OBJECTIVES

General:
This study aims to broaden the knowledge of the student – nurses as well as their
superiors about the disease, to be able to respond and intervene with client's correctly,
render accurate nursing care needed in order to provide an effective nursing
management in a hospital set – up until the client is ready for discharge.

Specific:

• To identify the major disease manifestations, risk factors and etiology.

• To understand the pathophysiology of Nephrotic Syndrome in relation to the
anatomy and physiology.
• To assess a patient with Nephrotic Syndrome.
• To know the nature of the drugs administered with compliance to nursing
responsibilities.
• To formulate a nursing care plan for Nephrotic Syndrome
• To implement effective nursing intervention.
Introduction

Definition

• Nephrotic syndrome is a group of symptoms including protein in the urine

(more than 3.5 grams per day), low blood protein levels, high cholesterol
levels, high triglyceride levels, and swelling
• Autoimmune process leading to structural alteration of glomerular
membrane that results in increased permeability to plasma proteins,
particulary albumin.
• Nephrotic syndrome is a disorder of the glomeruli (clusters of microscopic
blood vessels in the kidneys that have small pores through which blood is
filtered) in which excessive amounts of protein are excreted in the urine.
This typically leads to accumulation of fluid in the body (edema) and low
levels of the protein albumin and high levels of fats in the blood.
• Nephrotic syndrome is not a specific glomerular disease but a cluster of
clinical findings, including:Marked increase in protein (particularly albumin)
in the urine (proteinuria), Decrease in albumin in the blood
(hypoalbuminemia), Edema, High serum cholesterol and low-density
lipoproteins (hyperlipidemia).
CLASSIFICATION
Idiopathic nephrotic syndrome (90% of cases)
Minimal change nephrotic syndrome
Nephrotic syndrome with mesangial proliferation
Nephrotic syndrome with focal sclerosis
Nephrotic syndrome secondary to glomerulonephritis (10% of cases)
Membranous glomerulopathy
MPGN
OTHRS as SLE and HSP
Congenital nephrotic syndrome AR presenting at birth or during the 1st 6 months

Causes:
Nephrotic syndrome has many causes and may either be the result of a disease limited to
the kidney, called primary nephrotic syndrome, or a condition that affects the kidney and
other parts of the body, called secondary nephrotic syndrome.

Primary causes of nephrotic syndrome are usually described by the histology, i.e.,
minimal change disease (MCD), focal segmental glomerulosclerosis (FSGS) and
membranous nephropathy (MN), sickle cell disease, diabetes mellitus and malignancy
such as leukemia.
PREDISPOSING
FACTO RATIONALE
R
Age Children ages 1 1⁄2 and 4 yr are predisposed in having nephrotic
syndrome.
Sex Males are more predisposed than males in acquiring nephrotic syndrome.
Genetic People with family history of nephrotic syndrome increases likelihood of
s developing nephrotic syndrome.

PRECIPITATING RATIONALE
FACTOR
Focal segmental Most common cause of idiopathic NS among adults. May be
glomeruloscleros secondary to HIV/AIDS infection or loss of nephrons.
is
- HIV/AIDS
- Nephrectomy
Membranous Deposition of immune complexes on the glomerular basement
nephropathy membrane causing it to thicken. It can be secondary to certain
– Hepatitis B cancers, Hepatitis B infections and autoimmune disorders such as
infection SLE.
– SLE
– Cancer
Minimal change Causes 80 to 90% of childhood nephrotic syndrome in children 4 to
disease 8 years of age idiopathic in nature.
Diabetes Mellitus Prolonged elevated blood glucose levels alters glomerular base
membranes thereby causing impaired renal function.
Drugs These drugs can contribute to the development of focal segmental
– Heroin glomerulosclerosis, membranous nephropathy and minimal change
– NSAID disease which in turn precipitate occurrence of nephrotic syndrome.
– Gold
– Penicillamine
Human anatomy (KIDNEY)

NORMAL KIDNEY SIZE

- The normal kidney size of an adult human is about 10 to 13 cm (4 to 5

inches) long and about 5 to 7.5 cm (2 to 3 inches) wide. It is approximately the
size of a conventional computer mouse.
NORMAL KIDNEY COLOR
The kidneys are dark-red, bean-shaped organs. One side of the kidney bulges
outward (convex) and the other side is indented (concave)
NORMAL KIDNEY LOCATION
– towards the back of the abdominal cavity, just above the waist. One
kidney is normally located just below the liver, on the right side of the
abdomen and the other is just below the spleen on the left side.
–
Kidney anatomy and excretion
The most basic structures of the kidneys, are nephrons. They are responsible for filtering
the blood.

The renal artery delivers blood to the kidneys each day. Over 180 liters (50 gallons) of
blood pass through the kidneys every day. When this blood enters the kidneys it is filtered
and returned to the heart via the renal vein.
The process of separating wastes from the body fluids and eliminating them, is known as
excretion. The urinary system is one of the organ systems responsible for excretion. The
kidneys are the main organs of the urinary system.

Kidney anatomy and blood vessels

The kidney is full of blood vessels. Every function of the kidney involves blood, therefore,
it requires a lot of blood vessels to facilitate these functions.

Together, the two kidneys contain about 160 km of blood vessels.

Renal capsule
is a tough fibrous layer surrounding the kidney and covered in a thick layer of adipose
tissue. It provides some protection from trauma and damage

Renal cortex
is the outer portion of the kidney between the renal capsule and the renal medulla. In the
adult, it forms a continuous smooth outer zone with a number of projections (cortical
columns) that extend down between the pyramids.

Ultrafiltration occurs.

Renal medulla
is the innermost part of the kidney split up into a number of sections, known as the renal
pyramids

contains the structures of the nephrons responsible for maintaining the salt and water
balance of the blood

is hypertonic to the filtrate in the nephron and aids in the reabsorption of water
Patient's Profile
a. Demographic Data

Name: Baby X
Age: 3 years old
Sex: M
Nationality: Filipino
Religion: Catholic
Physician: Joselito Mattheus, MD
Informant: Minerva Flores (mother)
Mother: Minerva Del Valle Flores
Father: Christian Flores
Date of Arrival: February 4, 2011 5:55 pm

b. Chief Complaint: Periorbital Edema

c. History of Present Illness:
Was diagnosed with Nephrotic Syndrome last July 2010. Three days Prior to
Admission, the patient had a non productive cough but with no other sign and symptoms
of the illness. The patient noted to have periorbital edema upon waking up. And one day
prior to admission, the patient was to have bipedal edema. This prompted the mother to
seek medical attention.

d. Past Medical History

Baby X haven't undergone any surgery but was hospitalized last July 2010 in this
institution due to the illness, Nephrotic Syndrome. He doesn't have any history of other
disease. But the patient was already taking Prednisone even before.
He doesn't have also any other childhood illness. Baby X had her immunization of
BCG, Hepa (I, II, III), MMR, DPT (I, II, III), and OPV (I, II, III).

e. Family History
Mother Father
HPN (+) (+)
Cancer (-) (-)
TB (-) (-)
Asthma (-) (-)
Diabetes Mellitus (-) (-)

f. Maternal and Perinatal History

Born to a 21 year old with a G2P1 in the year 2002. The mother had UTI
during the second semester. Was a normal delivery in a lying-in by a midwife.
Baby X was breastfed, and then shifted to bottled milk. Baby X started having solid
food when he was 9 month old.

Laboratory
Total Protein Albumin Globulin

Result Values Analysis Interpretation

Total Protein 31.99 Adult:66-8 Decreased Due to low
1-18y/o: 57-80 Albumin level
Newborns (1-
28days): 41-63
Albumin 10.21 35-50 Decreased Dehydration,kid
ney losses
Globulin 22.00 11-35 Normal Normal
A/C Ratio 0.47 1.1-2.2 Decreased Liver
dysfunction

Result Values Interpretation Analysis

Creatinine 20.77 mmol/L Adults 45- Normal Normal
104
Neonate 27-
87
Infant 14-34
Child 23-68
Potassium 3.64 mmol/L 3.6-5.5 Normal Potassium is the
most abundant
intracellular cation,
much smaller
accounts are found
in the blood. K is
essential for the
transmission of
electrical impulses
in cardiac and
skeletal muscle. In
addition, it helps to
maintain the
osmolality and
electroneutrality of
cells, functions in
enzyme reactions
that transform
glucose into energy
and amino acids
into proteins and
participates in the
maintenance of
acid base balance.
Na 130.30 135-145 Decreased Sodium is the most
mmol/L abundant
electrolytes in ECF,
its concentration
 ranges from 135-
145 mmol/L.
Hyponatremia
refers to a serum
Na level that is
below normal (less
than 135 meq/L)
Na maybe lost by
way of vomiting,
use of diuretics
particularly in
combination with a
low salt diet.
Cl 102.20 100-111 Normal Normal
Calcium 1.89 mmol/L 2.20-2.65 Below the normal Low blood calcium (or
range hypocalcemia) can have
various causes,
including: bone
problems, low levels of
the blood protein
albumin, inflammation of
the pancreas, kidney
disease, malfunction of
the parathyroid gland
(hypoparathyroidism)
and improper absorption
of food or calcium.

URINALYSIS

A urinalysis is usually ordered when a doctor suspects that a child has a urinary
tract infection or a health problem that can cause an abnormality in the urine.
This test can measure:

• the number and variety of red and white blood cells

• the presence of bacteria or other organisms
• the presence of substances, such as glucose, that usually shouldn't be found in
the urine
• the pH, which shows how acidic or basic the urine is
• the concentration of the urine

RESULT Normal Intepretation Analysis

Color Yellow Amber pale to Normal Urine is normally
dark yellow clear yellow or
amber in color. The
color of urine is
 mainly a result of
the presence of the
pigment urochrome,
which is produced
through endogenous
metabolic processes.
Transparenc Slightly Clear Normal Transparency refers
y Turbid to the clarity of the
urine.
Reaction 6.5 5-6 Increase Acidic, may indicate
(ph) infection.
Specific 1.025 1.010-030 Normal Specific gravity is an
Gravity indicator of urine
concentration of the
amount of solutes
(metabolic waste
and electrolytes)
present in the urine.
Sugar (-) Negative ↑-diabetes mellitus,
renal glycosuria
(excretion of
glucose),
nephrotoxic
chemicals (carbon
monoxide)
Protein (+) Negative -

EXAM RESULT NORMAL INTEPRETATION ANALYSIS

NAME VALUE
RBC 6-9 0-2/hpf Normal -
WBC 20-25 0-5/hpf Normal -
Crystals Amorphous None Some crystals are
Urates – found exclusively in
Few acid urine. Healthy
people often have only
a few crystals in their
urine. A large number
of crystals, or certain
types of crystals, may
mean kidney stones
are present or there is
a problem with how
the body is using food
(metabolism).
Epithelial Few Few Normal Epithelial cells are
cells found in urine samples
are derived a.) the
lining of female lower
urethra and the
vagina. b.) linings of
the renal pelvis
bladder. c.) renal
 tubules themselves
Bacteria cast Few Few Normal -
Casts Hyaline cast None Hyaline casts are formed in
1-2/hpf the absence of cells in the
renal tubular lumen. They
have a smooth texture and a
refractive index very close to
that of the surrounding fluid.
When present in lower
numbers (0-1/LPF) in
concentrated urine of
otherwise normal patients,
hyaline casts are not always
indicative of clinically
significant disease.

Complete Blood Count

The complete blood count (CBC) is a common blood test that evaluates the
three major types of cells in the blood: red blood cells, white blood cells, and
platelets. A CBC may be ordered as part of a routine checkup, or if your child is
feeling more tired than usual, seems to have an infection, or has unexplained
bruising or bleeding. The CBC can also test for loss of blood, abnormalities in
the production or destruction of blood cells, acute and chronic infections,
allergies, and problems with blood clotting.

Result Values Interpretation Analysis

Hgb 12.6 12-14 g/L Normal Hgb is the
main
intracellular
protein. Its
primari
Hct 0.403 0.37-0.47 Normal range Hct or packed
RBC volume
measure the
proportion of
RBC's in a
volume of
whole blood
and is
expressed as
a percentage.
RBC 4.88 4.7-6.1 x10^9/L Normal Erythrocytes
are the most
 abundant
cells of the
blood. Its
primarily
responsible
for tissue
oxygenation
thus, a
decreased
level of RBC
indicates
anemia.
MCV 82.4 80-95fL Normal Mean
corpuscular
volume
indicates the
volume/size
of the hgb
each RBC.
Very useful in
differentiatin
g anemia.
MCH 25.8 27-31pg Below the normal
range
31.3 32-36 g/dL Below the normal MCHC is the
MCHC range proportion of
the hgb
contained in
each RBC.
Indication of
hgb
deficiency
and of the
oxygen
carrying
capacity of
the individual
erythrocytes.
MEDICAL MANAGEMENT

Fluid and sodium restriction, oral or intravenous diuretics, and angiotensin-

converting enzyme inhibitors.
• Fluid and sodium restrictions
Creating a negative sodium balance will help reduce edema, presumably as the
underlying illness is treated or as renal inflammation slowly resolves. Patients should limit
their sodium intake to 3 g per day, and may need to restrict fluid intake (to less than
approximately 1.5 L per day). Large doses (e.g., 80 to 120 mg of furosemide) are often
required and these drugs typically must be given intravenously because of the poor
absorption of oral drugs caused by intestinal edema. Low serum albumin levels also limit
diuretic effectiveness and necessitate higher doses. Thiazide diuretics, potassium-sparing
diuretics, or metolazone (Zaroxolyn) may be useful as adjunctive or synergistic diuretics.
• Diuretics
"Diuretics are the mainstay of medical management; however, there is no evidence to
guide drug selection or dosage," Dr. Kodner writes. "Based on expert opinion, diuresis
should aim for a target weight loss of 1 to 2 lb (0.5 to 1 kg) per day to avoid acute renal
failure or electrolyte disorders. Loop diuretics, such as furosemide (Lasix) or bumetanide,
are most commonly used."
• Angiotensin-converting enzyme
In persons with nephrotic syndrome, angiotensin-converting enzyme inhibitors have been
shown to decrease proteinuria and lower the risk for progression to renal disease.
Angiotensin-converting enzyme (ACE) inhibitors have been shown to reduce pro-teinuria
and reduce the risk of progression to renal disease in persons with nephrotic
syndrome.15,16 One study found no improvement in response when corticosteroid
treatment was added to treatment with ACE inhibitors.17 The recommended dosage is
unclear, and enalapril (Vasotec) dosages from 2.5 to 20 mg per day were used. Most
persons with nephrotic syndrome should be started on ACE inhibitor treatment to reduce
protein-uria, regardless of blood pressure.

* Although corticosteroid treatment may benefit some adults with nephrotic syndrome,
research evidence supporting this therapy is limited. At present, intravenous albumin,
prophylactic antibiotics, and prophylactic anticoagulation are not advised.

ALBUMIN Intravenous albumin has been proposed to aid diuresis, because edema
may be caused by hypoalbuminemia and resulting oncotic pressures. However,
there is no evidence to indicate benefit from treatment with albumin, and adverse
effects, such as hypertension or pulmonary edema, as well as high cost, limit its use.
CORTICOSTEROIDS Treatment with corticosteroids remains controversial in the
management of nephrotic syndrome in adults. It has no proven benefit, but is
recommended in some persons who do not respond to conservative treatment. Treatment
of children with nephrotic syndrome is different, and it is more clearly established that
children respond well to corticosteroid treatment. Family physicians should discuss with
patients and consulting nephrologists whether treatment with corticosteroids is advisable,
weighing the uncertain benefits and possibility of adverse effects. Alkylating agents (e.g.,
cyclophosphamide [Cytoxan]) also have weak evidence for improving disease remission
and reducing proteinuria, but may be considered for persons with severe or resistant
disease who do not respond to corticosteroids.

LIPID-LOWERING TREATMENT A Cochrane review is underway to investigate the

benefits and harms of lipid-lowering agents in nephrotic syndrome. Some evidence
suggests an increased risk of athero-genesis or myocardial infarction in persons with
nephrotic syndrome, possibly related to increased lipid levels. However, the role of
treatment for increased lipids is unknown and, at present, the decision to start lipid-
lowering therapy in persons with nephrotic syndrome should be made on the same basis
as in other patients.

ANTIBIOTICS There are no data from prospective clinical trials about treatment and
prevention of infection in adults with nephrotic syndrome. Given the uncertain risks of
infection in adults with nephrotic syndrome in the United States, there are currently no
indications for antibiotics or other interventions to prevent infection in this population.
Persons who are appropriate candidates should receive pneumococcal vaccination.

ANTICOAGULATION THERAPY There are currently no recommendations for prophylactic

anticoagulation to prevent thromboembolic events in persons with nephrotic syndrome
who have not had previous thrombotic events, and clinical practice varies. A Cochrane
review is in process. Physicians should remain alert for signs or symptoms suggesting
thromboembolism and, if it is diagnosed, these events should be treated as in other
patients. Persons who are otherwise at high risk of thromboembolism (e.g., based on
previous events, known coag-ulopathy) should be considered for prophy-lactic
anticoagulation while they have active nephrotic syndrome.

NURSING MANAGEMENT

• Assess and document the location and character of the patient's edema.
• Weigh the patient each morning after he voids and before he eats, make sure he's
wearing the same amount of clothing each time you weigh him.
• Measure blood pressure with the patient lying down and standing. Immediately
report a decrease in systolic or diastolic pressure exceeding 20 mm Hg.
• Monitor intake and output
• Ask the dietitian to plan a low-sodium diet with moderate amounts of protein.
• Frequently check urine for protein
• Provide meticulous skin care to combat the edema that usually occurs with
nephrotic syndrome
• Use a reduced-pressure mattress or padding to help prevent pressure ulcers.
• To prevent the occurrence of thrombophlebitis, encourage activity and exercise,
 and provide antiembolism stockings as ordered
• Give the patient and family reassurance and support, especially during the acute
phase, when edema is severe and the patient's body image changes.

DISCHARGE PLANNING
MEDICATION

• Advice patient to continue the medications prescribed by the physician.

• Emphasize the strict adherence to dosage and the frequency for desired
therapeutic effect

• Explain the possible consequences of not adhering the medication and the
possible side effects while taking the medications.

• Caution patients who are receiving steroid therapy to take the dosages
exactly as prescribed; explain that skipping doses could be harmful or life-
threatening.

• In cases of long-term steroid therapy, explain the signs of complications,

such as GI bleeding, stunted growth (children), bone fractures, and
immunosuppression.

EXERCISE

• Advice the client to perform light exercise such as: stretching of the upper
and lower extremities and carrying out some simple chores as form of
exercise for good circulation. To prevent atrophy of the muscles especially
on the affected part of the body and body weakness
• Do not restrict on activity, unless the client is severely edematous

TREATMENT

• Encourage patients with hypercoagulability to maintain hydration and

mobility and to follow the medication regimen.

• Explain that they need to monitor the urine daily for protein and keep a
diary with the results of the tests.

HEALTH TEACHING
 • Teach the patient and family about the disease process, prognosis, and
treatment plan.

• Instruct the patient and family to avoid exposure to communicable diseases

and to engage in scrupulous infection control measures such as frequent
hand washing.

• Teach family members to report even mild signs of infection.

OUT – PATIENT

• Inform about possible check – ups and treatment especially if fever and
abdominal pain recur.

DIET

• Advise the mother of the client to avoid adding extra salt to food at the
table and try to reduce the intake of processed foods such as: chips, canned
goods, tocino, instant noodles, seasoning, etc. Reduce sodium intake to
1000-2000mg daily, sodium should be less than or equal to calories per
serving
• Instruct the mother when giving her child of fluids; it should be less than
1000 liter per day. Limit on intake of fluid to avoid edematous
SPIRITUALITY

• Encourage creative expression, as in art, music and writing. This keeps the
imagination alive and serves to regenerate the body, mind and spirit.