OBJECTIVES
General:This study aims to broaden the knowledge of the student – nurses as well as their superiors about the disease, to be able to respond and intervene with client's correctly, render accurate nursing care needed in order to provide an effective nursing
management in a hospital set – up until the client is ready for discharge.
Specific:
• To identify the major disease manifestations, risk factors and etiology.
• To understand the pathophysiology of Nephrotic Syndrome in relation to the anatomy and physiology.
• To assess a patient with Nephrotic Syndrome.
• To know the nature of the drugs administered with compliance to nursing responsibilities.
• To formulate a nursing care plan for Nephrotic Syndrome • To implement effective nursing intervention.
Introduction
Definition
•
Nephrotic syndrome is a group of symptoms including protein in the urine
(more than 3.5 grams per day), low blood protein levels, high cholesterol
levels, high triglyceride levels, and swelling
•
Autoimmune process leading to structural alteration of glomerular
membrane that results in increased permeability to plasma proteins,
particulary albumin.
•
Nephrotic syndrome is a disorder of the glomeruli (clusters of microscopic
blood vessels in the kidneys that have small pores through which blood is
filtered) in which excessive amounts of protein are excreted in the urine.
This typically leads to accumulation of fluid in the body (edema) and low
levels of the protein albumin and high levels of fats in the blood.
•
Nephrotic syndrome is not a specific glomerular disease but a cluster of
clinical findings, including:Marked increase in protein (particularly albumin)
in the urine (proteinuria), Decrease in albumin in the blood
(hypoalbuminemia), Edema, High serum cholesterol and low-density
lipoproteins (hyperlipidemia).
CLASSIFICATION
Idiopathic nephrotic syndrome (90% of cases)
Minimal change nephrotic syndrome
Nephrotic syndrome with mesangial proliferation Nephrotic syndrome with focal sclerosis
Nephrotic syndrome secondary to glomerulonephritis (10% of cases)
Membranous glomerulopathy MPGN
OTHRS as SLE and HSP
Congenital nephrotic syndrome AR presenting at birth or during the 1st 6 months
Causes:
Nephrotic syndrome has many causes and may either be the result of a disease limited to the kidney, called primary nephrotic syndrome, or a condition that affects the kidney and other parts of the body, called secondary nephrotic syndrome.
Primary causes of nephrotic syndrome are usually described by the histology, i.e., minimal change disease (MCD), focal segmental glomerulosclerosis (FSGS) and
membranous nephropathy (MN), sickle cell disease, diabetes mellitus and malignancy such as leukemia.
PREDISPOSING FACTO
R RATIONALE
Age Children ages 1 1⁄
2 and 4 yr are predisposed in having nephrotic syndrome.
Sex Males are more predisposed than males in acquiring nephrotic syndrome. Genetic
s
People with family history of nephrotic syndrome increases likelihood of developing nephrotic syndrome.
PRECIPITATING FACTOR RATIONALE Focal segmental glomeruloscleros is - HIV/AIDS - Nephrectomy
Most common cause of idiopathic NS among adults. May be secondary to HIV/AIDS infection or loss of nephrons.
Membranous nephropathy – Hepatitis B infection
–
SLE–
CancerDeposition of immune complexes on the glomerular basement membrane causing it to thicken. It can be secondary to certain cancers, Hepatitis B infections and autoimmune disorders such as SLE.
Minimal change
disease Causes 80 to 90% of childhood nephrotic syndrome in children 4 to 8 years of age idiopathic in nature. Diabetes Mellitus Prolonged elevated blood glucose levels alters glomerular base
membranes thereby causing impaired renal function. Drugs
– Heroin – NSAID – Gold
– Penicillamine
These drugs can contribute to the development of focal segmental glomerulosclerosis, membranous nephropathy and minimal change disease which in turn precipitate occurrence of nephrotic syndrome.
Human anatomy (KIDNEY)
NORMAL KIDNEY SIZE
- The normal kidney size of an adult human is about 10 to 13 cm (4 to 5
inches) long and about 5 to 7.5 cm (2 to 3 inches) wide. It is approximately the size of a conventional computer mouse.
NORMAL KIDNEY COLOR
The kidneys are dark-red, bean-shaped organs. One side of the kidney bulges outward (convex) and the other side is indented (concave)
NORMAL KIDNEY LOCATION
– towards the back of the abdominal cavity, just above the waist. One kidney is normally located just below the liver, on the right side of the abdomen and the other is just below the spleen on the left side.
–
Kidney anatomy and excretion
The most basic structures of the kidneys, are nephrons. They are responsible for filtering the blood.
The renal artery delivers blood to the kidneys each day. Over 180 liters (50 gallons) of blood pass through the kidneys every day. When this blood enters the kidneys it is filtered and returned to the heart via the renal vein.
The process of separating wastes from the body fluids and eliminating them, is known as excretion. The urinary system is one of the organ systems responsible for excretion. The
kidneys are the main organs of the urinary system. Kidney anatomy and blood vessels
The kidney is full of blood vessels. Every function of the kidney involves blood, therefore, it requires a lot of blood vessels to facilitate these functions.
Together, the two kidneys contain about 160 km of blood vessels. Renal capsule
is a tough fibrous layer surrounding the kidney and covered in a thick layer of adipose tissue. It provides some protection from trauma and damage
Renal cortex
is the outer portion of the kidney between the renal capsule and the renal medulla. In the adult, it forms a continuous smooth outer zone with a number of projections (cortical columns) that extend down between the pyramids.
Ultrafiltration occurs. Renal medulla
is the innermost part of the kidney split up into a number of sections, known as the renal pyramids
contains the structures of the nephrons responsible for maintaining the salt and water balance of the blood
Patient's Profile
a. Demographic Data Name: Baby X
Age: 3 years old Sex: M
Nationality: Filipino Religion: Catholic
Physician: Joselito Mattheus, MD Informant: Minerva Flores (mother) Mother: Minerva Del Valle Flores Father: Christian Flores
Date of Arrival: February 4, 2011 5:55 pm b. Chief Complaint: Periorbital Edema c. History of Present Illness:
Was diagnosed with Nephrotic Syndrome last July 2010. Three days Prior to
Admission, the patient had a non productive cough but with no other sign and symptoms of the illness. The patient noted to have periorbital edema upon waking up. And one day prior to admission, the patient was to have bipedal edema. This prompted the mother to seek medical attention.
d. Past Medical History
Baby X haven't undergone any surgery but was hospitalized last July 2010 in this institution due to the illness, Nephrotic Syndrome. He doesn't have any history of other disease. But the patient was already taking Prednisone even before.
He doesn't have also any other childhood illness. Baby X had her immunization of BCG, Hepa (I, II, III), MMR, DPT (I, II, III), and OPV (I, II, III).
e. Family History Mother Father HPN (+) (+) Cancer (-) (-) TB (-) (-) Asthma (-) (-) Diabetes Mellitus (-) (-) f. Maternal and Perinatal History
Born to a 21 year old with a G2P1 in the year 2002. The mother had UTI during the second semester. Was a normal delivery in a lying-in by a midwife.
Baby X was breastfed, and then shifted to bottled milk. Baby X started having solid food when he was 9 month old.
Total Protein Albumin Globulin
Result Values Analysis Interpretation
Total Protein 31.99 Adult:66-8 1-18y/o: 57-80
Newborns (1-28days): 41-63
Decreased Due to low Albumin level
Albumin 10.21 35-50 Decreased Dehydration,kid
ney losses
Globulin 22.00 11-35 Normal Normal
A/C Ratio 0.47 1.1-2.2 Decreased Liver
dysfunction
Result Values Interpretation Analysis
Creatinine 20.77 mmol/L Adults 45-104 Neonate 27-87 Infant 14-34 Child 23-68 Normal Normal
Potassium 3.64 mmol/L 3.6-5.5 Normal Potassium is the most abundant intracellular cation,
much smaller accounts are found
in the blood. K is essential for the transmission of electrical impulses in cardiac and skeletal muscle. In addition, it helps to maintain the osmolality and electroneutrality of cells, functions in enzyme reactions that transform glucose into energy
and amino acids into proteins and participates in the
maintenance of acid base balance.
Na 130.30
mmol/L
135-145 Decreased Sodium is the most abundant electrolytes in ECF,
ranges from 135-145 mmol/L. Hyponatremia refers to a serum
Na level that is below normal (less
than 135 meq/L) Na maybe lost by way of vomiting, use of diuretics particularly in combination with a
low salt diet.
Cl 102.20 100-111 Normal Normal
Calcium 1.89 mmol/L 2.20-2.65 Below the normal range
Low blood calcium (or hypocalcemia) can have
various causes, including: bone problems, low levels of
the blood protein albumin, inflammation of
the pancreas, kidney disease, malfunction of
the parathyroid gland (hypoparathyroidism) and improper absorption
of foodor calcium.
URINALYSIS
A urinalysis is usually ordered when a doctor suspects that a child has a urinary
tract infection or a health problem that can cause an abnormality in the urine.
This test can measure:
•
the number and variety of red and white blood cells
•
the presence of bacteria or other organisms
•
the presence of substances, such as glucose, that usually shouldn't be found in
the urine
•
the pH, which shows how acidic or basic the urine is
• the concentration of the urineRESULT Normal Intepretation Analysis
Color Yellow Amber pale to
dark yellow Normal Urine is normally clear yellow or amber in color. The
mainly a result of the presence of the pigment urochrome,
which is produced through endogenous metabolic processes. Transparenc
y Slightly Turbid Clear Normal Transparency refers to the clarity of the urine.
Reaction
(ph) 6.5 5-6 Increase Acidic, may indicate infection. Specific
Gravity 1.025 1.010-030 Normal Specific gravity is an indicator of urine concentration of the amount of solutes
(metabolic waste and electrolytes) present in the urine.
Sugar (-) Negative ↑-diabetes mellitus,
renal glycosuria (excretion of glucose), nephrotoxic chemicals (carbon monoxide) Protein (+) Negative -EXAM NAME RESULT NORMAL VALUE INTEPRETATION ANALYSIS RBC 6-9 0-2/hpf Normal -WBC 20-25 0-5/hpf Normal -Crystals Amorphous Urates – Few
None Some crystals are
found exclusively in acid urine. Healthy people often have only
a few crystals in their urine. A large number of crystals, or certain types of crystals, may
mean kidney stones are present or there is
a problem with how the body is using food
(metabolism). Epithelial
cells Few Few Normal found in urine samples Epithelial cells are are derived a.) the lining of female lower
urethra and the vagina. b.) linings of
the renal pelvis bladder. c.) renal
tubules themselves
Bacteria cast Few Few Normal
-Casts Hyaline cast
1-2/hpf None
Hyaline casts are formed in the absence of cells in the renal tubular lumen. They have a smooth texture and a refractive index very close to that of the surrounding fluid.
When present in lower numbers (0-1/LPF) in
concentrated urine of otherwise normal patients, hyaline casts are not always
indicative of clinically significant disease.
Complete Blood Count
The complete blood count (CBC) is a common blood test that evaluates the three major types of cells in the blood: red blood cells, white blood cells, and platelets. A CBC may be ordered as part of a routine checkup, or if your child is
feeling more tired than usual, seems to have an infection, or has unexplained bruising or bleeding. The CBC can also test for loss of blood, abnormalities in
the production or destruction of blood cells, acute and chronic infections, allergies, and problems with blood clotting.
Result Values Interpretation Analysis
Hgb 12.6 12-14 g/L Normal Hgb is the
main intracellular
protein. Its primari Hct 0.403 0.37-0.47 Normal range Hct or packed
RBC volume measure the proportion of RBC's in a volume of whole blood and is expressed as a percentage. RBC 4.88 4.7-6.1 x10^9/L Normal Erythrocytes
abundant cells of the blood. Its primarily responsible for tissue oxygenation thus, a decreased level of RBC indicates anemia. MCV 82.4 80-95fL Normal Mean corpuscular volume indicates the volume/size of the hgb each RBC. Very useful in differentiatin g anemia.
MCH 25.8 27-31pg Below the normal
range
MCHC 31.3 32-36 g/dL Below the normal range proportion of MCHC is the the hgb contained in each RBC. Indication of hgb deficiency and of the oxygen carrying capacity of the individual erythrocytes.
MEDICAL MANAGEMENT
Fluid and sodium restriction, oral or intravenous diuretics, and angiotensin-converting enzyme inhibitors.
• Fluid and sodium restrictions
Creating a negative sodium balance will help reduce edema, presumably as the underlying illness is treated or as renal inflammation slowly resolves. Patients should limit their sodium intake to 3 g per day, and may need to restrict fluid intake (to less than approximately 1.5 L per day). Large doses (e.g., 80 to 120 mg of furosemide) are often required and these drugs typically must be given intravenously because of the poor absorption of oral drugs caused by intestinal edema. Low serum albumin levels also limit diuretic effectiveness and necessitate higher doses. Thiazide diuretics, potassium-sparing diuretics, or metolazone (Zaroxolyn) may be useful as adjunctive or synergistic diuretics.
• Diuretics
"Diuretics are the mainstay of medical management; however, there is no evidence to guide drug selection or dosage," Dr. Kodner writes. "Based on expert opinion, diuresis should aim for a target weight loss of 1 to 2 lb (0.5 to 1 kg) per day to avoid acute renal failure or electrolyte disorders. Loop diuretics, such as furosemide (Lasix) or bumetanide, are most commonly used."
• Angiotensin-converting enzyme
In persons with nephrotic syndrome, angiotensin-converting enzyme inhibitors have been shown to decrease proteinuria and lower the risk for progression to renal disease.
Angiotensin-converting enzyme (ACE) inhibitors have been shown to reduce pro-teinuria and reduce the risk of progression to renal disease in persons with nephrotic syndrome.15,16 One study found no improvement in response when corticosteroid treatment was added to treatment with ACE inhibitors.17 The recommended dosage is unclear, and enalapril (Vasotec) dosages from 2.5 to 20 mg per day were used. Most persons with nephrotic syndrome should be started on ACE inhibitor treatment to reduce protein-uria, regardless of blood pressure.
* Although corticosteroid treatment may benefit some adults with nephrotic syndrome, research evidence supporting this therapy is limited. At present, intravenous albumin, prophylactic antibiotics, and prophylactic anticoagulation are not advised.
ALBUMIN Intravenous albumin has been proposed to aid diuresis, because edema
may be caused by hypoalbuminemia and resulting oncotic pressures. However,
there is no evidence to indicate benefit from treatment with albumin,
and adverse effects, such as hypertension or pulmonary edema, as well as high cost, limit its use.CORTICOSTEROIDS Treatment with corticosteroids remains controversial in the management of nephrotic syndrome in adults. It has no proven benefit, but is recommended in some persons who do not respond to conservative treatment. Treatment of children with nephrotic syndrome is different, and it is more clearly established that children respond well to corticosteroid treatment. Family physicians should discuss with patients and consulting nephrologists whether treatment with corticosteroids is advisable, weighing the uncertain benefits and possibility of adverse effects. Alkylating agents (e.g., cyclophosphamide [Cytoxan]) also have weak evidence for improving disease remission and reducing proteinuria, but may be considered for persons with severe or resistant disease who do not respond to corticosteroids.
LIPID-LOWERING TREATMENT A Cochrane review is underway to investigate the benefits and harms of lipid-lowering agents in nephrotic syndrome. Some evidence suggests an increased risk of athero-genesis or myocardial infarction in persons with nephrotic syndrome, possibly related to increased lipid levels. However, the role of treatment for increased lipids is unknown and, at present, the decision to start lipid-lowering therapy in persons with nephrotic syndrome should be made on the same basis as in other patients.
ANTIBIOTICS There are no data from prospective clinical trials about treatment and prevention of infection in adults with nephrotic syndrome. Given the uncertain risks of infection in adults with nephrotic syndrome in the United States, there are currently no indications for antibiotics or other interventions to prevent infection in this population. Persons who are appropriate candidates should receive pneumococcal vaccination.
ANTICOAGULATION THERAPY There are currently no recommendations for prophylactic anticoagulation to prevent thromboembolic events in persons with nephrotic syndrome who have not had previous thrombotic events, and clinical practice varies. A Cochrane review is in process. Physicians should remain alert for signs or symptoms suggesting thromboembolism and, if it is diagnosed, these events should be treated as in other patients. Persons who are otherwise at high risk of thromboembolism (e.g., based on previous events, known coag-ulopathy) should be considered for prophy-lactic anticoagulation while they have active nephrotic syndrome.
NURSING MANAGEMENT
• Assess and document the location and character of the patient's edema.
• Weigh the patient each morning after he voids and before he eats, make sure he's wearing the same amount of clothing each time you weigh him.
• Measure blood pressure with the patient lying down and standing. Immediately report a decrease in systolic or diastolic pressure exceeding 20 mm Hg.
• Monitor intake and output
• Ask the dietitian to plan a low-sodium diet with moderate amounts of protein. • Frequently check urine for protein
• Provide meticulous skin care to combat the edema that usually occurs with nephrotic syndrome
• Use a reduced-pressure mattress or padding to help prevent pressure ulcers.
and provide antiembolism stockings as ordered
• Give the patient and family reassurance and support, especially during the acute phase, when edema is severe and the patient's body image changes.