21 terms

Acute poststreptococcal glomerulonephritis

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Overview
Renal disease in which the glomeruli become inflamed
Usually associated with a postinfectious state, commonly a streptococcal infection of the respiratory tract or, less commonly, a skin infection such as impetigo
Full recovery in up to 70% of adults
In elderly patients, possible progression to chronic renal failure within months
Relatively common
Also called acute glomerulonephritis
Overview-Pathophysiology
Antigen-antibody complexes are produced in response to group A beta-hemolytic streptococcus infection.
Antigen-antibody complexes are trapped in the glomerular capillary membranes.
Inflammatory damage results leading to thickening of the glomerular basement membrane, possibly affecting the renal vessels, renal interstitium, and tubular epithelium, subsequently, impairing glomerular function.
Immune complexes activate secondary mediators such as the complement pathways, neutrophils, macrophages, prostaglandins, and leukotrienes, further affecting vascular tone and permeability.
Glomerular filtration volume is reduced.
Damaged inflamed glomeruli lose the ability to be selectively permeable; salt and water excretion usually decreases, leading to an increase in extracellular fluid volume.
Red blood cells (RBCs) and proteins then filter through as the glomerular filtration rate decreases.
Scarring and loss of filtering surface can lead to renal failure.
Overview-Causes
Untreated group A beta-hemolytic streptococcus infection, such as of the respiratory tract or the skin (impetigo).
Overview-Incidence
Acute poststreptococcal glomerulonephritis occurs most commonly in males.
The disease can occur at any age.
Overview-Complications
Hypertensive retinopathy or encephalopathy
Anemia
Pulmonary edema
Rapidly progressive glomerulonephritis
Microhematuria (persisting for years)
Chronic renal failure (rare)
Nephrotic syndrome
Assessment-History
Untreated respiratory streptococcal infection or impetigo within the last 1 to 3 weeks
Abdominal pain
Anorexia
Back pain
Fatigue
Dyspnea and orthopnea
Cough
Assessment-Physical Findings
Decreased urination, anuria, or oliguria
Gross hematuria or smoky or coffee-colored urine
Proteinuria
Mild to moderate periorbital edema
Mild to severe hypertension
Bibasilar crackles (with heart failure)
Pallor
Fever (rare)
Costovertebral tenderness (rare)
Bradycardia or tachycardia
Diagnostic Test Results-Laboratory
Urinalysis reveals protein, blood, red blood cells (RBCs), white blood cells (WBCs), or casts.
Electrolyte levels are imbalanced (elevated serum potassium levels, decreased serum calcium levels, and metabolic acidosis).
Blood urea nitrogen (BUN) and creatinine levels are elevated.
Serum protein levels are decreased.
The presence of RBCs, WBCs, mixed cell casts, and protein in the urine indicate renal failure.
Levels of fibrin degradation products are increased.
Diagnostic Test Results-Imaging
Kidney-ureter-bladder radiography or renal ultrasonography reveals bilateral kidney enlargement.
Chest X-ray may reveal a hilar pattern of congestion that correlates with the degree of increased extracellular fluid volume.
Diagnostic Test Results-Diagnostic Procedures
Renal biopsy or renal tissue assessment is used to confirm the diagnosis if renal dysfunction is progressive or presentation is atypical.
Treatment-General
Correction of electrolyte imbalances
Peritoneal dialysis or hemodialysis (for symptomatic azotemia or hyperkalemia, acidosis, or pulmonary edema that's unresponsive to treatment)
Treatment-Diet
No-added salt diet until edema and hypertension resolve
Protein restriction if azotemia and metabolic acidosis are present
Fluid restriction (amount decreased to insensible losses plus two-thirds of urine output until diuresis occurs)
Avoidance of high-potassium foods
Treatment-Activity
Bed rest, with gradual return to usual activity as status improves
Treatment-Medications
Sodium polystyrene sulfonate (Kayexalate) for hyperkalemia
I.V. calcium gluconate or oral calcium carbonate for hypocalcemia
I.V. sodium bicarbonate for acidosis
Furosemide to treat peripheral and pulmonary edema
Antihypertensives, such as labetalol or diazoxide, or vasodilators, such as sodium nitroprusside (Nitropress), hydralazine (Apresoline), or NIFEdipine (Procardia), for hypertension
Supplemental oxygen therapy
Penicillin V potassium (or erythromycin if the patient has an allergy to penicillin) over 10 days for streptococcal infection
Nursing Considerations-Nursing Diagnoses
Acute pain
Decreased cardiac output
Excess fluid volume
Fatigue
Imbalanced nutrition: Less than body requirements
Impaired gas exchange
Impaired physical mobility
Risk for infection
Risk for injury
Nursing Considerations-Expected Outcomes
express feeling of comfort and relief from pain
maintain adequate cardiac output
maintain fluid balance
express feelings of energy and decreased fatigue
consume required caloric intake
maintain adequate ventilation
perform activities of daily living within the confines of the disorder
remain free from all signs and symptoms of infection
remain free from injury.
Nursing Considerations-Nursing Interventions
Give prescribed drugs. If I.V. medications are prescribed, ensure patent I.V. access for drug administration. Inspect I.V. insertion site and perform I.V. site care according to facility policy.
Obtain urine specimens as ordered for testing; obtain blood specimens to evaluate electrolyte levels.
Obtain daily weights; check skin turgor.
Provide meticulous skin care, especially to edematous areas.
Administer supplemental oxygen as prescribed if pulmonary edema is present.
Assist with fluid restriction as indicated. Maintain dietary restrictions as appropriate.
Consult with a nutritional therapist about low-sodium, low-potassium foods and protein restrictions, as appropriate.
Encourage the patient to verbalize feelings about the diagnosis. Assist with positive coping strategies.
Provide support and encouragement. Allow for frequent rest periods. Assist with energy conservation measures; cluster nursing care activities as appropriate.
Nursing Considerations-Monitoring
Vital signs, especially blood pressure
Electrolyte values, especially serum potassium and calcium levels
Serum creatinine and BUN levels
Urine creatinine clearance test results
Intake and output
Daily weight
Nursing Considerations-Associated Nursing Procedures
12- or 24-hour timed urine collection
Blood pressure assessment
Calculating and setting an IV drip rate
Cardiac monitoring
Cardiac output measurement with iced injectate
Cardiac output measurement with room temperature injectate
Continuous renal replacement therapy (CRRT)
Fall prevention
Health history interview and physical assessment
Hemodialysis, arteriovenous access
Hemodialysis, double-lumen catheter
IV bag preparation
IV bolus injection
IV catheter insertion
IV pump use
IV secondary line drug infusion
IV solution change
IV time tape use
IV tubing change
Indwelling urinary catheter (Foley) care and management
Intake and output assessment
Intermittent infusion device drug administration
Nutritional screening
Oral drug administration
Oxygen administration
Pain management
Peritoneal dialysis
Pulmonary artery pressure and pulmonary artery wedge pressure monitoring
Pulse assessment
Pulse oximetry
Respiration assessment
Temperature assessment
Urine pH
Urine specific gravity
Urine specimen collection from an indwelling urinary catheter (Foley)
Urine specimen collection, random
Venipuncture
Weight measurement
Patient Teaching-General
disorder, diagnosis, treatment, prognosis, and possible complications, including that the disease is usually self-limiting, lasting approximately 2 to 3 weeks
long-term prognosis, explaining that almost all patients completely recover
prescribed medications, including dosages and possible adverse effects
need to complete the full prescription of antibiotics, if ordered, to ensure eradication of the infection
possibility of microscopic hematuria persisting for up to 2 years and possibly longer with complete recovery
possibility of proteinuria persisting for up to 3 months
signs and symptoms of diminished renal function and need to notify practitioner immediately if they are present
need for follow-up urinalysis at 2, 4, and 8 weeks and then at 4, 6, and 12 months; serum creatinine levels at 2, 6, and 12 months
importance of long-term follow-up examinations, with blood pressure monitoring at each visit.
Patient Teaching-Discharge Planning
Refer the patient to appropriate resources for information and support.
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