This study guide is about nephrotic syndrome, diagnosis of nephrotic syndrome, treatment of nephrotic syndrome, and 5 nursing care plan examples for nephrotic syndrome. It can be used to create nursing care plans for nephrotic syndrome.
What is nephrotic syndrome?
Nephrotic syndrome is an alteration of kidney function caused by increased glomerular basement membrane permeability to plasma protein (albumin). Altered glomerular permeability result in characteristic symptoms of gross proteinuria, generalized edema (anasarca), hypoalbuminemia, oliguria, and increased serum lipid level (hyperlipidemia).
Nephrotic syndrome is classified either by etiology or the histologic changes in the glomerulus. Nephrotic syndrome is further classified into three forms: primary minimal change nephrotic syndrome (MCNS), secondary nephrotic syndrome, and congenital nephrotic syndrome. The most common type of nephrotic syndrome is MCNS (idiopathic type) and it accounts for 80% of cases of nephrotic syndrome. MCNS can occur at any age but usually, the age of onset is during the preschool years. MCNS is also seen more in male children than in female children. Secondary nephrotic syndrome is often associated with secondary renal involvement from systemic diseases. Congenital nephrotic syndrome (CNS) is caused by a rare autosomal recessive gene which is localized on the long arm of chromosome 19. Currently, CNS has a better prognosis due to early management of protein deficiency, nutritional support, continuous cycling peritoneal dialysis (CCPD), and renal transplantation. The prognosis for MCNS is usually good, but relapses are common, and most children respond to treatment.
What are the symptoms of nephrotic syndrome?
Signs and symptoms of nephrotic syndrome include:
- Severe swelling (edema), particularly around your eyes and in your ankles and feet
- Foamy urine, a result of excess protein in your urine
- Weight gain due to fluid retention
- Loss of appetite
What are the causes of nephrotic syndrome?
Nephrotic syndrome is usually caused by damage to the clusters of tiny blood vessels (glomeruli) of your kidneys.
The glomeruli filter your blood as it passes through your kidneys, separating things your body needs from those it doesn’t. Healthy glomeruli keep blood protein (mainly albumin) — which is needed to maintain the right amount of fluid in your body — from seeping into your urine. When damaged, glomeruli allow too much blood protein to leave your body, leading to nephrotic syndrome.
Many possible causes
Many diseases and conditions can cause glomerular damage and lead to nephrotic syndrome, including:
- Diabetic kidney disease. Diabetes can lead to kidney damage (diabetic nephropathy) that affects the glomeruli.
- Minimal change disease. This is the most common cause of nephrotic syndrome in children. Minimal change disease results in abnormal kidney function, but when the kidney tissue is examined under a microscope, it appears normal or nearly normal. The cause of the abnormal function typically can’t be determined.
- Focal segmental glomerulosclerosis. Characterized by scarring of some of the glomeruli, this condition can result from another disease, a genetic defect or certain medications or occur for no known reason.
- Membranous nephropathy. This kidney disorder is the result of thickening membranes within the glomeruli. The thickening is due to deposits made by the immune system. It can be associated with other medical conditions, such as lupus, hepatitis B, malaria and cancer, or it can occur for no known reason.
- Systemic lupus erythematosus. This chronic inflammatory disease can lead to serious kidney damage.
- Amyloidosis. This disorder occurs when amyloid proteins accumulate in your organs. Amyloid buildup often damages the kidneys’ filtering system.
What are the risk factors of nephrotic syndrome?
Factors that can increase your risk of nephrotic syndrome include:
- Medical conditions that can damage your kidneys. Certain diseases and conditions increase your risk of developing nephrotic syndrome, such as diabetes, lupus, amyloidosis, reflux nephropathy and other kidney diseases.
- Certain medications. Medications that might cause nephrotic syndrome include nonsteroidal anti-inflammatory drugs and drugs used to fight infections.
- Certain infections. Infections that increase the risk of nephrotic syndrome include HIV, hepatitis B, hepatitis C and malaria.
What will happen if nephrotic syndrome is left untreated?
Possible complications of nephrotic syndrome include:
- Blood clots. The inability of the glomeruli to filter blood properly can lead to loss of blood proteins that help prevent clotting. This increases your risk of developing a blood clot in your veins.
- High blood cholesterol and elevated blood triglycerides. When the level of the protein albumin in your blood falls, your liver makes more albumin. At the same time, your liver releases more cholesterol and triglycerides.
- Poor nutrition. Loss of too much blood protein can result in malnutrition. This can lead to weight loss, which can be masked by edema. You may also have too few red blood cells (anemia), low blood protein levels and low levels of vitamin D.
- High blood pressure. Damage to your glomeruli and the resulting buildup of excess body fluid can raise your blood pressure.
- Acute kidney injury. If your kidneys lose their ability to filter blood due to damage to the glomeruli, waste products can build up quickly in your blood. If this happens, you might need emergency dialysis — an artificial means of removing extra fluids and waste from your blood — typically with an artificial kidney machine (dialyzer).
- Chronic kidney disease. Nephrotic syndrome can cause your kidneys to lose their function over time. If kidney function falls low enough, you might need dialysis or a kidney transplant.
- Infections. People with nephrotic syndrome have an increased risk of infections.
Diagnosis of Nephrotic Syndrome
How do you diagnose nephrotic syndrome?
Tests and procedures used to diagnose nephrotic syndrome include:
- Urine tests. A urinalysis can reveal abnormalities in your urine, such as large amounts of protein. You might be asked to collect urine samples over 24 hours.
- Blood tests. A blood test can show low levels of the protein albumin and often decreased levels of blood protein overall. Loss of albumin is often associated with an increase in blood cholesterol and blood triglycerides. The creatinine and urea nitrogen levels in your blood also might be measured to assess your overall kidney function.
- Kidney biopsy. Your doctor might recommend removing a small sample of kidney tissue for testing. During a kidney biopsy, a needle is inserted through your skin and into your kidney. Kidney tissue is collected and sent to a lab for testing.
Treatment of Nephrotic Syndrome
What are the available treatment options for a patient suffering from nephrotic syndrome?
Treatment for nephrotic syndrome involves treating any medical condition that might be causing your nephrotic syndrome. Your doctor might also recommend medications and changes in your diet to help control your signs and symptoms or treat complications of nephrotic syndrome.
Medications might include:
- Blood pressure medications. Drugs called angiotensin-converting enzyme (ACE) inhibitors reduce blood pressure and the amount of protein released in urine. Medications in this category include lisinopril (Prinvil, Qbrelis, Zestril), benazepril (Lotensin), captopril and enalapril (Vasotec).Another group of drugs that works similarly is called angiotensin II receptor blockers (ARBs) and includes losartan (Cozaar) and valsartan (Diovan). Other medications, such as renin inhibitors, also might be used, though ACE inhibitors and ARBs are generally used first.
- Water pills (diuretics). These help control swelling by increasing your kidneys’ fluid output. Diuretic medications typically include furosemide (Lasix). Others include spironolactone (Aldactone, Carospir) and thiazides, such as hydrochlorothiazide or metolazone (Zaroxolyn).
- Cholesterol-reducing medications. Statins can help lower cholesterol levels. However, it’s not clear whether cholesterol-lowering medications can improve the outcomes for people with nephrotic syndrome, such as avoiding heart attacks or decreasing the risk of early death.Statins include atorvastatin (Lipitor), fluvastatin (Lescol XL), lovastatin (Altoprev), pravastatin (Pravachol), rosuvastatin (Crestor, Ezallor) and simvastatin (Zocor).
- Blood thinners (anticoagulants). These might be prescribed to decrease your blood’s ability to clot, especially if you’ve had a blood clot. Anticoagulants include heparin, warfarin (Coumadin, Jantoven), dabigatran (Pradaxa), apixaban (Eliquis) and rivaroxaban (Xarelto).
- Immune system-suppressing medications. Medications to control the immune system, such as corticosteroids, can decrease the inflammation that accompanies some of the conditions that can cause nephrotic syndrome. Medications include rituximab (Rituxan), cyclosporine and cyclophosphamide.
5 Nursing Care Plan Examples for Nephrotic Syndrome
What are some of the available nursing care plans for a patient suffering from nephrotic syndrome?
Nursing care planning for a client with nephrotic syndrome include relief from edema, enhance nutritional status, conserve energy, supply sufficient information about the disease, importance of strict compliance with the medication and nutritional therapy, and absence of infection or prevention of a relapse.
May be related to
- Decreased kidney function
- Fluid accumulation
Possibly evidenced by
- Pitting edema
- Periorbital and facial puffiness in morning and dependent in the evening
- Abdominal ascites,
- Scrotal or labial edema
- Edema of mucous membranes of intestines
- Slow weight gain
- Decreased urine output
- Altered electrolytes, sp. gr., BP, R
- Child’s edema will be decreased.
- Child will achieve ideal body weight without excess fluids.
|Weigh child daily; Utilize same weighing scale every day.||Daily body weight is a good indicator of hydration status. A weight gain of more than 0.5 kg/day suggests fluid retention.|
|Strictly monitor and record intake and output.||Accurate measurement determines fluid balance.|
|Determine potential sources of excess fluid (e.g., food, medications used)||Identification of other sources of excess fluid aids in the therapeutic regimen.|
|Advised to limit fluid intake as ordered.||Amount of allowed fluid intake is determined based on child’s weight, urine output and response to treatment.|
|Administer corticosteroid (e.g., prednisone) as prescribed.||Corticosteroid therapy continues until the urine is protein free and continues to be normal for 10 days to 2 weeks. A therapeutic response usually occurs in 1 to 3 weeks.|
|Instruct parents to provide frequent oral hygiene.||Oral hygiene reduces dryness of mouth and mucous membranes.|
|Teach parents on how to do dipstick urine testing and urine collection and instruct to keep a record of results.||Collecting and examining urine for protein shows the gravity of protein loss.|
|Teach parents regarding kidney function and disease condition.||Knowing the disease condition enables the parents to follow through with the therapeutic regimen.|
- Imbalanced Nutrition: Less Than Body Requirements
May be related to
- inability to ingest and digest foods and absorb nutrients
Possibly evidenced by
- Weight loss
- Edema of intestinal tract affecting absorption
- Rejection of low salt diet
- Loss of protein [negative nitrogen balance]
- Client will consume a nutritionally balanced diet.
|Monitor client’s weight daily (using the same scale with the child in the same clothing at the same time of the day).||Parents need to weigh children to monitor fluid and nutritional status.|
|Assess child’s nutritional daily patterns including food preference, caloric intake, and diet history.||Dietary patterns are considered in planning meals.|
|Encourage high potassium, low-fat, low sodium diet with moderate amounts of protein.||A high potassium diet maintains therapeutic serum potassium level, especially if the child is receiving a potassium-wasting diuretic; A low-sodium diet helps prevent or decrease fluid retention; Protein intake is needed to compensate for protein loss.|
|Provide comfortable and delightful environment during meal times.||Reduces unpleasant factors that add to appetite loss.|
|Consider six small nutrient-dense meals instead of three larger meals daily to reduce the feeling of fullness.||Eating small, frequent meals diminishes the feeling of fullness and reduces the stimulus to vomit.|
|Schedule medications in such a way that they are not administered immediately prior meals.||Taking of medications before meals may produce a feeling of fullness that contributes to anorexia.|
|Refer to a dietitian for a comprehensive nutrition assessment and methods for nutritional support.||A dietician determines the client’s daily requirements of specific nutrients to promote sufficient nutritional intake.|
May be related to
Possibly evidenced by
- Easily fatigued with any activity
- Extreme edema
- Child will alternate activity with rest periods.
|Assess extent of fatigue, weakness, degree of edema and difficult movement or activity in bed.||Reveals information regarding fatigue and tendency of lying in the prone position and not moving or changing position.|
|Plan activities with consideration and observe for changes in behavior following an activity.||Enhances endurance while avoids fatigue; disease condition, steroid therapy, and inactivity result in mood swings and irritability in the child.|
|Reinforce bed rest during the most acute stage.||Prevents energy expenditure when edema is severe.|
|Provide chosen play activities as tolerated and modify the schedule to allow for rest periods and after activity.||Provides stimulation and activity within tolerance level as edema is relieved.|
|Allow for quiet play accompanied by an
open activity and encourage the child to establish own limits when feasible.
|Promotes independence and control of situations.|
|Advise child to rest during times of exhaustion.||Decreases fatigue and conserves energy.|
|Inform parents and child that complete
participation in activities will be permitted as the disease is resolved.
|Promotes a return to active life for the child.|
- Deficient Knowledge
May be related to
- Lack of exposure to information about the disease
Possibly evidenced by
- Expressed need for information about the disease, drug administration, follow-up care and procedures
- Anxiety associated with relapse of disease
- Parents verbalize understanding of cause and treatment for illness.
|Assess knowledge of disease, signs and symptoms of relapse, dietary and activity aspects of care, medication administration and side effects, monitoring urine and vital signs.||Provides information about education needs for follow-up care.|
|Assess anxiety level and need for assistance in the care of the ailing child and possible relapse.||Anxiety will hinder the ability to learn.|
|Educate parents and child about the cause of the child’s illness and expected treatments. Encourage questions and allow time for discussion.||Teaching supplies required information about the condition and management.|
|Notify parents that immunizations may
|Promotes safety measure to avoid complications in an immunocompromised child.|
|Educate about the administration of medications including reversible side effects of steroid and immunosuppressive when discontinued abruptly; that they must be stopped gradually to avoid complication.||Promotes compliance of proper medication administration and what can be expected from drug therapy.|
|Educate parents and child possibility
for relapse to prevent infection.
|Avoids the risk of infection that may precipitate a relapse.|
|Demonstrate and allow for parents to
return demonstrate urine testing by
dipstick for albumin, monitor for edema, taking daily weights and blood pressure, and to immediately notify physician on changes of increased weight or presence of albumin in urine.
|Facilitates monitoring of possible relapse of disease.|
|Offer parents and child with praise and encouragement as they acquire skills.||Positive reinforcement improves willingness to learn new skills.|
|Reinforce physician instructions about sodium restriction, activity progression, and pacing.||Promotes a return to usual patterns of living.|
|Provide information about the disease, its causes, need for frequent hospitalizations if the disease becomes prolonged or is a relapsing type with remissions and exacerbations.||Promotes understanding of disease process and importance of compliance with therapy to prevent exacerbation.|
- Risk for Infection
May be related to
- Inadequate secondary defenses
Possibly evidenced by
- [not applicable]
- Child’s temperature will remain <99° F.
- Child’s breath sounds will be clear bilaterally.
- Child’s urine will be clear without foul odor.
|Assess for an increase in temperature, respiratory changes (dyspnea, productive cough with yellow sputum), urinary changes (cloudy, foul-smelling urine), skin changes (tenderness, redness, swelling).||Indicates presence of infectious process as a result from steroid and immunosuppressant therapy administered to improve body defenses and lessen relapse rate.|
|Maintain and teach medical aseptic
techniques and handwashing when providing care.
|Promotes preventive measures against infection.|
|Maintain warmth for the child, regulate
room environmental temperature
|Avoids chilling and susceptibility to upper respiratory infection.|
|Provide private room or share room with children who are free from infections.||Protects the child from transmission of microorganism.|
|Administer antibiotic therapy as ordered.||Prevents or treats infection depending on the result of culture and sensitivities.|
|Advise parents and child to avoid
exposure to persons with existing infections.
|Provides an understanding of susceptibility to infections.|
|Advise parents to immediately notify the physician of sign or symptom of infection.||Allows for prompt medical intervention to avoid relapse.|