ACUTE GLOMERULONEPHRITIS updated 2017.pptx

glomerunephritis

1. ACUTE GLOMERULONEPHRITIS E KHOLOWA

2. Objectives Define glomerulonephritis Outline causes of glomerulonephritis Describe the pathophysiology of glomerulonephritis Outline the clinical manifestations of glomerulonephritis Explain the Diagnosis of glomerulonephritis Identify the medical management of glomerulonephritis Discuss the nursing management of glomerulonephritis Outline the complications of glomerulonephritis

3. Assignment In groups -differentiate the causes of glomerulonephritis and nephrotic Outline the clinical manifestations of GN and NS Differentiate the medical management of GN and NS

4. Definition and causes Inflammation of glomeruli of the kidneys Develops due to streptococci infection in the pharynx or the skin It usually follows an infection with scabies or impetigo and a throat infection such as tonsilitis , pharyngitis Mostly seen in boys between ages of 3 and 15

5. PATHOPHYSIOLOGY Not clearly understood Bacteria or viral agents invade the urinary system Components or antigens from the streptococcal bacteria lodge in the glomeruli basement membrane The immune system responds by trying to fight the infection It produces antibodies to attack the foreign antigens and the antibodies fix to the antigens forming an immune complex

6. Pathophysiology The immune complexes start another Inflammatory process which involves activation of complement ( a complement is a substance in blood consisting of a group of nine different elements that aid the body defences when antibodies combine with the invading antigen ) Complement triggers a series of events that results in glomerular inflammation As a result of the inflammation, capillaries become blocked resulting in impairment of glomerular filtration

7. Pathophysiology Protein and blood are lost in the urine, urine output diminishes In some patients acute renal failure results due to the reduced GFR Protein loss leads to hypoalbuminemia and massive proteinuria Na+ and water retention in plasma occurs due to decrease in water and Na+ filtration as a result of diminished GFR leading to increasing blood volume This necessitates redistribution of fluid leading to oedema of the tissues Hypertension occurs due to water and sodium retention

8. Clinical manifestations Hematuria due to damage to glomeruli , Oedema of varying degrees Periorbital oedema which may be mild to extensive Ascites or pleural effusion in some cases Reduced urine output Mild to moderate to massive proteinuria depending on the extent of the injury to the glomeruli Hypertension Fatigue Hypernatremia Hyperkalemia

9. Clinical manifestations ctd The above occur due to inflammation process changing permeability of the glomerular membrane leading to progressive kidney damage Increased creatinine and urea due to protein loss and kidney damage Hematuria is the essential symptom for the diagnosis of AG . Urine may also be blood tinged smoky, tea coloured ,

10. Diagnosis History of throat or skin infection Culture from site of infection e.g. throat or skin will show presence of streptococcus Urinalysis – blood in urine, high protein content, high urine specific gravity Blood analysis for complement activity- reduction in C3 and C4 reveal post strep glomerulonephritis Antistreptolysin O (ASO) – ASO <166 Todd units is normal

11. Treatment Based on degree of kidney damage and symptoms Aims of treatment include: Identify source of infection and treat Maintain fluid and electrolyte balance Maintain blood pressure within normal ranges

12. Medical management History of symptoms: exposure to other children or adults; treatment for any minor infections, aches and pains, infections of the upper respiratory system, any cough; respiratory difficulties causing difficulty in sleep Thorough physical examination including the throat for redness or inflammation;

13. Medical management Antibiotics to eliminate infection … penicillin is drug of choice Dose : penicillin 12.5 – 25mg/kg qid for 7 days or amoxycillin as above for skin or throat infection Benzathine penicillin (600000 units if weight <30kg and 1.2 mega units if >30kg weight ) is given for tonsilitis Frusemide in case of oedema – 1-2mg/kg once a day or 12hourly IV or IM. Can cause hypokalemia and dehydration Antihypertensives in case of high BP as prescribed Hospitalisation in case of the following Hypovolemia Generalised oedema - Gross haematuria - Hypertension - Oliguria Treat scabies if present

14. Fluid and dietary restrictions Restrict water or sodium intake to reduce oedema Restrict protein in case of elevation of urea Reduce potassium intake (fruits, vegetables, meat and fizzy drinks) during the acute phase while there is oliguria . ( potassium intake may have to be increased later as urination increases since potassium and sodium is lost The above pose a greater risk of acute renal failure

15. Nursing management Assess for signs of fluid overload Assess for oedema in lower extremities and periorbital Observe skin for dryness, redness or other indications of breakdown Assess resp system for cough, tachypnea , abnormal lung sounds and increased work of breathing Assess V/S for fever, raised BP, Daily weight monitoring

16. Nursing diagnosis Fluid volume excess RT compromised renal perfusion evidenced by decreased urine outpu and oedema Expected outcome The child will have normal urine output of at least 1-2ml/kg per hour

17. Measure intake and output 2-4 hourly to determine if renal function is returning Measure urine specific gravity2-4 hourly. Urine specific gravity is an indicator of good kidney function. The higher the SG, the poor the urine output and likelihood of dehydration and hematuria Weigh pt daily using same scale and at the same time and same clothing – increasing weight indicates more fluid retention. Weight loss indicates improvement or dehydration

18. Observe for signs of oedema , oedema is an indication of poor renal function Administer diuretics as prescribed if there is oedema -diuretics help to remove excess fluids Restrict fluids and sodium intake to reduce oedema and hypervolemia No salty food and added salt to meals Antihypertensives if diet and fluid restriction as well as diuretics alone do not reduce BP

19. Imbalanced nutrition, less than body requirements related to dietary restrictions evidenced by reduced oral intake Outcome The child will exhibit no decreased oral intake Interventions Offer small frequent low sodium and protein meals which are more tolerated by children. Low sodium and protein meals which are necessary for children with renal problems are not appealing for most children

20. Allow the child to choose foods he likes to increase the chance that he will eat Weigh the child (as above) Measure and record intake and output – comparison of I and O will give an indication of how well the child is maintaining fluid, electrolyte and nutritional balance

21. Risk for impaired skin integrity RT oedema evidenced by reddened or taut skin or actual skin breaks Expected outcome the child will not show signs of impaired skin integrity as evidenced by lack of redness , actual skin breakdown

22. Observe the skin for signs of redness or oedema 4 hourly. This allows for early identification of signs of skin breakdown Change child’s position 2 hourly to prevent development of pressure sores Bathe the child daily and cleanse as needed. Attention to hygiene prevents skin breakdown Apply lotion over areas of dry skin . Lotion adds moisture to the skin and decreases chance of skin breakdown Support an odematous extremity using a pillow . This will increase circulation and decrease pressure points that may lead to skin breakdown

23. Fatigue related to infectious process evidenced by complaints of tiredness and unwillingness to participate in activities Expected outcome The child will not experience fatigue as evidenced by no complainants of tiredness and participation in activities

24. Assess the child for signs of fatigue such as excessive sleepiness , yawning or inability to help with ADLs . A child can show signs of fatigue in not so obvious ways such as sleepiness Ask the child what activities he wants to engage in - toddlers and school age children like to play and if they have a choice of games they may play more Observe the child ‘s ability to do any activities including those he does in bed. Observation swill be on child’s tolerance of an activity and level of fatigue

25. Pain RT infection and edema evidenced by complaints of pain , wincing on movement Expected outcome Child will experience no pain Interventions Assess the child for signs of pain such as grimacing , crying, staying quiet, verbal complaints of pain or reluctance to move. Pain assessment allows for early intervention to promote comfort Gently move and reposition child 2 hourly if bedridden. Moving gently promotes circulation and lessens chances of pain and helps comfort the child

26. Position an oedematous extremity on a support pillow. Supporting a swollen leg will relieve pain Keep room quiet and at room temperature – a calm and moderate room temperature helps comfort the child

27. Education Explain prognosis - child will be on therapy for one to 3 weeks without long lasting effects Teach signs of edema or worsening of renal condition Dietary and fluid restrictions such as low sodium, protein Skin integrity and need for cleanliness . Teach to observe for red areas , excessively dry areas, that may appear red or bruised Need for changing position regularly

28. Education Elevation of lower extremities to encourage cardiac circulation Rest periods during activities because the child will tire easily Signs of dehydration and the need to report them immediately Signs of worsening condition e.g. grossly bloody urine, increased oedema , increased lethargy or activity intolerance and resp distress

29. Complications Hypertensive convulsions Renal failure Cardiac failure