds, upper respiratory

infections (URI), the “stomach bug”, and a few ear infections. He has only taken a

“pink” antibiotic for ear infections. His last reported illness was October 2009 when he

had a 24-hour episode of vomiting and diarrhea.

Labs. S.H. cannot recall any lab work performed on her son. She notes that the

previous PCP was “very conservative” and “did not believe in running any extra or

unnecessary tests.”

Procedures. The only procedure that K.H. has had is a circumcision shortly

after his birth. S.H. reports that the previous PCP performed the circumcision on

November 14, 2000 in the newborn nursery. There were no complications or sequela

associated with this procedure.


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Allergies. K.H. does not report any food or medication allergies. His mother

reports that he has seasonal allergies and is well managed with his over-the-counter

medication.

Past Medications taken.

1. Children’s Junior Strength Acetaminophen 160 mg. chewable tablets, 2

tablets every 4 hours as needed for fever or discomfort.

2. Children’s Junior Strength Ibuprofen 100 mg. tablets, 1-2 tablets every

six hours as needed for fever or discomfort.

3. Amoxicillin suspension, either 125/5 or 250/5, assumed to be the “pink”

medication noted above (note: K.H. has not taken this medication this

past year).

Medications currently taken.

1. Loratidine OTC 10 mg. p.o. daily each morning.

2. Flintstone© multi-vitamin with iron 1 tablet p.o. daily each morning.

Family History (FH)

K.H. lives with his biologic parents and three year old sister. They have lived in

the same town all of his life. His father works as a sales manager for a large company

in Dallas and his mother does not currently work outside of the home. There are no

smokers or handguns in the home. K.H. and his sister “get along well.” Both parents

are college graduates and have been “happily married for 12 years.” All immediate

family members are in good health. K.H.s paternal uncle (F1,4) and male cousin (F2,3)

report a history of bedwetting. He has two other cousins (F2,5 and F2,6) who are not

yet potty trained (see Appendix). Multiple family members suffer from seasonal


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allergies and one member has hypertension. There are no reported genetic anomalies,

chronic, or mental illnesses in any extended family members.

Social History (SH)

K.H. is in the third grade at a local elementary school. He states that he “makes

straight A’s” and that he “has a ton of friends” at school. He denies getting in trouble at

school and also denies that anyone bullies him. He is active in a local Cub Scout group

and church Sunday school class. He plays outside with neighborhood children after

school and on the weekends. He frequently visits the grocery store and shopping malls

with his parents. He only spends the night at his grandparents’ house “because they

know I wet the bed, like my uncle, so they have a waterproof sheet for me to sleep on.”

Growth and Development

Physical. K.H. is able to climb, run, crawl, and jump without any difficulty. He is

able to swing a baseball bat and hit the ball 50% of the time. He is able to manipulate

small objects, such as marbles, Legos©, and can write with a pen or a pencil. He does

not tire easily and his mother states that he has “boundless energy.” He falls asleep

without difficulty and sleeps 10 hours every night. He has lost 5 baby teeth. His mother

reports that he is gaining weight and growing taller, according to the findings from his

last physical examination in November 2009.

Cognitive. K.H. enjoys all of his classes in school and denies difficulty with

reading or managing class assignments. He likes to play board games with his family

and is concerned that everyone follows the rules. He collects baseball cards and

attempts to memorize the stats for each of his favorite players. He enjoys playing video

games, watching family-oriented DVD’s, and reading books from his school library.


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Emotional. K.H. is basically happy and easygoing. When he gets frustrated he

cries on occasion. He is sensitive to animals and protective of his younger sister. He

does not have reported anger or temper outbursts at home, school, or church. He

separates easily from his parents to go to school, church, and to visit family and friends.

Moral. K.H. likes to follow the rules and becomes upset when others do not. He

is learning to accept responsibility when he does something wrong. His parents punish

him by removing his video games removed for a specific period of time.

Review of Systems (ROS)

General. He reports eating a wide variety of healthy foods. He likes meats,

pasta, dairy products, and fruits, but does not like to eat vegetables. He does not

consume caffeine or refined sugar. K.H. drinks “a lot of water and milk” from the time

he arrives home from school until bedtime.

Skin/Hair/Nails. Denies rashes, pruritis, or changes in temperature or

pigmentation. There is no reported hair loss or change in color or texture. Denies nits

or dandruff. Nails are trimmed weekly and there is no reported clubbing or discoloration

reported. No reported incidence of redness, swelling, or drainage around cuticles.

Denies nail biting.

Head/Neck. Denies plaques, scaly patches, or rashes on scalp. No masses,

asymmetry, or lacerations. Denies problems with headaches, torticollis, or enlarged

lymph nodes.

Eyes. Eyes itch and water bilaterally during the spring and the fall seasons. No

excessive tearing, drainage, redness, or blurred vision. Denies trauma or pain. Does

not wear glasses and has not visited an ophthalmologist.


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Ears. Denies chronic middle or outer ear infections. No drainage, redness, or

trauma of outer ears. Denies any problems with hearing. States he had a “hearing test

at school and passed it”.

Nose. Occasional “runny nose” during spring and fall that is usually well

managed with loratidine. No bloody or colored nasal drainage. Sometimes nose itches,

but does not interfere with activities of daily living (ADL). Sense of smell is present and

he detects food, perfume, and foul odors. Denies snoring or sleep apnea.

Throat/Mouth. Able to chew food and swallow without difficulty or choking. No

drooling, coughing, throat clearing, cheilosis, or halitosis. Denies dental caries and

visits the dentist every six months. No bleeding gums, loose teeth, or mechanical

appliances in mouth.

Neck/Lymph. Full range of motion is present. Denies enlarged lymph nodes,

masses, cysts, webbing, extra skin folds, acanthus nigricans, or venous distention.

Cardiovascular. Denies history of murmurs or any cardiac anomalies. No

cyanotic episodes, mottling, pallor, or edema.

Pulmonary. Denies history of pneumonia, asthma, or chronic cough. No

shortness of breath or dyspnea with physical exertion.

Gastrointestinal. Reports periodic “stomach aches” that are relieved upon

passing stool. K.H. reports that he does not like to use the restroom at his elementary

school because “it smells funny.” He cannot remember how often he has a bowel

movement. He reports only having bowel movements in his home bathroom. S.H.

“assumes” that K.H. “goes everyday, but I don’t ask him about it.” He reports firm,


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brown, large volume stools that sometimes require straining. He denies having

“accidents” or stool stains in his underwear.

Genitourinary. Denies history of urinary tract infections. Denies dysuria, pyuria,

or hematuria. Does not wet his underwear during the daytime and does not have urine

leakage on his daytime underwear. He urinates upon awakening each morning.

Sometimes he voids at school, but he usually “waits to go” until he arrives home. He

does not strain to urinate. He was circumcised within hours of his birth. Denies

redness, swelling, ulcerations, rashes or skin discolorations on glans, shaft, or scrotal

area. Urinates prior to going to bed, however, he wakes up every morning with a very

saturated Pull-up©. When patient does not wear a Pull-up©, he awakens with urine

saturated clothing and bed sheets.

Endocrine. Denies pubic or axillary hair. No diaphoresis or alteration in skin

temperature. No excessive daytime thirst, hunger, or weight loss. He reports that he

does not drink a lot at school and he drinks when he arrives home. His mother reports

that he drinks “a lot of water and milk from the time he gets home from school until the

time he goes to bed.”

Musculoskeletal. Denies muscle weakness or alteration in gait when walking or

running. Moves all extremities bilaterally. Denies history of scoliosis or erythematous

or edematous joints. No history of hip deformity at birth.

Hematologic. Denies bruising, petecchia, or pallor.

Neurologic. Denies head trauma, falls, sports or motor vehicle accidents.

Denies past meningitis.


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Psychologic/Emotional. Denies recent family changes of stressful life events.

Denies anxiety, worrying, anger outbursts, trouble concentrating or falling asleep. States

he is very “happy” and is usually “in a good mood.”

Pathophysiology Overview

Definition. There is an inconsistent use of enuresis terminology found in the

current literature. In an effort to clarify and provide uniformity, the International

Children's Continence Society (ICCS) established guidelines to assure the consistent

use of lower urinary tract terminology by health care providers. The ICCS categorized

enuresis as monosymptomatic or nonmonsymptomatic. Patients that wet the bed at

night but do not demonstrate daytime voiding symptoms such as daytime incontinence,

frequency, or urgency are categorized as monosymptomatic. Enuresis is also

categorized into primary and secondary types. Primary enuresis implies that the child

has never achieved periods of dryness whereas secondary enuresis occurs after six

months of dryness (Robson, 2009).

Prevalence. Nocturnal enuresis (NE), also known as bedwetting, is a common

disorder that affects approximately 5-7 million children in the United States and is twice

as common in males than in females (Neveus & Stenberg, 2010). In the pediatric

population, bedwetting occurs in 15-25% of five year olds and decreases to 8% by

puberty. If untreated, 5% will continue into adulthood. Dunlop (2005) noted that 68% of

patients, 3-14 years of age, reported their primary care provider never addressed

bedwetting during a routine visit.

Multifactoral factors. Bedwetting was once considered a psychological

problem, however, current research determined multiple factors that contributed to this


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condition. Multifactoral variables included genetics, increased nighttime urine

production, arousal disorder, decreased bladder capacity, and constipation (Rogers,

2009).

Genetics. NE is an autosomal dominant condition with a high penetrance.

There is an increased genetic propensity in family members with gene locations

identified on chromosome 8, 12, 13, and 22. NE is present 44% of the time when there

is one parent with a reported history. When both parents report a history of bedwetting,

the incidence increased to 77%. In the case of twins, both children are usually affected

(Ramakrishnan, 2008).

Increased nighttime urine production. Some children experience an increase

in their nighttime production of urine. During sleep their body does not produce enough

vasopressin. Vasopressin reduces the amount of urine produced by the kidneys and

allows the reabsorption of water back into the bloodstream. A decrease in vasopressin

secretion increases the amount of urine that the kidney excrete, causing the child to wet

the bed (Caldwell, Edgar, Jones, Hodson & Craig, 2009).

Arousal disorder. A third contributing factor in NE is arousal disorder. The child

cannot wake from sleep in response to a full bladder (Caldwell et al., 2009).

Decreased bladder capacity. A decreased bladder capacity also contributes to

NE. The body maintains homeostasis by balancing the amount of urine produced and

the ability for the bladder to hold urine. In children with a decreased bladder capacity,

the volume of urine triggers an overactive bladder, producing an inability to store urine

throughout the night. Children with a decreased bladder capacity often dribble urine in

their underwear during the day (Rogers, 2009).


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Constipation. An under-recognized contributor to NE is constipation. A large

volume of stool exerts rectal pressure and causes a decreased bladder capacity

(Caldwell et al., 2009).

Other concerns. Underlying physical conditions such as diabetes insipidus,

diabetes mellitus, and chronic renal disease can precipitate NE and must be

investigated. Patients with developmental delays and central nervous system

anomalies exhibit primary enuresis. In addition, diuretics, lithium, and sedating

medications, such as antihistamines can produce temporary NE symptoms (Fitzgerald,

2009; Masharani, 2009).

Objective Data

Age of patient

K.H. is nine years and two months at today’s visit.

Vital signs

Weight: 62 pounds/28 kilograms (50th percentile)

Height: 54 ¼” (75th percentile)

Temperature: 98.1o F/ 36.7oC

Pulse: 84 beats per minute (apical)

Resp: 22 per minute

BP: 98/62

Physical Examination

General. Nine year-old Caucasian male who is well nourished. Appearance is

consistent with stated age. He is dressed appropriately for the weather and is well

groomed.


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Skin/Hair/Nails. Skin is pink, warm and dry. There are no rashes, scars,

abrasions, bruising, cyanosis, yellowing, hypo or hyperpigmented areas noted. Hair is

brown, fine and evenly distributed on scalp. Scalp is free of dandruff, lesions, or nits.

Nails are clean and well groomed. There is no clubbing noted and brisk capillary refill

<2 seconds is noted on all fingers and toes.

Head. Normocephalic and without any asymmetries. No sinus tenderness or

facial edema noted.

Eyes. Round and symmetric bilaterally. No ptosis or epicanthal folds. Pupils

are equal, round, reactive to light and accommodation. Extra ocular movements are

intact in all six fields of gaze. There is no nystagmus present. Irises are round and

clear. Sclera is white and conjunctiva is pink and glossy without drainage noted

bilaterally. Visual acuity screening deferred.

Ears. Outer ears are clean and normal alignment and there is no discharge,

excoriations, skin tags, ear pitting or sinuses noted. Tympanic membranes are pearly,

translucent, with light and landmarks identifiable bilaterally. Hearing screening deferred.

Nose. Symmetric and in center of face. Nares are patent bilaterally.

Turbonates are pink and free of polyps, discharge, blood, or odor. Horizontal skin

crease noted over bridge of nose.

Throat/Mouth. Lips are intact, pink, and firm. Oral membranes are pink, firm,

smooth, and moist. Soft and hard palate are intact. There are five adult teeth and 19

deciduous teeth present without evidence of black spots or decay. Tonsils are pink and

2+ bilaterally without crypts or exudate. Uvula is midline and moves upward with

gagging. Voice is smooth and without hoarseness or nasal quality.


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Neck/Lymph. Holds head at midline and has full range of motion. Trachea

midline. Neck is supple without masses or lympadenopathy.

Cardiovascular. No mottling, cyanosis, or edema. S1 and S2 auscultated

without murmurs, splits, or rubs and heart rate is synchronous with radial pulse.

Peripheral pulses are strong and equal bilaterally.

Pulmonary. Bilateral breath sounds are auscultated in all lung fields. No

retractions and thorax moves symmetrically. No cough present. Percussion is deferred.

Gastrointestinal. Abdomen pink without veins, scars, ecchymosis, or striae.

Slightly prominent when standing but appears flat when supine. No visible peristaltic

waves and bowel sounds auscultated in all four quadrants. Dullness noted along right

costal margin and lower left quadrant. Denies pain in upper quadrants, costovertebral

angle, or right lower quadrant with palpation. Kidneys and spleen not palpated. Bladder

is not distended. Firm, sausage-shaped mass (approximately 2 inches) palpated in the

lower left quadrant. Anus free of redness, rash, fissures, hemorrhoids, skin tags, or

polyps. No rectal prolapse. Quick anal reflex (wink) present.

Genitourinary. Circumcised penis without masses, lesions, or integument rash

noted. Urinary meatus is free of redness, discharge, or lesions. It is slightly ventral at

the tip and appears slitlike. Testes present bilaterally, freely movable, smooth, and

equal in size (approximately 1.5 cm.). No retractile testis noted. The left testis is

slightly lower than right. No inguinal hernias or bulging palpated. Pubic hair, penis, and

scrotum are Tanner I stage. No urine or stool stain present on underwear.

Endocrine. Skin is warm and without diaphoresis. Patient is calm and

cooperative.


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Musculoskeletal. Spine intact without curvature, dimple or hair tufts. Has

adequate range of motion of all extremities without flaccidity or spasticity. Exhibits

bilateral muscle strength and symmetry.

Hematologic. Mucous membranes pink. No ecchymosis noted.

Neurologic. All cranial nerves (I-XII) intact. Deep tendon reflexes 2+ and

symmetric. Patient has steady gait without ataxia. Hops, skips, and walks heel-to-toe.

Psychologic/Emotional. Cooperative, friendly, awake, and alert. Oriented to

person, place, and time. Speech is clear and appropriate. Answers questions to the

best of his ability and refers to biologic mother when he is unsure. Sits on exam table

independent of mother.

Laboratory Review

A first morning urinalysis and urine culture was ordered and obtained two days

prior to this visit (01/21/10).

Urinalysis (UA).

Appearance: Clear Ketones: negative Color: Light amber Bilirubin: negative Odor: Aromatic Urobilinogen: negative pH: 6.1 (4.6-8.0) Casts: none Protein: 1 mg/dL (0-8 mg/dL) Crystals: none Specific gravity: 1.021 (1.003-1.030) Glucose: negative Leukocyte esterase: negative WBCs: 0 (0-4) Nitrites: negative WCB casts: none RBCs: 0 (< 2) RBC casts: none Microalbumin: negative

Urine culture (UC) and sensitivity.

No growth after 48 hours.


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Discussion of Findings

At this first visit, the DNP student focused on a detailed history and physical

examination (PE). A UA and UC were obtained prior to this first visit and the results

were on the chart. Children with primary monosymptomatic nocturnal enuresis require

an enuresis focused history, physical examination, and urinalysis before the initiation of

treatment. Imaging and urodynamic studies are rarely needed (Ramakrishnan, 2008).

History. K.H. has demonstrated consistent nighttime bed wetting without any

periods of continence. His Pull-up © or his underwear and bedding are saturated every

morning. He does not demonstrate daytime incontinence or other genitourinary

symptoms. He consumes an increased amount of liquids during the afternoon and early

evening hours. Neither he nor his mother can recall his stool habits, and he avoids

using the school restroom. He does, however, report the passage of large stools that

provide relieve for his periodic stomachaches. He does not have any history of

neurologic or developmental delays. His family history reveals that his paternal uncle

and male cousin are both reported bed wetters. His medical history is unremarkable,

with the exception of seasonal allergies. He denies sleep apnea. K.H. has not

attempted any past treatments for this condition. There are no red flags elicited in his

history.

The history should include the following components: 1) the onset, duration, and

severity of enuresis, 2) presence of daytime wetting, constipation, genitourinary

symptoms, and neurologic symptoms 3) family history of enuresis, 4) medical and

psychosocial history, and 5) details of previous treatments. Both the child and the

parents should be included in the history taking (Ramakrishnan, 2008). Red flags


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include dysuria, genital or rectal pain or discharge, straining to urinate, and combined

diurnal and nocturnal enuresis.

PE. K.H.s vital signs were within normal limits for his age. His HEENT exam

was unremarkable for adenotonsillar hypertrophy, however, his nasal crease confirms

an allergic rhinitis symptom, the allergic salute. Genitalia and anal exam did not reveal

external structural abnormalities, erythema, or discharge. His neurologic exam was

also within normal limits. His abdominal exam revealed residual stool palpated in the

left lower descending colon. He did not, however, have stool soiling in his underwear.

There were no visible signs suggesting sexual abuse.

The physical examination (PE) should include an evaluation of the ears, nose,

and throat. The presence of adenotonsillar hypertrophy/sleep apnea is suspected to

contribute to PNE. The abdomen, genitalia, rectum, and spine, should be examined,

with special attention to the neurologic exam. The abdomen should be examined for

enlarged bladder or kidneys and fecal masses that would indicate constipation and

encopresis. The genitals should be inspected for hypospadias or epispadias, or meatal

stenosis. The rectal examination should evaluate perianal sensation and rectal

sphincter tone. The focused neurologic exam includes gait, muscle tone, strength, and

perianal sensation. Red flags include any abnormalities in the previous findings as well

as signs of sexual abuse (Ramakrishnan, 2008).

Labs. Initially, UA and UC should be collected. A UA and UC will suggest the

presence of a urinary tract infection (UTI), renal disease, diabetes mellitus, and diabetes

insipidus. It is preferable to obtain the first urine of the day to detect urine concentration

and rule out occult renal disease. In patients with primary NE, urinalysis and a urine


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culture are appropriate for initial assessment (Ramakrishnan, 2008). The first morning

urine specimen obtained by K.H. did not reveal the presence of white blood cells,

nitrites, or elevated pH, all of which are suggestive of UTI. The UC confirms these

findings. The urine did not contain ketones, glucose, or an acetone odor that would

suggest diabetes mellitus. With renal disease the patient may demonstrate a low

specific gravity, proteinuria, microalbumin, casts, crystals, and red blood cells in the

urine (Fitzgerald, 2009). These findings were not present in K.H.s urine. Since the

specific gravity was within normal limits and there was no proteinuria or glycosuria,

further evaluation of osmolality (diabetes insipidus) is not warranted (Omokaro, 2009;

Pagana & Pagana, 2006). K.H.s UA and UC were within normal limits. At this point, no

further testing should be conducted.

Medications. K.H. is currently taking loratidine for seasonal allergies and a

chewable multivitamin as a dietary supplement. Morning administration of loratidine

might contribute to an increase in afternoon and early evening thirst. Classified as an

antihistamine, loratidine provides symptomatic relief from nasal and non-nasal

symptoms of allergic rhinitis. Dry mouth and abdominal upset are common side effects.

The half-life of loratidine is 8.4 hours and the time to peak concentration occurs in 1-2

hours. Ingestion with food increases bioavailability by 40% (Vallerand & Deglin, 2009).

The role of a multivitamin ensures the proper growth of infants and children (McEvoy,

2009).

Growth and Development. K.H. demonstrates normal physical, cognitive,

emotional, and moral development for his age. Feigelman (2007) notes that growth

during middle childhood occurs in spurts, with the average weight gain approximately 7


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pounds and the average height increasing by 2.5 inches per year. The loss of

deciduous teeth and the eruption of adult teeth occur during this stage. By age the age

of 10, most children understand fairness and reciprocity. School success, involvement

with family and peers, and mood stability are hallmarks of healthy emotional

development during middle childhood.

Family. Although NE affects the child, the family is also impacted. Dunlop

(2005) noted that as the child ages, parents became less tolerant of bedtime wetting.

The author reported 33% of parents punished their bedwetting children, which

exacerbated an already stressful situation. Families cited the burdens of increased

laundry, determining who should change the sheets, and disparate views between

parents about the child’s ability to control bedwetting as sources of frustration. In

addition, bedwetting is an increased financial burden. An estimated $1000 is spent a

year for disposable underwear, waterproof sheets, and laundry expenses (Walle &

Laecke, 2008).

Assessment/Impression

Presenting Problem

The presenting problem is persistent night bedwetting.

Acute Diagnosis

564.00 Constipation (without encopresis). Constipation accompanies

approximately 75 percent of children with primary nocturnal enuresis (Ramakrishnan,

2008). Constipation contributes to PMNE by producing added pressure on the bladder,

causing spasms and an increased urge to void despite a small volume of urine (Wyllie,

2007). The patient reports hard, large stools that require straining. The patient and his


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mother deny stool incontinence or leakage. Stool is not present on his underwear at

this exam. The presence of palpated stool and the unreliable bowel history of the patient

confirms this diagnosis.

Chronic Diagnosis

788.36 Primary monosymptomatic nocturnal enuresis (PMNE). PMNE is

diagnosed in children five years of age and older who are free of UTI or daytime

symptoms and have never established nighttime urinary continence for more than six

months (Neveus & Stenberg, 2010). K.H. meets the age criteria and has an absence of

dysuria or daytime enuresis and frequency. He has never had dry nights and has family

members who report nocturnal enuresis. Based on his family history, ROS, and PE,

this diagnosis will be retained.

477.9 Allergic rhinitis (intermittent). The diagnosis of allergic rhinitis is based

on recurrent symptoms of sneezing, rhinorrhea, nasal itching, and congestion that occur

in the absence of an upper respiratory infection or structural abnormalities. Signs

exhibited on the PE include the allergic gape (mouth breathing), allergic shiners, and

frequently, the nasal crease (Milgrom & Leung, 2007). A previous healthcare provider

originally made K.H.s diagnosis of allergic rhinitis. The nasal crease noted on exam

confirms this diagnosis today. The use of daily loratidine relieves his allergic symptoms

and he presents symptom-free at today’s visit. This diagnosis will be retained.

Differential Diagnosis

599.0 Urinary tract infection (UTI). UTI has a clinical presentation of dysuria,

secondary enuresis (diurnal and nocturnal), abdominal pain, and in some cases, fever.

It is more common in females than males. UTIs usually occur in males during the first


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year of life and in uncircumcised patients. Predominant bacterial UTIs in males

originate from Staphylococcus saprophyticus and enterococcus. If a child is

asymptomatic and the UA result is normal, it is unlikely that there is a UTI. A final

culture of <100,000 colonies of a single pathogen from a voided midstream sample of

an asymptomatic child is considered normal (Elder, 2007). Results from K.H.s UA and

UC do not indicate a UTI. This diagnosis can be excluded.

250.0 Diabetes mellitus (DM). Type 1 DM has a clinical presentation of

polyuria, polydipsia, and weight loss. Patients with this condition have a deficiency of

insulin secretion or a combination of insulin resistance with an inadequate

compensatory insulin secretion. Increased urination, resulting from osmotic diuresis

secondary to hyperglycemia, can produce diurnal and nocturnal enuresis. Increased

thirst results from the hyperosmolar state and weight loss results despite a normal or

increased appetite. Glucosuria and ketonuria are initial diagnostic screening measures

(Masharani, 2009). K.H. does not have weight loss, increased appetite, or urine

abnormalities. This diagnosis can be excluded.

253.5 Diabetes insipidus (DI). DI has a clinical presentation of polyuria and

polydipsia. Patients with this condition have a vasopressin deficiency or vasopressin

insensitivity within the kidneys that is precipitated by trauma, genetic mutations, and

malformations of the hypothalamus or pituitary (Breault & Majzoub, 2007). Patients with

suspected DI have an increase in thirst, especially cravings for ice water, and consume

2-20 liters of fluid daily. Their urine specific gravity is low (<1.006). These patients

exhibit secondary diurnal and nocturnal enuresis due to the excretion of large quantities

of urine (Fitzgerald, 2009). K.H. does not have any history of trauma, genetic


22

mutations, or other signs and symptoms suggestive of hypothalamus or pituitary

insufficiency. K.H. only exhibits thirst in the afternoons and early evenings. He does

not have diurnal enuresis and does not meet the criteria for secondary nocturnal

enuresis. This diagnosis can be excluded.

Psychosocial Issues

Patient stress/anxiety. A study conducted on nine year olds with NE ranked

bedwetting as the third most distressing life event after divorce and parental fighting.

The authors concluded that even at this young age these children were able to

recognize that bedwetting was a troublesome event to deal with and that it contained

potential and difficult social ramifications (Butler & Heron, 2007). Enuresis that occurred

as infrequently as once a month correlated with a reduced self-esteem. Involving the

patient in an individualized treatment plan positively impacts self-esteem (Robson,

2009). Due to his current stage of development and the opportunity to attend a Cub

Scout camping trip, K.H. was beginning to realize the social implications of his PMNE.

Open lines of communication between the DNP, the patient, and the parents will provide

a trusting relationship and assures K.H. that he does not have to handle this situation

alone.

Impact on Family. S.H. expressed her frustrations with her son’s bedwetting.

She also noted that K.H. does not have dry nights however, his three-year old sister

does. Education for this family must include explaining the physical and emotional

components that accompany PMNE. PMNE affects the patient as well as the family.

Before starting any therapeutic plan, the parents must determine their attitudes toward

bedwetting. In some instances, additional education is necessary to insure that the


23

child is not blamed or punished for bedwetting. The family will also need to discuss how

episodes are currently handled and understand that a therapeutic plan might how future

episodes will be handled. Comparing the patient with other siblings or causing the

patient to feel shameful can be detrimental to the child’s self-esteem and should be

avoided (Breault & Majzoub, 2007; Robson, 2009).

Plan with Rationale

Conventional treatments for enuresis include behavioral, alarm, and

pharmacologic therapies. Determining the best therapy for treatment can be confusing

for the DNP because PMNE is not a homogenous condition. Many pediatric studies

have examined PMNE, however, population bias, heterogeneity of pathogenesis, poor

study design, and semantic differences in lower urinary tract terminology are

weaknesses in these studies that should be considered (Walle & Laecke, 2008).

Behavioral Therapy

Behavioral therapy involves consistent bladder and bowel training habits. It

encourages the child to drink fluids consistently throughout the day in order to avoid

consuming large amounts in the evening. The child should also be encouraged to

urinate at school, using the teacher as a partner to allow for bathroom breaks and

record the number of attempts each day. Children with PMNE and constipation need

regular time each day to attempt a bowel movement. Having the parents remind the

child after breakfast and dinner, and recording the time and amount of stool passed

helps alleviate bladder pressure. The recorded bowel and bladder information should be

brought to every office visit. Current literature does not support biofeedback, bladder

holding or stretching exercises for PMNE (Dommelen et al., 2009).


24

Alarm Therapy

Enuresis alarms condition children to awaken or contract their pelvic muscles at

the moment of wetting. Used alone or in conjunction with other therapies, its ultimate

success is dependent upon the tenacity of the patient and their family. These alarms

should be considered in older, motivated children because most children require 6-16

weeks of consistent treatment to achieve success. Factors that produced successful

outcomes included a cooperative family, no additional behavior problems, and frequent

bed-wetting (four or more wet nights per week) (Ramakrishnan, 2008). In a study by

Ozgur, Ozgur, Dogan and Orun (2009), relapse occurs in 67% of patients. Although its

role as a first-line treatment is disputed among researchers, it is an acceptable initial

nonpharmacological intervention for older children and adolescents.

Pharmocologic Therapy

Medications used in the treatment of PMNE include desmopressin,

anticholinergic agents, and tricyclic antidepressants. Desmopressin is a synthetic

analogue of vasopressin, the ADH hormone that prevents excessive water loss in the

urine. Desmopressin reduces urine output and increases urine osmolality, which results

in a decrease in NE. Doses of 0.1 mg to 0.2 mg produce antidiuretic effects up to eight

hours (Vallerand & Deglin, 2009). When compared with placebo, desmopressin reduced

NE 50% from baseline number of wet nights per week within 6 weeks (p<.05).

However, failure with desmopressin resulted from poor compliance with evening fluid

restriction and reduced bladder capacity (Ozden et al., 2008). A Cochrane review of

over 40 randomized clinical trials supported the role of desmopressin in reducing


25

bedwetting. Optimal outcomes occurred when desmopressin was used in conjunction

with alarm and behavior therapy (Glazener & Evans, 2005).

Other classifications of drugs, such as anticholinergics (oxybutynin and

tolterodine), improved bladder capacity and reduced detrusor activity. Side effects

included constipation and evidence for efficacy in PMNE has not been established.

Tricyclic antidepressants, including imipramine, improved PMNE outcomes. These

medications had unfavorable side effects such as mood changes, sleep disturbances,

and cardiovascular toxicity. The ICCS recommends using anticholinergics and tricyclic

antidepressant only when all other therapies, such as desmopressin, have failed

(Robson, 2009).

New drugs and new indications for current medications are on the horizon. A pilot

study of children with NE compared the use of ibuprofen, pseudoephedrine, and

placebo. Pseudoephedrine use did not affect NE, however, children who received

ibuprofen had 2.9 fewer wet nights compared with 1.4 nights with placebo (Gelotte,

Prior & Gu, 2009). A new drug, reboxetine, is pharmacologically similar to imipramine

but did not produce cardiovascular side effects. When combined with desmopressin,

children resistant to other therapies had dry nights in 27% of the cases (Neveus, 2006).

Further research is needed to determine the role of these agents in PMNE therapy.

Key Recommendations for Practice Evidence Based Treatment

1. Provide patient and family with all of the treatment options. The DNP

discussed the three treatment options. She explained that non-pharmacologic treatment

involved behavior interventions such as motivational therapy. Simple behavior

interventions included positive reinforcement for desired behaviors and encouraging the


26

child to take responsibility for the enuresis. She discussed that K.H. will need to drink

less water during the evening hours, limit his caffeine intake, use the restroom at

school, and spend time each day trying to have a bowel movement. She reminded his

mother that she (or dad) must observe K.H.s bowel movements daily. According to

Ramakrishnan, 2008, these methods were associated with significantly fewer wet

nights, higher resolution rates, and lower relapse rates when compared with control

groups. The DNP then explained that the use of bedwetting alarms. She discussed the

time and commitment that is involved with this type of treatment. She also discussed

that success occurred within the first few months. Enuresis alarms, when used in

conjunction with behavior and pharmacologic therapy produced increased rates of dry

nights and lower rates of relapse. Factors that produced successful outcomes included

a cooperative family and no additional behavior problems (Ramakrishnan). Finally, the

DNP discusses the use of medication. She explains the different drug classes, modes of

actions, side effects, and success rates. She explains that it is possible to combine

these different treatments if necessary. Pharmacologic therapies are not curative but

reduce the frequency of enuresis or temporarily resolve symptoms over time until

spontaneous resolution occurs. Desmopressin was the first-line medication , followed by

anticholinergic agents and tricyclic antidepressants. Of the therapies, only

desmopressin and imipramine have been approved by the United States Food and Drug

Administration for the treatment of enuresis in children (Ramakrishnan).

2. Involve patient and family in the choice of the treatment plan. K.H. and

his mother are provided ample time to ask questions and verbalize their thoughts and

concerns regarding each mode of therapy. Since the Cub Scout camping trip is in


27

approximately 10 weeks the patient and his mother decided that they will start with the

suggested behavioral treatments (bladder and bowel retraining, limited night time fluids)

and begin the use of alarm therapy. The patient will maintain a written record of bowel

movements and the number of dry nights and bring to the next visit (in 2 weeks). The

patient and family will discuss the use of desmopressin and decide at the next visit if

this medication should be implemented. Simple behavioral interventions are first-line

treatment approaches. Arousal alarms and medications should be considered in older

children who have greater social pressures and lower self-esteem (Ramakrishnan,

2008).

3. Treat the underlying condition of constipation. K.H. needs behavior

modification and pharmacotherapy to resolve his constipation. K.H. will start taking

polyethylene glycol, increase the amount of fiber and fluids in his daily diet, and have

consistent times to attempt a bowel movement. Secondary causes that contribute to

PMNE that are identified with the history, physical examination, and/or laboratory testing

should be treated (Ramakrishnan, 2008).

4. Provide consistent follow up to avoid non-compliance. K.H. and his

mother are encouraged to call the office for any questions, concerns, or if they begin to

feel discouraged. The importance of the follow up visit is reinforced. Treatment of PNE

should occur when the child is able and willing to adhere to the treatment regime and is

rarely indicated for children under the age of seven. In most cases, it takes many

months for a treatment to be successful; therefore, it is vital that both the child and the

family demonstrate high motivation when starting treatment (Ramakrishnan, 2008).


28

5. Provide verbal and written instruction and education materials. K.H. and

his parents were provided with verbal teaching and educational handouts from the DNP

student. Information about desmopressin was given so that the family could make an

informed choice about implementing in the future. The material provided addressed the

learning needs of the nine year old as well as his parents. The DNP student provided

reassurance that PMNE usually resolves spontaneously, however, it takes time.

Discussion about how bedwetting does not always affect all siblings in one family, which

explains why his sister does not wet the bed. The DNP student reinforced that since

K.H.s uncle and cousin were also bedwetters, his condition was probably genetically

inherited and will eventually resolve. Both the child and the parents should be informed

about the factors that contribute to PNE. Educating parents and child about the

condition, providing reassurance about the child’s physical and emotional health, and

counseling regarding guilt, shame, and punishment should be addressed by the DNP.

The evidence rating for this clinical recommendation is an A, meaning that there is

consistent, good quality patient oriented evidence (Ramakrishnan, 2008).

Medications

1. Polyethylene glycol 3350 without electrolytes 17g/capful powder (Miralax): This

osmotic diuretic is a safe and effective treatment option for treating constipation. When

added to eight ounces of liquid and consumed every morning it produces a bowel

movement within a few days. Multiple studies have shown it to increase the number of

bowel movements, soften the stool, and decrease straining. A three-day course (1.0-

1.5g/kg/day) is taken initially and then a maintenance dose (0.4-0.8g/kg/day) can be

titrated based on effectiveness and side effects (Chung, Cheng & Goldman, 2009).


29

K.H. will take 1.5 capfuls dissolved in eight ounces of liquid every morning X3 days. He

will then take 1 capful (17g) every morning for maintenance (Vallerand & Deglin, 2009).

2. Loratidine ODC 10mg : Continue daily administration but take before bedtime

instead of in the morning to prevent excessive dry mouth and thirst (Vallerand & Deglin,

2009).

Laboratory/Procedures

None ordered at this time. The use of ultrasonography along with additional

serum chemistry and blood counts should be considered only when the patient does not

respond to standard treatments (Ramakrishnan, 2008).

Continuity of Care

Outcome of Intervention

The DNP was only able to see this patient for the primary visit. The DNP will

follow K.H.s progress by communicating with Dr. M. in 2 weeks

Follow up and Referrals

Follow up. K.H. is scheduled for a 2-week follow-up to assess the progress of

his daytime bowel and bladder habits. At this time, the written bowel and bladder

records will be reviewed. The use of the alarm will also be discussed, noting successes

and failures. She will then discuss the addition of desmopressin at this visit based upon

the findings. Bimodal treatment, the use of alarm in conjunction with desmopressin, had

documented efficacy in the treatment of PMNE (Glazener & Evans, 2005; Ozden et al.,

2008; Robson, 2009). Treatment is considered successful when the child achieves

continence for 14 consecutive nights within a 16-week period. Non-response to


30

treatment is defined as less than 50 percent decrease in enuresis (Ramakrishnan,

2008).

Referrals. None required at this time. The patient should be scheduled every

two weeks for follow up during the next three months. Progress, failures, and

frustrations can be addressed at these visits. If patient does not respond to therapy after

12 weeks a referral to a pediatric urologist is recommended (Neveus & Stenberg, 2010;

Robson, 2009).

Interdisciplinary Care

School resources. S.H. will contact K.H.s teachers so that they can help

encourage daytime restroom use and allow K.H. to drink water throughout the day.

Collaboration with the teacher and school nurse are important for bladder and bowel

retraining success. Including these individuals lets the child know that there are caring

individuals that want to help him achieve his goals. Including these individuals helps to

reduce parental stress (Butler & Heron, 2007).

Support groups. S.H. was encouraged to access local and online support

groups. Communicating with others about bedwetting failures and successes provide

support and encouragement for the bedwetting patient and family members. This

provides an outlet for frustrations and prevents feelings of isolation. Online and local

support groups provide further information and support. Listening to the experiences of

others prevent the feeling of isolation and despair (Butler & Heron, 2007).

Family and Patient Education (online and print versions)

Bedwetting information.

http://kidshealth.org/parent/general/sleep/enuresis.html


31

(Bedwetting information and treatment options written specifically for school-age

children; Nemours Foundation, updated March 2007)

http://kidshealth.org/parent/general/sleep/enuresis.html

(Bedwetting information and treatment options written specifically for parents;

Nemours Foundation, updated October 2008)

http://www.nlm.nih.gov/medlineplus/ency/article/001556.htm

(Bedwetting information written for the healthcare consumer; Medline, updated

May 2009)

Constipation.

http://kidshealth.org/kid/ill_injure/sick/constipation.html

(Explains constipation and treatment options written specifically for school age

children; Nemours Foundation, updated March 2008)

http://kidshealth.org/parent/firstaid_safe/sheets/constipation.html

(Explains constipation and treatment options written specifically for parents;

Nemours Foundation, updated November 2008)

Follow-up

K.H. and his mother followed up at the clinic on March 5, 2010. The patient saw

Dr. M. since the DNP student was not present for this visit. The patient reported having

softer, daily bowel movements. He denied abdominal discomfort. He was drinking

more water during the morning and early afternoon and he was using the restroom at

school. The alarm was waking the patient each night, however, his underwear was

saturated each time. K.H. and S.H. decided to initiate desmopressin therapy at this

time. The patient will continue to take Miralax, and continue to keep a record of stool


32

and urine for another 2 weeks. The patient will also continue to use the alarm each

night. Desmopressin 0.2mg tabs (1 at bedtime) were added to the treatment plan. The

patient was scheduled to return to the office in another 2 weeks to evaluate this new

plan. The patient and mother were encouraged to call the office for any questions or

concerns.


33

References

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Jensen & B. Stanton (Eds.), Nelson textbook of pediatrics (18th ed., pp. 2299-

2301). Philadelphia: Saunders Elsevier.

Butler, R., & Heron, J. (2007). An exploration of children’s views of bed-wetting at 9

years. Child: care, health and development, 34,65-70.

Caldwell, P., Edgar, D., Jones, M., Hodson, E., & Craig, J. (2009). Treatment of

enuresis: alarm monotherapy versus multi-modal treatment approach in a multi-

disciplinary clinic. Australian and New Zealand Continence Journal, 15(3), 61-67.

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A., & Verkerk, P. (2009). The short- and long-term effects of simple behavioral

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Current medical diagnosis and treatment (48th ed., 965-1051). New York:

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Glazener, C., & Evans, J. (2005). Desmopressin for nocturnal enuresis in children.

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Ozgur, B., Ozgur, S., Dogan, V., & Orun, U. (2009). The efficacy of an enuresis alarm

in monosymptomatic nocturnal enuresis. Singapore Medical Journal, 50, 879-

880.

Pagana, K., & Pagana, T. (2006). Mosby’s manual of diagnostic laboratory tests (3rd

ed.). St. Louis: Mosby Elsevier.

Ramakrishnan, K. (2008). Evaluation and treatment of enuresis. American Family

Physician, 78, 489-496.

Robson, L. (2009). Evaluation and management of enuresis. New England Journal of

Medicine, 360, 1429-1436.

Rogers, J. (2009). Nocturnal Enuresis in childhood. Nurse Prescribing, 7, 57-62.

Vallerand, A., & Deglin, J. (2009). Davis’s drug guide for nurses (11th ed.).

Philadelphia: F.A. Davis.

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36

Wyllie, R. (2007). Major symptoms and signs of digestive tract disorders. In R.

Kliegman, R. Behrman, H. Jensen & B. Stanton (Eds.), Nelson textbook of

pediatrics (18th ed., pp. 1521-1529). Philadelphia: Saunders Elsevier.


37

= Normal female, male

= Female, male night time bedwetting = Female, male hypertension

P1

F1

F2

3 4

1

2 3 1

Legend:

2 1

3 4 5 6 7

= Female, male sleep apnea

4

3 yr. 5 yr..

36 yr..

9 yr.. 10 yr.

1 yr. 2 yr.

= Female, male unknown night time bedwetting

34 yr. 32 yr. 35 yr. 29 yr. 28 yr.

52 yr. 54 yr.

29 yr.

57 yr. 56 yr.

Appendix

= Female, male seasonal allergies

2

5 6

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