Peds ATI Ch. 26 (Renal Disorders)
risk factors for nephrotic syndrome
--Minimal change nephrotic syndrome (MCNS) ● Peak incidence is between 2 and 3 years of age. ● Cause is unknown, but it can have a multifactorial etiology (metabolic, biochemical, or physiochemical disturbance in the basement membrane of the glomeruli). --Secondary nephrotic syndrome: occurs after or is associated with glomerular damage due to a known cause --Congenital nephrotic syndrome: an inherited disorder
risk factors for acute glomerulonephritis
Acute poststreptococcal glomerulonephritis
medications for nephrotic syndrome (cyclophosphamide)
Administer for children who cannot tolerate prednisone or who have repeated relapses of MCNS.
lab tests/diagnostic tests for acute renal failure
Assess kidney function related to preexisting renal disease. ● Hyperkalemia ● Hyponatremia ● Metabolic acidosis ● Hypocalcemia ● Anemia ● Azotemia ● Elevated plasma creatinine ● Elevated BUN ● ECG for cardiac arrhythmias
complicaitons of nephrotic syndrome
Circulation insu ciency Thromboembolism Sepsis/infection ● Steroid therapy increases the risk for infection. ● Keep the child away from potential infection sources. ● Monitor for ndings of infection. ● CLIENT EDUCATION ◯ Educate about the importance of completing the full dose of antibiotic. ◯ Educate about the need for performing frequent hand hygiene. ◯ Educate about manifestations of infection and when to contact the provider. ◯ Educate about potential infection sources (sick family members).
medications for nephrotic syndrome (diuretic: furosemide)
Eliminates excess uid from the body NURSING CONSIDERATIONS ● Encourage the child to eat foods that are high in potassium. ● Monitor serum electrolyte levels periodically.
medications for nephrotic syndrome (25% albumin)
Increases plasma volume and decreases edema NURSING CONSIDERATIONS ● Administer per protocol. ● Monitor I&O. ● Monitor for anaphylaxis.
diagnostic procedures for nephrotic syndrome
Kidney biopsy is indicated only if nephrotic syndrome is unresponsive to steroid therapy. Biopsy will show damage to the epithelial cells lining the basement membrane of the kidney.
meds for acute renal failure
Mannitol and furosemide to provoke a ow of urine in child who has oliguria and no lower tract obstruction. Calcium gluconate 0.5 mL/kg IV every 2 to 3 min with continuous ECG monitoring to reduce serum potassium levels Sodium bicarbonate 2 to 3 mEq/kg IV every 30 to 60 min, elevates serum pH and transient uid shift to reduce serum potassium levels. Glucose 50% and insulin 1 unit/kg IV causes glucose and potassium to move into cells. Insulin facilitates entry of glucose into cells and helps to reduce serum potassium levels. To remove potassium from the body ● Sodium polystyrene sulfonate 1g/kg orally or rectally to bind potassium and excrete it from body ● Dialysis or continuous hemo ltration For hypertension if encephalopathy threat present ● Labetalol IV ● Sodium nitroprusside IV with close monitoring Less urgent medications for hypertension ● Hydralazine IV ● Clonidine IV ● Verapamil IV ● Antiepileptic drugs if seizures present
medications for nephrotic syndrome (corticosteroid: prednisone)
NURSING CONSIDERATIONS ● 60 mg/m2/day for 4 to 6 weeks followed by 40 mg/m2 every other day for 2 to 5 months with taper. ● Monitor for adverse e ects such as hirsutism, slowed linear growth, hypertension, GI bleeding, infection, and hyperglycemia. ● Administer with meals. CLIENT EDUCATION ● Educate the client and family to avoid large crowds (to decrease the risk of infection). ● Inform the client and family that using corticosteroids can increase appetite, cause weight gain (especially in the face), and cause mood swings. ● Educate the client and the family on the medication regime. ● Educate the client and the family on adverse e ects and when to notify the provider.
interprofesional care for nephrotic syndrome
Obtain a dietary consult.
interprofessional care for acute glomerulonephritis
Obtain a dietary consult.
interprofessional care for hemolytic uremic syndrome
Obtain a dietary consult.
expected findings for chronic renal failure
PHYSICAL ASSESSMENT FINDINGS ● Loss of energy ● Increase fatigue on exertion ● Pallor ● Occasional elevated blood pressure ● Delayed growth ● Anorexia ● Nausea and vomiting ● Decrease interest in activities ● Decreased or increased urinary output and compensatory increase in uid intake ● Anemia ● Headache ● Muscle cramps ● Nausea ● Weight loss ● Pu ness to face ● Malaise ● Bone or joint pain ● Itchy, bruised skin ● Amenorrhea in adolescent girls ● Circulatory overload manifested by hypertension, congestive heart failure and pulmonary edema ● Confusion, dulling of sensorium and coma are ndings of neurologic involvement. ● Tremors, muscle twitching and seizures are also ndings of neurologic involvement.
lab/diagnostic tests for chronic renal failure
PHYSICAL ASSESSMENT FINDINGS ● Loss of energy ● Increase fatigue on exertion ● Pallor ● Occasional elevated blood pressure ● Delayed growth ● Anorexia ● Nausea and vomiting ● Decrease interest in activities ● Decreased or increased urinary output and compensatory increase in uid intake ● Anemia ● Headache ● Muscle cramps ● Nausea ● Weight loss ● Pu ness to face ● Malaise ● Bone or joint pain ● Itchy, bruised skin ● Amenorrhea in adolescent girls ● Circulatory overload manifested by hypertension, congestive heart failure and pulmonary edema ● Confusion, dulling of sensorium and coma are ndings of neurologic involvement. ● Tremors, muscle twitching and seizures are also ndings of neurologic involvement.
expected findings for hemolytic uremic syndrome
PHYSICAL ASSESSMENT FINDINGS ● Occurs after prodromal period of diarrhea and vomiting ● Occasionally occurs after varicella, measles, or a UTI ● Loss of appetite ● Irritable ● Lethargy ● Pallor ● Bruising, purpura, or rectal bleeding ● Anuric and hypertensive in severe form ● Urinary output can be reduced or increased
expected findings for acute renal failure
PHYSICAL ASSESSMENT FINDINGS ● Oliguria: in reversible ARF there is a period of severe low urinary output ● Abrupt diuresis: with return to normal urine volumes ● Edema ● Drowsiness ● Circulatory collapse ● Cardiac arrhythmia: from hyperkalemia ● Seizures: from hyponatremia or hypocalcemia ● Tachypnea: from metabolic acidosis ● CNS manifestations: from continued oliguria
expected findings for nephrotic syndrome
PHYSICAL ASSESSMENT FINDINGS ● Weight gain over a period of days or weeks ● Facial and periorbital edema: decreased throughout the day ● Ascites ● Edema to lower extremities and genitalia ● Anorexia ● Diarrhea ● Irritability ● Lethargy ● Decreased frothy urine ● Blood pressure within expected reference range or slightly below
expected findings for acute glomerulonephritis
Recent upper respiratory infection or streptococcal infection PHYSICAL ASSESSMENT FINDINGS ● Cloudy, tea-colored urine ● Decreased urine output ● Irritability ● Ill appearance ● Lethargy ● Anorexia ● Vague reports of discomfort (headache, abdominal pain, dysuria) ● Periorbital edema ● Facial edema that is worse in the morning but then spreads to extremities and abdomen with progression of the day ● Mild to severe hypertension
nursing care for hemolytic uremic syndrome
SUPPORTIVE MEASURES ● Monitor I&O. ● Obtain daily weights. ● Administer uid replacement. ● Treat hypertension. ● Correct acidosis and electrolyte imbalances. ● Monitor CNS for seizure activity and stupor. ● Provide seizure precautions. ● Blood transfusions with fresh, washed packed cells for severe anemia: used with caution ● For child anuric for 24 hr or having oliguria with uremia or hypertension and seizures ◯ Hemodialysis ◯ Peritoneal dialysis ◯ Continuous hemo ltration
interprofessional care for acute renal failure
Support the child and family
medications for acute glomerulonephritis (diuretics and antihypertensives)
To remove accumulated uid and manage hypertension NURSING CONSIDERATIONS ● Monitor blood pressure. ● Monitor I&O. ● Monitor for electrolyte imbalances, such as hypokalemia. ● Observe for adverse e ects of medications. CLIENT EDUCATION ● Inform the client and family that dizziness can occur with the use of antihypertensives. ● Instruct the client and family to take the medication as prescribed and notify the provider if adverse e ects occur. Give instructions to continue the medication unless instructed otherwise.
acute renal failure
● ARF is the inability of the kidneys to excrete waste material, concentrate urine, and conserve electrolytes. ● The disorder can be acute or chronic and a ects most of the systems of the body ● Causes are classi ed as prerenal, intrinsic renal, and postrenal. Prerenal are most common cause of ARF
lab tests for hemolytic uremic syndrome
● CBC: decreased hemoglobin and hematocrit ● Elevated reticulocyte count ● Hematuria ● Proteinuria ● Elevated BUN and serum creatinine ● Fibrin split products in serum and urine (thrombocytopenia)
chronic renal failure
● CRF or insu ciency begins when the diseased kidneys can no longer maintain the normal chemical structure of body uids under normal conditions. ● A variety of diseases and disorders can result in CRF.
nursing care for acute glomerulonephritis
● Clients who have normal blood pressure and urine output can be managed at home. ● Monitor I&O. ● Monitor daily weights; weigh the child on the same scale with the same amount of clothing daily. ● Monitor vital signs. ● Monitor neurologic status and observe for behavior changes, especially in children who have edema, hypertension, and gross hematuria. Implement seizure precautions if condition indicates. ● Encourage adequate nutritional intake. ◯ Possible restriction of sodium and uid. ◯ Restrict foods high in potassium during periods of oliguria. ◯ Provide small, frequent meals of favorite foods due to a decrease in appetite. ◯ Refer the child for dietary consultation if indicated. ◯ Avoid added salt and salty foods such as chips. ● Manage uid restrictions as prescribed. Fluids can be restricted during periods of edema and hypertension. ● Monitor skin for breakdown. ◯ Encourage frequent turning and repositioning. ◯ Keep skin dry. ◯ Pad bony prominences and use a specialty mattress. ◯ Elevate edematous body parts. ● Assess tolerance for activity. Provide frequent rest periods. ● Provide for age-appropriate diversional activities. ● Cluster care to facilitate rest and tolerance of activity. ● Monitor and prevent infection. ◯ Advise the child to turn, cough, and deep breathe to prevent pulmonary involvement. ◯ Monitor vital signs, especially temperature, for changes secondary to infection. ◯ Maintain good hand hygiene. ◯ Administer antibiotic therapy as prescribed (indicated for children who have evidence of persistent streptococcal infection). ● Provide emotional support.
acute glomerulonephritis
● Common features are oliguria, edema, hypertension and circulatory congestion, hematuria, and proteinuria. ● Acute poststreptococcal glomerulonephritis (APSGN) is an antibody-antigen disease that occurs as a result of certain strains of the Group A β-hemolytic streptococcal infection and is most commonly seen in children between the ages of 5 and 8 years.
client education for acute renal failure
● Encourage adequate rest. ● Educate the family about therapeutic regimen. ● Keep family informed of child's progress. ● Encourage follow-up care.
client education for chronic renal failure
● Encourage rest. ● Educate the family about therapeutic regimen. ● Keep family informed of child's progress. ● Encourage follow-up care.
client education for acute glomerulonephritis
● Encourage the child to verbalize feelings related to body image. ● Educate the child regarding appropriate dietary management. ● Encourage adequate rest. ● Educate the family about the need for follow-up care. ● Teach the family how to monitor blood pressure and daily weight. ● Teach the family about administration and side e ects of diuretics and antihypertensive medications. ● Encourage the child and family to avoid contact with others who might be ill.
client education for nephrotic syndrome
● Encourage the client to verbalize feelings related to body image. ● Educate the client regarding appropriate dietary management. ● Encourage adequate rest. ● Educate the family about the need for follow-up care. ● Inform the family of strategies to decrease the risk of infection (good hand hygiene, up-to-date immunizations, avoidance of infected people). ● Teach the family how to monitor blood pressure, daily weight, and protein in urine. Instruct the family to notify the provider if manifestations worsen, which indicates relapse. ● Teach the family about administration and side e ects of medication. ● Provide support to families and make appropriate referrals as needed. Relapses can cause physical, emotional, and nancial stress for the client and family.
complications of chronic renal failure
● End-stage renal disease ● Progressive deterioration ● Irreversible progress of renal insu ciency
nutrition for chronic renal failure
● Goal is to provide adequate calories and protein for growth. ● Dietary phosphorus can need to be restricted. ● Potassium is restricted if oliguria or anuria. ● Reduce protein and milk. ● Dietary sources of folic acid and iron.
hemolytic uremic syndrome
● HUS is an acute renal disease characterized by acute renal failure, hemolytic anemia and thrombocytopenia. ● HUS represents one of the main causes of acute renal failure in early childhood. ● Breakdown of red blood cells clog the kidneys.
lab tests for nephrotic syndrome (serum chemistry)
● Hypoalbuminemia: reduced serum protein and albumin ● Hyperlipidemia: elevated serum lipid levels ●Hemoconcentration: elevated Hgb, Hct, and platelets ● Possible hyponatremia: reduced sodium level ●Glomerular ltration rate: normal or high
nutrition for acute renal failure
● Ingest concentrated foods without uids ● Maintain calories while minimizing tissue catabolism, metabolic acidosis, hyperkalemia, and uremia. ● When nourishment is via IV route, prevent uid overload.
risk factors for chronic renal failure
● Most common causes before 5 years of age are congenital renal and urinary tract malformations and vesicoureteral re ux. ● Glomerular and hereditary renal disease predominate in the 5- to 15-year-old age group.
meds for hemolytic uremic syndrome
● No evidence that heparin, corticosteroids, or fibrinolytic agents are beneficial. ● Plasma infusion is under study and can be useful.
interprofessional care for chronic renal failure
● Obtain a dietary consult. ● Encourage dental care.
nutrition for hemolytic uremic syndrome
● Once vomiting and diarrhea resolves, enteral nutrition is initiated. ● Parenteral nutrition for children who have severe, persistent colitis and marked tissue catabolism
risk factors for hemolytic uremic syndrome
● Peak incidence 6 months to 3 years ● Predominantly in Caucasian people, and prevalent in South Africa, Argentina, and west coasts of North and South America. ● Toxins enter the bloodstream and destroy red blood cells Diarrhea-positive (D+) HUS: responsible for 90% of cases caused by ingestion of Shiga toxin producing Escherichia coli, E. coli 0157:H7 is common pathogen Diarrhea-negative (D-) or atypical HUS: can be due to nonenteric infections, disturbances in the complement system, malignancies, or genetic disorders
risk factors for acute renal failure
● Prerenal ● Dehydration secondary to diarrheal disease or persistent vomiting. ● Surgical shock and trauma (including burns)
lab tests for nephrotic syndrome (urinalysis)
● Proteinuria: protein greater than 2+ on dipstick ● Hyaline casts ● Few RBCs ● Oval fat bodies
nursing care for chronic renal failure
● Provide rest. ● Monitor I&O. ● Monitor vital signs. ● Monitor daily weights. ● Manage hypertension. ● Monitor for infection. ● Monitor sensorium. ● Maintain sodium restriction. ● Initiate uid restriction if edema present. ● Encourage reduction of dietary phosphorus.
nursing care for nephrotic syndrome
● Provide rest. ● Monitor I&O. Monitor urine for protein. ● Monitor vital signs. ● Monitor daily weights; weigh the child on the same scale with the same amount of clothing. ● Monitor edema and measure abdominal girth daily. Measure at the widest area, usually at or above the umbilicus. Assess degree of pitting, color, and texture of skin. ● Monitor and prevent infection. ◯ Assist the client to turn, cough, and deep breathe to prevent pulmonary involvement. ◯ Monitor vital signs, especially temperature, for changes secondary to infection. ◯ Maintain good hand hygiene. ◯ Administer antibiotic therapy as prescribed. ● Encourage nutritional intake within restriction guidelines. Salt can be restricted during the edematous phase. ● Cluster care to provide for rest periods. ● Assess skin for breakdown areas. ◯ Avoid use of urinary collection bags in very young children. ◯ Pad bony prominences, or use a specialty mattress to reduce breakdown of skin. ◯ Encourage frequent turning and repositioning. ◯ Keep the client's skin dry. ◯ Elevate edematous body parts.
client education for hemolytic uremic syndrome
● Teach the family to avoid undercooked meat, especially ground beef. Internal temperature of meat should be at least 74° C (165° F). ● Avoid unpasteurized apple juice and unwashed raw vegetables. ● Avoid alfalfa sprouts. ● Avoid public pools. ● Do not use antimotility medications for diarrhea. ● Support the child and family regarding severity of the illness.
meds for chronic renal failure
● Thiazides or furosemide for hypertension ● Beta-blockers and vasodilators for severe hypertension ● Phosphorus binding agent ● Calcium ● Vitamin D: active form ● Water-soluble vitamins ● Sodium bicarbonate and potassium citrate to alleviate acidosis ● Folic acid and recombinant human erythropoietin for anemia ● Recombinant growth hormone for children who have growth retardation ● Antimicrobials for infection ● Antiepileptic for seizures ● Diphenhydramine for pruritus
lab tests for acute glomerulonephritis
● Throat culture: to identify possible streptococcus infection (usually negative by the time of diagnosis) ● Urinalysis: proteinuria, smoky or tea-colored urine, hematuria, increased speci c gravity ● Renal function: elevated BUN and creatinine ●Antistreptolysin O (ASO) titer: positive indicator for the presence of streptococcal antibodies ● Antihyaluronidase (AHase) ●Antideoxyribonuclease B (ADNase-B) ● Antistreptokinase (ASKase) ● Antideoxyribonuclease B (ADNase-B) ● Serum complement (C3): decreased initially; increases as recovery takes place; returns to normal at 8 to 10 weeks post glomerulonephritis
nursing care for acute renal failure
● Treat underlying cause of ARF. ● Admit to pediatric intensive care unit. ● Monitor strict I&O. ● Assess uid and electrolyte balance. ● Limit uid intake. ● Obtain daily weights. ● Monitor vital signs for hypertension complication. ● Maintain neutral temperature ● Provide replacement IV uids. ● Monitor central venous pressure. ● Maintain urinary catheterization. ● Limit activity. ● Assess sensorium. ● Assess for behavior changes or seizure activity. ● Implement seizure precautions if indicated. ● Assess for infection.
nephrotic syndrome
●Alterations in the glomerular membrane allow proteins (especially albumin) to pass into the urine, resulting in decreased serum osmotic pressure. ●It can be primary, secondary, or congenital.
