Nephrotic syndrome

Nursing management of child with Nephrotic syndrome. The Nephrotic syndrome is a clinical state characterized by proteinuria, hypoalbuminemia, hyperlipidemia and edema, sometimes accompanied by hematuria, hypertension and reduced glomerular filtration rate.

1. NEPHROTIC SYNDROME Rajalakshmi.S Lecturer Josco College of Nursing Edappon , Mavelikkara

2. INTRODUCTION The Nephrotic syndrome is a clinical state characterized by proteinuria, hypoalbuminemia, hyperlipidemia and edema, sometimes accompanied by hematuria, hypertension and reduced glomerular filtration rate.

3. DEFINITION Nephrotic syndrome is clinical manifestation of a large number of glomerular disorders. It is characterized by massive proteinuria, hypoalbuminemia, hyperlipidemia and edema which generalized and also known as anasarca or dropsy.

4. Anatomy of kidney

5. INCIDENCE It is common among children in the age group of 2-6 years. It is more common in males than females.

6. ETIOLOGY 1.Primary renal cause Minimal change nephropathy Glomerulosclerosis Accute post stretococal glomerulonephritis Immune complex glomerulonephritis

7. 2.Systemic causes Infection Toxins Allergies Cardiovascular –sickle cell d iseases Malignancies –Leukemia Others –Amyloidosis, systemic lupus Erythematous etc.

8. CLASSIFICATION Primary nephrotic syndrome/ minimal change nephrotic syndrome(MCNS)/ idiopathic nephrosis / childhood nephrosis : result from the disorder within the glomerulus Secondary disorder- result from secondary to systemic disease such as hepatitis, systemic lupus erythematosus . Heavy metal poisoning, or cancer Congenital form inherited as an autosomal recessive disorder

9. PATHOPHYSIOLOGY . Due to metabolic, pathologic, biochemical, physiochemical, or immune mediated disturbances Alteration in glomerular basement membrane Increasingly permeable to protein Decreased colloidal pressure Increase secretion of aldosterone Edema Tubular Na+ and H2 O reabsorption Decreased vascular vollume Decreased renal blood flow

10. CLINICAL FEATURES Edema around eyes, legs and labia Anasarca Ascites Hydrothorax and hydrocele Decreased urine output frothy urine, increased specific gravity

11. Hematuria Fever , rash, joint pain Pallor Irritability Loss of appetite but weight gain Susceptibility to infections

12. DIAGNOSTIC EVALUATION 24 urine protein measurement Blood test – lipid profile, electrolytes, urea, creatinine Imaging of kidney Auto immune markers and Ultrasound of whole abdomen

13. MEDICAL MANAGEMENT The goal of medical management is reduction of protein excretion PREDNISOLONE – 2mg/kg/day – orally- divided doses for 6 weeks , thereafter 1.5 mg/ kg as single dose on alternate days for 6 weeks , after discontinued Protenuria disappears within the first week of therapy and negative dipstick test for 2 consecutive days shows positive response to treatment.

14. Frequent relapses are treated by alkylating agent such as CYCLOPHOSPHAMIDE ( 2mg/kg daily for 12 weeks ), NITROGEN MUSTARD, CYLOSPORINE OR LEVAMISOLE Diuretic and salt poor albumin may be indicated in presence of severe edema. FURESEMIDE ( 1-4 mg/kg/ day in 2 divided doses) along with aldosterone antagonist spironolactone ( 2-3 mg/kg/ day in 2 divided doses ) may be prescribed

15. Well balanced diet rich in protein. Restrict sodium when marked edema is present Water restriction – if decreasing salt intake does not control edema.

16. NURSING DIAGNOSIS Risk for impaired skin integrity related to edema and decreased circulation Risk for infection related to urinary loss of gamma globulins and immunosuppressive therapy Risk for deficient fluid volume( intra vascular) related to protenuria, edema, effects of diuretics Excess fluid volume related decreased excretion of sodium and fluid retension

17. Anxiety (parental ) related to hospitalization of child and caring for a child with a chronic disease Deficient knowledge about home management related to anxiety or incomplete understanding

18. Nursing management Care during hospitalization Administer the prescribed medications Maintain fluid and electrolyte balance Prevention of infection Promote rest Provide emotional support Discharge planning and home care teaching

19. Care during hospitalization Educate importance of hospitalization Involve the parents for caring the child during hospitalization Regularly monitor the vital signs Monitor the signs of infection Detailed charting of intake output Daily urine examination for albumin

20. Administer the prescribed medications Child is receiving steroids, so the nurse must be aware about the side effects of theses drugs Patients should be observed for gastrointestinal bleeding, gastrointestinal ulcers, hyperglycemia and cataract

21. Maintain fluid and electrolyte balance Monitor serum sodium level of the child Fluid intake either oral/ IV should be strictly monitored Assess for venous stasis, ascites and pulmonary edema Accurately document the daily weight

22. Prevention of infection Use strict aseptic technique during invasive procedure Monitor vital signs to detect early signs of infection Isolate the child as he is immunosuppressive therapy

23. Promote rest Provide passive play to the child as tolerated Allow a period of rest after activities Limit visitors during acute phase of illness

24. Provide emotional support Explain parents about disease and its treatment Allow the parents and child to express their feelings, due to sudden weight gain and disturbed body image

25. Discharge planning and home care teaching Explain to the parents about treatment program, follow-up and risk of relapse Encourage the parents to measure child’s weight weekly Tell them to contact doctor if any unusual symptoms appear Explain about the medications to be continued at home.

26. Dietary modification Advise them to reduce sodium intake 1-2gm daily Food should be avoided salt used in cooking and at table Seasoning blends ( garlic salt, season salt ) Canned soups Canned vegetable containing salt Prepared food

27. Fast foods Soya sauce Ketchup Salad dressing etc . Child can eat moderate amount of high protein animal food( lean cuts of meat, fish, poultry) Ask them to avoid saturated fats ( Butter, Cheese, Fried foods, Fatty cuts of red meat and egg yolk ) Ask to increase unsaturated fat intake ( olive oil, canola oil, peanut butter and nuts) The child can eat low fat desserts.

28. Increase intake of fruits and vegetables No potassium or phosphorus restriction is necessary Monitor fluid intake includes all fluids and foods that are liquid at room temperature.

29. COMPLICATIONS Acute renal failure, renal vein thrombosis Atherosclerosis and related heart disease Chronic kidney disease Fluid overload, congestive heart failure, pulmonary edema Infections, including pneumococcal pneumonia

30. REFERENCE Hockenberry Marilyn J Hockenberry , Wilson David, Rodgers Cheryl C. Wong’s essentials of peadiatric nursing; 10 th ed , Elsevier publications, New delhi ; 2017 James Rowen Susan; Nursing care of children: Principles and practice; 2 nd ed;elsevier publishers, London; 2002

31. Sharma Rimple ; Essentials of peadiatric nursing, 2nd ed;2017, Jaypee brothers medical publishers(p) Ltd, New delhi