Pathophysiology
Describe Nephrotic Syndrome Pathophysiology.
Nephrotic syndrome results when the glomerulus is excessively permeable to plasma protein. This causes proteinuria which leads to low plasma albumin and tissue edema.
List 3 Nephrotic Syndrome clinical manifestations.
Massive proteinuria, dark and foamy urine
Hypoproteinemia, hypoalbuminemia (ascites, edema) (risk for infection)
Peripheral edema
Fluid volume overload, fluid retention, weight gain, puffy eyes, bloating
Swelling in the legs, hands, face, or abdomen
Vomiting, loss of appetite, anorexia, pallor, fatigue
Hypercholesterolemia, Hyperlipidemia, fatty casts, foamy/ urine
At risk for hypercoagulation: blood clots, pain
Signs of infection: fever, high WBC
List 4 diagnostics of Glomerulonephritis.
-Urine Tests
-Blood Tests
-Imaging Tests: such as a kidney X-ray, an ultrasound examination or a CT scan
-Kidney Biopsy
What is the goal of treatment for Nephrotic syndrome
Goal: to control primary disease and relieve the symptoms
The management of APSGN focuses on symptomatic relief. Rest is recommended until the signs of glomerular inflammation (proteinuria, hematuria) and hypertension subside.
List 3 examples of nursing interventions commonly used to achieve this.
Obtain a complete physical assessment. (compare with the baseline for changes)
Monitor daily weight to have a measurable account on the fluid elimination. (weight gain is the earliest sign of fluid retention)
Monitor fluid intake and output every 4 hours to know progressing condition via glomerular filtration.
. Monitor BP and PR every hour to know the progression of hypertension. (hypertension can lead to hypertensive encephalopathy). The patient should be on bed rest.
.Assess for adventitious breath sounds to know for possible progression in the lungs. (crackles is a sign of pulmonary edema)
Assess for swelling the face around eyes and extremities (swelling is worse in the morning)
Monitor BUN/ Creatinine levels (renal failure)
List 3 common causes of Nephrotic Syndrome
Primary glomerular disease: membranous proliferative glomerulonephritis, primary nephrotic syndrome, focal glomerulonephritis and inherited nephrotic disease; Infections: Bacterial (strep, syphilis), viral (hepatitis, HIV) and protozoal (malaria); Multisystem disease: Systemic lupus erythematosus, diabetes mellitus, and amyloidosis; Neoplasms: Hodgkin’s lymphoma, solid tumors of lungs, colon, stomach, breast and leukemias; Allergens: bee sting or pollen; Drugs: penicillamine, NSAIDS and captopril heroin.
List 3 clinical manifestations of Glomerulonephritis
Clinical manifestations
Acute symptoms can come on suddenly and may be temporary or reversible, chronic symptoms you might not see for a while
Acute post-streptococcal glomerulonephritis: edema (eyes, legs, ascites), HTN, oliguria, hematuria, proteinuria, abdominal or flank pain, may be asymptomatic and find the problem on a urinalysis
Pink or brown-colored urine (hematuria)
Proteinuria, Foamy urine
Hypertension (in acute glomerulonephritis)
Edema/swelling/fluid retention (decreases GFR) - swelling evident in your face, hands, feet, and abdomen
Weight gain
Malaise, headache
Low-grade fever
What are you most likely to see in a blood test for diagnosing Nephrotic Syndrome?
Low levels of protein albumin and often decreased levels of blood protein overall.
List 3 nursing interventions for managing the edema associated with Nephrotic Syndrome.
Weight pt daily, record I&O
Measure abdominal girth, compare results Qday
Clean edematous skin carefully, avoid trauma to skin
Monitor diuretic therapy effectiveness
True or False
A patient who is experiencing post-streptococcal glomerulonephritis has edema mainly in the face and around the eye in the night
Answer
edema to be more prominent during the morning
A patient with nephrotic syndrome has proteinuria, how would this affect the patient’s plasma albumin and tissues?
Increased plasma albumin and tissue edema.
How will the urine appear in a patient with Nephrotic Syndrome and what caused the urine to appear this way?
Dark and foamy due to high levels of protein in the urine (proteinuria) and also high lipids in the blood (hyperlipidemia) can cause fatty casts which cause foamy urine
List the diagnostics of Nephrotic Syndrome.
Urine Tests
Blood Tests
Kidney Biopsy
What does the treatment of Glomerulonephritis focus on?
Focuses on symptomatic relief
-Rest until signs of glomerular inflammation (proteinuria, hematuria) and hypertension subside
-Edema treated by restricting sodium + fluid intake and by administering diuretics; Severe hypertension treated by antihypertensive drugs; Dietary protein intake may be restricted if there is evidence of increased nitrogenous wastes (elevated BUN)
-Antibiotics should be given ONLY if streptococcal infection still present
-Important way to prevent APSGN is early diagnosis and treatment of sore throats and skin lesions, if streptococci found in the culture- treat with antibiotics therapy (usually penicillin) and encourage to take the full course of antibiotics
List 3 Nephrotic Syndrome nursing interventions.
Interventions include
Edema management: Assess the edema by weighing the patient daily, accurately recording intake and output, and measuring abdominal girth or extremity size. Use baseline measurements to compare. (when obtaining daily weight, weigh the patient at the same time, the same clothes and the same scale)
Cleaning the edematous skin is another key intervention. When cleaning the skin avoid trauma to the skin also turn and position the patient every 1-2 hours and avoid tight gowns and clothes.
Patients with nephrotic syndrome are usually anorexic and have the potential to become malnourished from the excessive loss of protein in the urine.
Daily intervention to treat anorexia includes serving small, frequent meals in a pleasant setting to encourage better dietary intake.
Infection control is another important nursing consideration
Teach patients to avoid exposure to persons with known infections and proper aseptic techniques.
Monitor patient for potential blood clots
Assess respiratory status: increase respiratory rate, dyspnea, tachycardia, chest pain, decreased oxygen saturation. Assess for a DVT. Signs and symptoms include redness, swelling and pain in the leg.
Patients may also suffer from body image issues.
6. Helping them cope with an altered body image, is essential because of the embarrassment and shame often associated with the edematous appearance.
Within the past month, the admission rate of patients with post-streptococcal glomerulonephritis has doubled on your unit. You are educating the student nurse about this condition, which statement by the student nurse indicates effective teaching?
· A. "This condition tends to present 6 months after a strep infection of the throat or skin."
· B. "It is important the patient consumes a diet rich in potassium-based foods due to the risk of hypokalemia."
· C. "Patients are less likely to experience hematuria with this condition."
· D. "This condition is not caused by the streptococcal bacteria attacking the glomerulus, but by the immune system’s response to the bacteria by creating an antigen-antibody complex which inflames the glomerulus."
What is: D
What are the signs and symptoms of a patient experiencing nephrotic syndrome? Select all that apply.
Slight proteinuria
Hypoalbuminemia
Edema
Hyperlipidemia
Hypertension
2,3,4
What diagnostic test is most necessary to confirm a diagnosis of glomerulonephritis?
Answer: Kidney biopsy
What diet would a patient be put on with nephrotic syndrome?
Answer: Low sodium, moderate-protein
List three common causes of Glomerulonephritis
Common causes: Infections: post-streptococcal glomerulonephritis, infective endocarditis, viral infections; Immune diseases: systemic lupus erythematosus, scleroderma, Goodpasture syndrome, and IgA nephropathy; Vasculitis: polyarteritis, Wegener's granulomatosis; Conditions causing scarring of glomeruli: diabetic nephropathy, hypertension and focal segmental glomerulosclerosis; Other: amyloidosis and illegal drug use.
Poststreptococcal Glomerulonephritis: Antibodies to strep antigen develop and deposit in the glomeruli causing inflammation. This may develop 1-2 weeks after streptococcal infection.
What is the biggest cause of Glomerulonephritis?
Poststreptococcal infection.
Antibodies to strep antigen develop and deposit in the glomeruli causing inflammation. This may develop 1-2 weeks after streptococcal infection.
What abnormal finding is present in a urine sample for Glomerulonephritis that is absent in Nephrotic Syndrome?
Hematuria
What is an important way to prevent Acute Poststreptococcal glomerulonephritis?
Early diagnosis and treatment of sore throats and skin lesions that are culture positive of streptococci