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Renal Disorders chapter 26 Unit 2 nursing care of children with system disorders SectionGenitourinary and Reproductive Disorders Chapter 26 Renal Disorders Overview ●● Acute glomerulonephritis (AGN) ◯◯ ◯◯ ●● Acute glomerulonephritis may occur as a single episode or may be the result of a disease, usually following an infectious process. The most common types are pneumococcal, streptococcal, and viral infections. Oliguria, edema, hypertension, circulatory congestion, hematuria, and proteinuria are common findings associated with AGN. Nephrotic syndrome is a group of symptoms, not a disease. It is the most common presentation of glomerular injury in children. Three forms of the syndrome include primary, congenital, and secondary nephrotic syndrome. The most common form of disease in children is minimal change nephrotic syndrome and accounts for 80% of all cases. Acute glomerulonephritis (agn) Overview ●● Acute poststreptococcal glomerulonephritis (APSGN) is the most common of the postinfectious renal diseases. ◯◯ ◯◯ ◯◯ ◯◯ APSGN is an antibody-antigen disease that occurs as a result of certain strains of the Group A ß-hemolytic streptococcal infection and is most commonly seen in children between the ages of 6 and 7. The exact mechanism of the pathophysiology for APSGN is not certain. It is believed that immune complexes develop and become trapped in the glomerular capillary loop at the basement membrane. This produces swelling and occlusion of the capillary lumen and results in alterations in the glomerular filtration rate. Renal manifestations usually occur 10 to 21 days post infection. Prognosis varies depending upon the specific cause, but spontaneous recovery generally occurs after the acute illness. Recurrence is not common. rn nursing care of children 277 Renal Disorders Assessment ●● Risk Factors ◯◯ ●● Subjective Data ◯◯ ◯◯ ●● Infection with pneumococcal, streptococcal, or viral agent Recent upper respiratory infection or streptococcal infection Lack of specific reports (Older children may report abdominal discomfort, headaches, painful urination, and anorexia/nausea.) Objective Data ◯◯ Physical Assessment Findings ■■ Decreased glomerular filtration rate leading to decreased urine output ■■ Anorexia ■■ Pallor ■■ Vague reports of discomfort (headache, abdominal pain, dysuria) ■■ Dyspnea ■■ Orthopnea ■■ Moist crackles on auscultation ■■ Distended neck veins ■■ Periorbital edema ■■ ◯◯ ■■ Mild to severe hypertension ■■ Pale appearance, irritability, and lethargy (The child seems ill.) Laboratory Tests ■■ ■■ ■■ ■■ ■■ ■■ 278 Facial edema that is worse in the morning but then spreads to extremities and abdomen with progression of the day Throat culture to identify possible streptococcus infection (usually negative by the time of diagnosis) Urinalysis – Proteinuria, smoky or tea-colored urine, hematuria, cell debris (red cells and casts), elevated specific 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), and streptozyme antibodies may be present. Serum complement (C3) – Decreased initially; increases as recovery takes place; returns to normal at 8 to 10 weeks post glomerulonephritis rn nursing care of children Renal Disorders ◯◯ Diagnostic Procedures ■■ Chest x-ray ☐☐ ☐☐ ☐☐ Used to identify pulmonary complications, especially during the edematous phase XX Pulmonary edema XX Cardiac enlargement XX Pleural effusions Nursing Actions XX Ensure that adolescents are not pregnant. XX Assist with proper positioning. Client Education XX Explain the procedure to the child and family. Collaborative Care ●● Nursing Care ◯◯ ◯◯ ◯◯ ◯◯ ◯◯ ◯◯ ◯◯ ◯◯ 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 within restriction guidelines. A regular diet with elimination of high sodium foods will be appropriate for most. ■■ 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. Manage fluid restrictions as prescribed. Fluids may be restricted during periods of edema and hypertension. Monitor skin for breakdown areas and prevent pressure sores. ■■ 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 for frequent rest periods. rn nursing care of children 279 Renal Disorders ◯◯ 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. Provide emotional support. Medications ◯◯ Diuretics and antihypertensives ■■ Used to removal accumulated fluid and manage hypertension ■■ Nursing Considerations ■■ ☐☐ Monitor blood pressure. ☐☐ Monitor intake and output. ☐☐ Monitor for electrolyte imbalances, such as hypokalemia. ☐☐ Observe for side effects of medications. Client Education ☐☐ ☐☐ ☐☐ ●● Instruct the child and family to take the medication as prescribed and notify the provider if side effects occur. Give instructions to continue the medication unless instructed otherwise. Obtain a dietary consult. Care After Discharge ◯◯ Client Education ■■ Encourage the child to verbalize feelings related to body image. ■■ Educate the child regarding appropriate dietary management. ■■ Encourage adequate rest. ■■ 280 Inform the child and family that dizziness can occur with the use of antihypertensives. Interdisciplinary Care ◯◯ ●● Encourage the child to eat food high in potassium if potassium-sparing diuretics are not used. Educate the family about the need for follow-up care. The child should be seen by the provider weekly for several weeks and then monthly until the disease is fully resolved. rn nursing care of children Renal Disorders ■■ ■■ ■■ ●● Teach the family how to monitor blood pressure and daily weight. Teach the family about administration and side effects of diuretics and antihypertensive medications. Encourage the child and family to avoid contact with others who may be ill. Client Outcomes ◯◯ The child will maintain optimal renal function. ◯◯ The child will maintain blood pressure within the normal reference range. ◯◯ The child and family will have adequate support. Nephrotic Syndrome Overview ●● Nephrotic syndrome ◯◯ ◯◯ ◯◯ In nephrotic syndrome, alterations in the glomerular membrane allow proteins (especially albumin) to pass into the urine, resulting in decreased serum osmotic pressure. The exact cause of glomerular alteration is not well understood and is thought to be due to metabolic, biochemical, physiochemical, or immune-mediated causes. Nephrotic syndrome is characterized by hyperlipidemia, proteinuria, hypoalbuminemia, and edema. Management of nephrotic syndrome is aimed at reducing the excretion of protein, reducing fluid retention, preventing infection, and preventing complications. Assessment ●● Risk Factors ◯◯ Minimal change nephrotic syndrome (MCNS) ■■ ■■ ◯◯ ◯◯ ●● Peak incidence is between 2 and 7 years of age. Cause is unknown, but it may have a multifactorial etiology (immune-mediated, biochemical). Secondary nephrotic syndrome (occurs after or is associated with glomerular damage due to a known cause). Congenital nephrotic syndrome (an inherited disorder). Subjective Data ◯◯ Weight gain over a short period of days or weeks ◯◯ Poor appetite, possibly anorexia, nausea and vomiting, and diarrhea ◯◯ Decreased activity levels ◯◯ Irritability rn nursing care of children 281 Renal Disorders ●● Objective Data ◯◯ ◯◯ Physical Assessment Findings ■■ Weight gain ■■ Edema (facial/periorbital) is worse in morning and decreases as the day progresses ■■ Ascites and dependent edema (especially in the labia, scrotum, legs, and ankles) ■■ Dark, frothy urine, decreased urine output, and oliguria ■■ Normal or slightly elevated blood pressure Laboratory Tests ■■ ■■ ◯◯ Urinalysis/24-hr urine collection ☐☐ Proteinuria – Protein greater than 3+ or 4+ (greater than 3.5 g in 24 hr) ☐☐ Hyaline casts ☐☐ Increased specific gravity ☐☐ Color change Serum chemistry ☐☐ Hypoalbuminemia – Reduced serum protein and albumin ☐☐ Hyperlipidemia– Elevated serum lipid levels ☐☐ Hemoconcentration– Elevated Hgb, Hct, and platelets Diagnostic Procedures ■■ 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. Collaborative Care ●● Nursing Care ◯◯ Provide rest. ◯◯ Monitor I&O. Monitor urine for specific gravity and protein. ◯◯ ◯◯ ◯◯ 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. ■■ ■■ 282 Assist the child to turn, cough, and deep breathe to prevent pulmonary involvement. Monitor vital signs, especially temperature, for changes secondary to infection. rn nursing care of children Renal Disorders ◯◯ ●● ■■ Maintain good hand hygiene. ■■ Administer antibiotic therapy as prescribed. Encourage nutritional intake within restriction guidelines. Salt and fluids may be restricted during the edematous phase. Increase protein in diet to replace protein losses. ◯◯ Cluster care to provide for rest periods. ◯◯ Assess skin for breakdown areas. Prevent pressure sores. ■■ 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 of the child. ■■ Keep the child’s skin dry. ■■ Elevate edematous body parts. Medications ◯◯ Corticosteroid – Prednisone (Deltasone) ◯◯ Nursing Considerations ■■ ■■ ◯◯ Monitor for infection. Client Education ■■ ■■ ■■ ◯◯ Administer for 7 to 21 days (based on response) and then taper over several months with decreasing doses until discontinued. Educate the child and family to avoid large crowds (to decrease the risk of infection). Instruct the family to administer the medication on alternate days after the first 4 weeks of therapy. Inform the child and family that using corticosteroids can increase appetite, cause weight gain (especially in the face), and cause mood swings. Diuretic – Furosemide (Lasix) ■■ Eliminates excess fluid from the body ■■ Nursing Considerations ☐☐ Encourage the child to eat foods that are high in potassium. ☐☐ Monitor serum electrolyte levels periodically. rn nursing care of children 283 Renal Disorders ◯◯ ◯◯ 25% albumin ■■ Increases plasma volume and decreases edema ■■ Nursing Considerations ☐☐ Watch for anaphylaxis. Administer for children who cannot tolerate prednisone or who have repeated relapses of MCNS. Obtain a dietary consult. Care After Discharge ◯◯ Client Education ■■ Encourage the child to verbalize feelings related to body image. ■■ Educate the child regarding appropriate dietary management. ■■ Encourage adequate rest. ■■ ■■ ■■ ■■ ■■ ◯◯ 284 Monitor I&O. Interdisciplinary Care ◯◯ ●● Administer per protocol. ☐☐ Cyclophosphamide (Cytoxan) ■■ ●● ☐☐ Educate the family about the need for follow-up care. The child should be seen by the health care provider weekly for several weeks and then monthly until the disease is fully resolved. 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 symptoms worsen, which indicates relapse. Teach the family about administration and side effects of medication. Provide support to families and make appropriate referrals as needed. Relapses can cause physical, emotional, and financial stress for the child and family. Client Outcomes ■■ The child will be free of infection. ■■ The child will maintain optimal renal function. ■■ The child will maintain a blood pressure that is within a normal reference range. ■■ The child and family will have adequate support. rn nursing care of children Renal Disorders Complications ●● Sepsis/Infection ◯◯ Steroid therapy increases the risk for infection. ■■ ◯◯ ◯◯ Common infections seen in children with nephrotic syndrome include pneumonia, peritonitis, and cellulitis. Nursing Actions ■■ Keep the child away from potential infection sources. ■■ Monitor for signs 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 signs and symptoms of infection and when to contact the provider. Educate about potential infection sources (live plants, sick family members). rn nursing care of children 285 Renal Disorders Chapter 26: Renal Disorders Application Exercises Scenario: A child with acute poststreptococcal glomerulonephritis (APSGN) is admitted to the pediatric ICU for overnight observation. 1. When obtaining a nursing history from the child’s mother, the nurse should expect a recent infection. 2. Which of the following physical assessment findings should the nurse expect? (Select all that apply.) Flattened neck veins Decreased blood pressure Pallor Reports of anorexia Lethargy 3. What interventions should the nurse include in the child’s plan of care? 4. A child who has nephrotic syndrome is admitted. Which of the following should the nurse expect to find? (Select all that apply.) 286 Decreased specific gravity Proteinuria Hypoalbuminemia Hyperlipidemia Hematuria rn nursing care of children Renal Disorders Chapter 26: Renal Disorders Application Exercises Answer Key Scenario: A child with acute poststreptococcal glomerulonephritis (APSGN) is admitted to the pediatric ICU for overnight observation. 1. When obtaining a nursing history from the child’s mother, the nurse should expect a recent infection. Streptococcal Typically, a streptococcal infection precedes the majority of cases of acute glomerulonephritis. Other infections that can cause glomerulonephritis include pneumococcal infections and viral infections. NCLEX® Connection: Physiological Adaptation, Infectious Disease 2. Which of the following physical assessment findings should the nurse expect? (Select all that apply.) Flattened neck veins Decreased blood pressure X Pallor X Reports of anorexia X Lethargy A child with APSGN will likely present with pallor, reports of anorexia, and lethargy. Distended neck veins and increased blood pressure are expected findings. NCLEX® Connection: Reduction of Risk Potential, System Specific Assessment 3. What interventions should the nurse include in the child’s plan of care? Monitor daily weights. Monitor vital signs. Administer antihypertensives as prescribed. Administer diuretics as prescribed. Monitor I&O. Monitor urine output for: a. Color b. Specific gravity as ordered c. Protein dipsticks as ordered Implement fluid restrictions as ordered. Limit sodium intake with diet as ordered. NCLEX® Connection: Physiological Adaptation, Illness Management rn nursing care of children 287 Renal Disorders 4. A child who has nephrotic syndrome is admitted. Which of the following should the nurse expect to find? (Select all that apply.) Decreased specific gravity X Proteinuria X Hypoalbuminemia X Hyperlipidemia Hematuria The child’s specific gravity will most likely be elevated due to the presence of protein and casts in urine. The child who has nephrotic syndrome is experiencing increased permeability at the basement membrane. This child will experience hypoalbuminemia and hyperlipidemia. There is rarely hematuria. NCLEX® Connection: Reduction of Risk Potential, System Specific Assessment 288 rn nursing care of children
