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  1. NEPHROSIS
    Nephrosis (idiopathic nephrotic syndrome) is a chronic renal disease having no known cause, variable pathology, and no known cure. It is thought that several different pathophysiological processes adversely affect the glomerular membranes of the kidneys, resulting in increased permeability to protein. This "leakage" of protein into the urine results in massive proteinuria, severe hypoproteinemia, and total body edema. A chronic disease, nephrosis often has its onset during the preschool years but is characterized by periods of exacerbation and remission throughout the childhood years.
    The nursing care plan for the child with nephrosis is very similar to that for the adult with compromised renal functioning. Refer to Chapter 8. Physiological Integrity and Chapter 9. Physiological Integrity: Basic Care and Comfort—Nutrition for additional information about dietary restrictions and medications; refer to Table 5-17. Comparison of Nephrosis and Acute Poststreptococcal Glomerulonephritis for a chart comparing nephrosis and nephritis.
  2. ACUTE POSTSTREPTOCOCCAL GLOMERULONEPHRITIS
    1. Introduction: Acute poststreptococcal glomerulonephritis (APSGN) is a bilateral inflammation of the glomeruli of the kidneys and is the most common noninfectious renal disease of childhood. It occurs most frequently in early school-age children, with a peak age of onset of 6 to 7 years; it is twice as common in boys as in girls. Like rheumatic fever, acute glomerulonephritis is thought to be the result of an antigen-antibody reaction to a streptococcus infection (see Figure 5-8. Sequelae of Strep Infections); however, unlike rheumatic fever, it does not tend to recur, because specific immunity is conferred following the first episode of APSGN. (Further information about APSGN is found in Table 5-17. Comparison of Nephrosis and Acute Poststreptococcal Glomerulonephritis .)
    2. Assessment:
      1. Typical concerns from family about urine: change in color/appearance of urine (thick, reddish brown; decreased amounts).
      2. Acute edematous phase—usually lasts 4 to 10 days.
        1. Laboratory examination of urine:
          1. Severe hematuria.
          2. Mild proteinuria.
          3. Increased specific gravity.
        2. Hypertension
          1. Headache.
          2. Potential hypertensive encephalopathy leading to seizures, increased intracranial pressure.
        3. Mild-moderate edema: chiefly periorbital; increased weight due to fluid retention.
        4. General:
          1. Abdominal pain.
          2. Malaise.
          3. Anorexia.
          4. Vomiting.
          5. Pallor.
          6. Irritability.
          7. Lethargy.
          8. Fever.
      3. Diuresis phase:
        1. Copious diuresis.
        2. Decreased body weight.
        3. Marked clinical improvement.
        4. Decrease in gross hematuria, but microscopic hematuria may persist for weeks/months.
    3. Analysis/nursing diagnosis:
      1. Fluid volume excess related to decreased urine output.
      2. Pain related to fluid retention.
      3. Altered nutrition, less than body requirements, related to anorexia and vomiting.
      4. Impaired skin integrity related to immobility.
      5. Activity intolerance related to fatigue.
      6. Knowledge deficit related to disease process, treatment, and follow-up care.
    4. Nursing care plan/implementation:
      1. Goal: monitor fluid balance, observing carefully for complications.
        1. Check and record blood pressure at least every 4 hours to monitor hypertension.
        2. Monitor daily weights.
        3. Urine: strict I&O; specific gravity and dipstick for blood every void.
        4. Note edema: extent, location, progression.
        5. Adhere to fluid restrictions if ordered.
        6. Monitor for possible development of hypertensive encephalopathy (seizures, increased intracranial pressure); report any changes STAT to physician.
        7. Administer medications as ordered:
          1. Antibiotics—eradicate any lingering streptococcus infection; controversial.
          2. Antihypertensives (e.g., Apresoline).
          3. Rarely use diuretics—limited value.
          4. If CHF develops—may use digoxin.
          5. Refer to Chapter 8. Physiological Integrityfor additional information on medications.
      2. Goal: provide adequate nutrition.
        1. Diet: low sodium, low potassium—to prevent fluid retention and hyperkalemia; decrease protein (if azotemia develops). Refer to Chapter 9. Physiological Integrity: Basic Care and Comfort—Nutritionfor additional information on diets.
        2. Stimulate appetite: offer small portions, attractively prepared; meals with family or other children; offer preferred foods, if possible; encourage parents to bring in special foods (e.g., culturally related preferences).
      3. Goal: provide reasonable measure of comfort.
        1. Encourage parental visiting.
        2. Provide for positional changes, give good skin care.
        3. Provide appropriate diversion, as tolerated.
      4. Goal: prevent further infection.
        1. Use good hand washing technique.
        2. Screen staff, other clients, visitors (especially children) to limit contact with people who are infectious.
        3. pillImage Administer antibiotics if ordered (usually only for children with positive cultures).
        4. Keep warm and dry, stress good hygiene.
        5. Note possible sites of infection: increased skin breakdown secondary to edema.
      5. Goal: teach child and family about APSGN/discharge planning.
        1. Teach how to check urine at home: dipstick for protein and blood. ( Note: occult hematuria may persist for months.)
        2. Teach activity restriction: no strenuous activity until hematuria is completely resolved.
        3. Teach family how to prepare low-sodium, low-potassium diet.
        4. Arrange for follow-up care: physician, home health nurse.
        5. Stress: subsequent recurrences are rare because specific immunity is conferred.
    5. Evaluation/outcome criteria:
      1. No permanent renal damage occurs.
      2. Normal fluid balance is maintained/restored.
      3. Adequate nutrition is maintained.
      4. No secondary infections occur.
      5. Child/family verbalize their understanding of the disease, its treatment, and its prognosis.