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Terms in this set (92)

Pathophysiology
Nephrotic syndrome is a collection of symptoms that indicates kidney damage. These symptoms include albuminuria, hyperlipidemia, hypoalbuminemia and dependent edema. Damaged glomeruli allow proteins, most commonly albumin, to leak into the urine. As albumin leaks into the urine, the blood can no longer absorb the fluid which results in edema and leads to ascites.

Etiology
Primary nephrotic syndrome is caused by certain diseases that specifically affect the kidneys and include minimal change nephropathy, focal segmental glomerulosclerosis, which is the formation of scar tissue within the glomeruli and membranous nephropathy, which occurs when immune molecules form deposits on the glomeruli.

Secondary nephrotic syndrome occurs secondary to other systemic diseases such as diabetes (most common), lupus, amyloidosis, and renal vein thrombosis. The overuse of NSAIDS and some antibiotics is also attributed with damage to the glomeruli. Infections such as HIV, hepatitis B, hepatitis C and malaria may increase the risk of developing kidney disease.

Subjective Data
Weight gain
Fatigue
Loss of appetite

Objective Data
Foamy urine
Anemia
Vitamin D deficiency
Malnutrition
Ascites
Hypertension
Dependent edema

Symptoms of Nephrotic Syndrome
NAPHROTIC
N-Na+ decreased (dilutional)
A-Albumin decrease
P-Proteinuria
H-Hyperlipidemia
R-Renal Vein Thrombosis
O-Orbital Edema
T-Thromboembolism
I-Infection
C-Coagulability

Nursing Interventions
Monitor vitals

RATIONALE
Temperature- monitor for signs of infection, especially with immunosuppressant therapy

Blood pressure- hypotension may indicate hypovolemia

Heart rate- tachycardia may be a sign of infection or hypovolemia

Monitor fluid balance

RATIONALE
Measure for decreased output <400 mL/24 hr period may be evident by dependent edema
Daily weights at the same time on the same scale each day, >0.5kg/day is indicative of fluid retention
Note changes in characteristics of urine: dark, frothy or opalescent appearance, hematuria
Insert indwelling catheter unless contraindicated for infection

RATIONALE
Indwelling catheter will provide more accurate measurement of urine output

Monitor diagnostic studies

Lab
Ultrasound
Kidney biopsy (as indicated)
RATIONALE
Urine test

24 hour urine or single urine specimen / urinalysis
>30mg albumin / 1g creatinine
Increased protein, decreased creatinine clearance
Microhematuria
Proteinuria that does not contain albumin is indicative of multiple myeloma

Serum test

Serum albumin will be lower than 3.5 - 4.5 (normal range)
Tests for hepatitis B, hepatitis C, HIV, syphilis and lupus may be helpful in determining etiology

Ultrasound

Can help determine severity and cause of nephrotic syndrome

Kidney biopsy

Typically not needed, but may be indicated in diabetic patients
Assess for skin integrity

RATIONALE
Lack of protein in the blood reduces the integrity of skin and increases the risk of breakdown and ulceration.

Assess dependent and periorbital edema

RATIONALE
Evaluate and report degree of edema (+1 - +4)

There may be a gain of up to 10lbs of fluid before pitting is noticed

Administer medications and evaluate response

RATIONALE
ACE Inhibitors or ARBs: (benazepril, losartan) reduce amount of protein released in urine
Diuretics: (furosemide, spironolactone) Increase fluid output
Hypolipidemics: (atorvastatin, simvastatin) reduce cholesterol in the blood
Anticoagulants: (warfarin, apixaban) prevent blood clots
Immunosuppressants: (prednisone) corticosteroids decrease inflammation from underlying conditions such as lupus and amyloidosis
IV Albumin infusion: as ordered, to reduce ascites; draws fluid from the body to the bloodstream to treat hypovolemia and replace low serum protein
Monitor for volume depletion with use of diuretics

RATIONALE
Diuretics help to flush out fluid from the tissues to decrease edema. Excess urination may result in volume depletion and lead to dehydration or hypovolemia

Assess symptoms

Daily weights
Pulse
Blood pressure
Monitor for corticosteroid toxicity for ongoing use

RATIONALE
Long term use of corticosteroids can have severe side effects. Monitor for:

GI bleeding- higher risk of bleeding and perforation; use antacids to prevent GI symptoms
Blood sugar levels may be elevated;
Supplement with calcium and vitamin D to prevent bone loss
Encourage yearly eye exam to assess for cataracts and glaucoma as corticosteroids may increase intraocular pressure and cause clumping together of proteins that result in cataracts
Avoid exposure to communicable diseases with immunosuppressant therapy to prevent infections and disease complications.
Assist with Rest / Ambulation

RATIONALE
Initially, bed rest is encouraged to help mobilize edema.

After the first few days of treatment, encourage ambulation and elevation for venous return and prevent thromboses

Provide nutrition education

RATIONALE
Malnutrition may occur due to excretion of protein, but may not be evident in weights due to edema
Diet high in lean protein (1g/kg/day) and low sodium to reduce swelling
Limit foods that increase blood sugar such as simple carbohydrates, refined sugars and processed foods
Refer to dietitian as needed
Pathophysiology
A group of diseases that cause inflammation and injury to the part of the kidneys that filters blood (glomeruli). When the kidneys are injured or inflamed, they are unable to remove waste and extra fluid in the body. Prolonged disease may lead to kidney failure.

Etiology
Most commonly, acute glomerulonephritis develops as a complication following streptococcal infection of the throat or skin (rare). Bacterial infections such as endocarditis and strep throat and viral infections such as HIV and hepatitis B and C may result in inflammation of the glomeruli within the kidneys. Immune diseases such as lupus, Goodpasture's syndrome are also thought to lead to glomerulonephritis. The chronic form of the disease is thought to be hereditary, but may occur months or years following an acute attack of the disease.

Subjective Data
Puffiness of face in mornings
Urinating less frequently
Shortness of breath
Cough
Fatigue
Change in weight (recent/significant)

Objective Data
Hematuria / proteinuria
Hyper/hypotension
Bubbly / foamy urine
Dark colored urine

Fever
Cloudy urine (pyuria)
Azotemia
Anorexia, N/V
Fatigue / Malaise
↑ BUN / Creatinine
↓ Creatinine clearance (CrCl)
↓ Glomerular Filtration Rate (GFR)
↓ Uptake and excretion of dye with renal scan
Due to ↓ GFR
HTN due to water retention
Hematuria - RBC in urine
Hypoalbuminemia and Proteinuria - especially with associated Nephrotic Syndrome

Nursing Interventions
Perform head-to-toe assessment

RATIONALE
To establish a baseline by which to measure interventions and outcomes

Auscultate lungs, noting any adventitious breath sounds
Assess periorbital and dependent edema (+1 - +4)
Monitor vital signs

RATIONALE
Damage to the glomeruli prevent the emptying of sodium and fluid and can raise the heart rate and blood pressure.

Insert indwelling urinary catheter as necessary

RATIONALE
Provides a more accurate method of measuring output. If catheter is contraindicated,, provide urinary hat for toilet to measure urine.

Monitor fluid balance

I & O
Daily weights
Evaluate edema
RATIONALE
Measure for decreased output <400 mL/24 hr period may be evident by dependent edema
Daily weights at the same time on the same scale each day, >0.5kg/day is indicative of fluid retention
Note changes in characteristics of urine: dark, frothy appearance, hematuria
Elevate extremities

RATIONALE
Provide elevation for feet and ankles or arms as necessary to allow gravity to assist in reducing edema. There may be a gain of up to 10lbs of fluid before pitting is noticed

Monitor diagnostic testing:

Evaluate electrolyte levels

Calcium
Sodium
Magnesium
Potassium

Monitor renal function labs

BUN, Creatinine
Albumin
Glomerular Filtration Rate (GFR)
Kidney biopsy, as indicated

RATIONALE
Electrolyte imbalances can lead to muscle weakness or spasticity and affect cardiac output.



Monitor the amount of protein lost in the urine. Serum protein levels will be decreased, while urine protein levels will be elevated.

A kidney biopsy may be required, especially if patient is diabetic

Administer medications as indicated

Diuretics
Antihypertensives
Electrolyte supplements
RATIONALE
An acute attack of glomerulonephritis may clear on its own. Depending on severity of symptoms and progression of disease, diuretics are often given to remove excess fluid, antihypertensives to manage blood pressure caused by fluid retention and electrolyte supplements such as calcium or potassium to maintain homeostasis

Encourage healthy lifestyle and nutritional education

RATIONALE
Offer small, frequent meals
Restrict fluids as necessary
Limit sodium and protein intake
Encourage exercise to maintain a healthy weight
Control blood sugar (diabetic patients)
Quit smoking

Management of Glomerulonephritis
Please Help Deliver Diuretics
P-Plasmapheresis
H-Hemodialysis
D-Dietary changes
D-Diuretics
Pathophysiology
A common condition in the aging cycle of men that causes enlargement of the prostate gland that surrounds the urethra. The enlargement of the prostate may cause difficulty urinating, having to urinate more often, especially at night, and a weak urine stream. BPH is not cancer and does not increase the risk of developing cancer.

Etiology
Hormonal imbalances of androgen/estrogen are believed to be responsible for the growth of the prostate.

Subjective Data
Frequent / urgent need to urinate, especially at night
Difficulty urinating or weak urine stream
Inability to empty the bladder
Dribbling urine after voiding
Incontinence

Objective Data
Elevated PSA
Enlarged prostate on exam or ultrasound
Inability to pass catheter through urethra
Nursing Interventions
Assess and palpate suprapubic area

RATIONALE
Assess for bladder distention to suggest fluid retention

Monitor vital signs

RATIONALE
Observe for signs of hypertension and infection. Urinary retention may lead to infection which can be evidenced by fever. Fluid retention puts stress on the kidneys and heart and may increase blood pressure and heart rate.

Monitor I & O

RATIONALE
Monitor frequency of urination and volume, paying attention to characteristics of urine. Dark, malodorous or bloody urine may indicate further complications.

Encouraged increased fluids if indicated.

* limit fluids initially if urinary retention is an issue *

RATIONALE
Recommend 3000 mL fluid daily to promote flushing and circulation of fluid through kidneys, bladder and ureters.

Monitor labs / diagnostic tests

Prostate Specific Antigen (PSA)
Digital Rectal Exam (DRE)
RATIONALE
PSA- a protein produced by the prostate. Elevations in this blood test may indicate enlargement or inflammation of the prostate.
DRE- this physical exam may be performed if BPH is suspected by inserting a gloved finger into the rectum to palpate the prostate and assess for abnormalities in size and shape.
Administer medications and educate patient of proper use

RATIONALE
Alpha-adrenergic antagonists (tamsulosin) - relaxes the smooth muscle of the prostate to allow optimal urine flow
Antispasmodics- (oxybutynin) relieves muscle spasms that restrict the urethra
Antibiotics/antibacterials- may be given prophylactically as indicated to prevent bacterial infection
Insert indwelling catheter as indicated per facility protocol

RATIONALE
Indwelling catheter may be required to bypass the prostate and allow urine to flow freely, eliminating fluid retention in the bladder.

Nutrition and lifestyle education

RATIONALE
Excess weight can affect the hormone balance in the body. Maintaining a healthy weight through diet and exercise can help lower the risk of developing BPH.

BPH Symptoms
FUN WISE
F-Frequency
U-Urgency
N-Nocturia
W-Weak stream
I-Intermittency
S-Straining
E-Emptying incompletely

Prostate
FUN
F-Frequency
U-Urgency
N-Nocturia