GU Round 2

Acute Glomerulonephritis
Peaks at 7 years of age, unusual before age 3, occurs more often in males
Etiology an infection present in the body for at least 2-3 weeks, agents may be bacterial or viral.
Most common organism Group A beta hemolytic streptococcus
Henoch-Schonlein Nephritis (HSN) follows an upper respiratory tract infection
Suspect an immune response trigger

Bacterial or viral agent invades, antibodies are produced,
the antigen-antibody reaction in the glomeruli forms immune complexes which trigger inflammation.
Glomeruli membrane permeability is altered by the response.
Allowing protein and blood to leak into the urine.
Sodium and water are retained in the serum due to the decreased plasma filtration > edema, hypervolemia, hypertension

Clinical manifestations:
Hematuria (blood in the urine)
Dependent and periorbital edema
Diminished urinary output
Proteinuria
Hypertension
Diminished Glomerular filtration rate
*Elevated sodium levels
*Elevated potassium

*All these symptoms are related to the inflammation which changes the permeability of the glomerular membrane, this can lead to progressive kidney damage*

Diagnosis:

Urinalysis demonstrates hematuria, proteinuria, and increased specific gravity,
WBC with differential, antistreptolysin O titer, serum complement, culture of original infection site



Treatment:
To identify and treat the infection
Maintain fluid and electrolytes
Maintain blood pressure
Prevent complications


*Children with generalized edema, oliguria, hypertension, hematuria are hospitalized and treated with diuretics, antihypertensives and possibly antibiotics. Sodium, potassium, and fluids may be restricted*


*Children with normal BP and urinary output can be managed at home note care instructions below*
Care:
Mild cases can be treated at home if they have normal output and blood pressure
Caregivers need to be aware of worsening symptoms
Dietary and fluid restrictions (Low sodium, low potassium- apples, pears, cherries, grapes and plums)
Avoid high-potassium fruits, including bananas, strawberries and oranges.
Avoid high sodium, canned foods, canned vegetables, prepared sauces, food should have no more than 20% of daily requirement
Skin integrity, reposition every 2 hours
Elevation of dependent extremities
Rest periods
Signs of dehydration

Worsening = increased hematuria, edema, fatigue, restlessness, respiratory changes

Case Study 3: Acute Glomerulonephritis


Michael is 7 years old; he had a sore throat 3 weeks ago. This was all but forgotten until his latest trip to the doctor. He has been very tired and his mother is concerned because of his puffy appearance. Further, she states he has not been going to the bathroom and when he does, his urine is blood-tinged. As the nurse assesses Michael she notices his blood pressure is elevated. She retakes the blood pressure manually to ensure a proper reading. The doctor suspects acute glomerulonephritis.

What tests might be ordered and why?

Is this a ‘kidney infection’? If not what exactly is it?

Name some nursing diagnoses, nursing interventions, nursing outcomes specific to Michael’s care.

The doctors have decided that Michael’s case can be managed at home for now. What teaching topics are important for Michael and his family?

What is Michael's long-term prognosis?


What dietary considerations are important? (low sodium, low potassium)



Acute Glomerulonephritis



Nephrotic syndrome:

Massive proteinuria
Hypoalbuminemia (low albumin in blood)
Leads to edema and hyperlipidemia

Primary- glomerular disease of the kidney, most common
Secondary-renal malfunctioning due to systemic disease, hepatitis, lupus, toxins,

Incidence:
Higher in males, African-American, Native American, and Hispanic
Etiology- immune response alters the structure of the glomerulus

Clinical Manifestations:
Periorbital edema upon awakening
Anorexia
Abdominal pain, swelling caused by inflammation of the kidney
Fatigue
History of recent respiratory infection
Rapid weight gain
Hyperlipidemia
Normal vital signs at first

Diagnosis:
Dependent on proteinuria
Serum albumin is decreased (hypoalbuminemia)

Lab tests:
Urinalysis for protein, red blood cell casts
Serum albumin levels (decreased)
Serum cholesterol, triglycerides (increased)
Hemoglobin, hematocrit (decreased)
Platelet count (decreased)
Electrolytes (altered)
BUN, creatinine
Complement levels
Antistreptolysin O titer (ASO) rule out

Treatment:
Reducing proteinuria
Controlling edema
Preventing infection
Corticosteroid treatment to decrease inflammation and the loss of proteins
Treatment continues until free from proteinuria for three months

*Relapse rate- 60-70% often triggered by upper respiratory infection*
Treated with high dose steroids until free from proteinuria for 3 days
Diuretics are only used to treat severe edema
Albumin may be given, helps to move interstitial fluid back to intravascular space
Albumin is followed by furosemide to reduce possible fluid overload

Care:
Maintain fluid and electrolyte balance
Administer medications
Prevent infection, skin breakdown
Family education
I&O
Daily weights
Assess edema, dehydration
Breath sounds
Observe for signs and symptoms of infection
Serum and urine electrolytes
Good hand washing, no sick visitors

Family teaching:
Expected course
Teach to dip urine
Daily weights
Identifying relapses
Hand washing and infection protection
Nutritious snacks in response to steroid hunger
Notify caregiver if exposed to chickenpox
No live viruses may be administered during steroid treatment




Case Study 1: Nephrotic Syndrome


Instead of solving for a diagnosis. Here is your patient! He is precious and so brave. Answer the questions at the bottom of the page when the video finishes.







  1. How does Tyler’s case match the profile for nephrotic syndrome?
  2. What is the treatment of choice?
  3. What are some possible side effects of the treatment?
  4. What are some important nursing considerations to consider?
  5. Name some possible complications of this syndrome for Tyler.
  6. Name some topics for teaching for this family.



The Answer:




Wilms Tumor Nephroblastoma



Most common renal and intra abdominal tumor of children. Commonly discovered at approximately age three, almost always by age 5. More common in AA. Slightly more common in boys. 1-2.5% have a familiar history. Favors the left kidney although both can be involved.

Symptoms:
Most children present with abdominal swelling. It is firm, nontender and confined to one side.
Other symptoms common with a Wilms tumor include: hematuria, fatigue, malaise, hypertension, weight loss and fever.


Diagnostic tests include radiographs, abdominal ultrasound, abdominal and chest CT, biochemical tests, blood work, urinalysis. Possibly an inferior venacaogram to see if there is any involvement close to the vena cava and possibly a bone marrow aspiration if metastasis is suspected. Fortunately this is rare.

The tumor can be staged I-V. Survival rates are 90% for grades I and II.


*Do not palpate the abdomen! This can lead to shedding and spreading of cells.

Radiotherapy and chemotherapy are usually initiated after surgery. Occassionally these are instituted prior to surgery if the tumor is large or both kidneys are involved.

Meet Sydney!




Renal Failure and dialysis




Acute kidney failure:
Kidneys filter waste, excess fluid and electrolytes
When they don't toxins accumulate causing edema, hypertension, bone or blood problems

Symptoms:
Low back pain in kidney area
Painful frequent, urination, pressure
Urine color changes, foamy, concentrated, blood in urine
Skin itching, rashes, and dryness
Edema face, joint and limbs
Decreased erythropoiten leads to decrease in RBC
Shortness of breath due to decreased RBC
Metalic taste in the mouth
Bad concentration and dizziness

Common labs to assess kidney function:

Serum Creatinine: Creatinine is a waste product in your blood that comes from muscle activity. It is normally removed from your blood by your kidneys, but when kidney function slows down, the creatinine level rises. The doctor uses the results of the serum creatinine test to calculate the GFR.

Glomerular Filtration Rate (GFR) The GFR tells how much kidney function you have. It may be estimated from your blood level of creatinine. If the GFR falls below 30 a kidney disease specialist (called a nephrologist) is needed. Treatments for kidney failure like dialysis or kidney transplant may be needed. A GFR below 15 indicates the need for treatment.

Blood Urea Nitrogen (BUN): Urea nitrogen is a normal waste product in the blood that comes from the breakdown of protein from the foods and body metabolism. It is normally removed from the blood by the kidneys, but when kidney function slows down, the BUN level rises. BUN also rises from eating more protein, and will fall from eating less protein.

Urine Protein: When kidneys are damaged, protein leaks into the urine. A simple test can be done to detect protein in the urine. Persistent protein in the urine is an early sign of chronic kidney disease.

Microalbuminuria: This is a sensitive test that can detect a small amount of protein in the urine.

Urine Creatinine: This test estimates the concentration of the urine and helps to give an accurate protein result. Protein-to-Creatinine Ratio: This estimates the amount of protein excreted in the urine in a day and avoids the need to collect a 24-hour sample of the urine.

Serum Albumin: Albumin is a type of body protein made from the protein eaten each day. A low level of albumin in the blood may be caused by not getting enough protein or calories from the diet. A low level of albumin may lead to health problems such as difficulty fighting off infections.





Word Match:


1. Dysuria


2. Hypospadias


3. Cryptorchordism


4. Enuresis


5. C-reactive protein


6. Escherichia Coli (E-Coli)


7. Hydrocele


8. bacteriuria


9. Cystitis


10. Inguinal hernia


11. Chordee


12. Pyuria


13. Erythrocyte sedimentation rate


14. Hydronephrosis

A. involuntary voiding of urine


B. presence of bacteria in urine


C. swelling of the kidney


D. ESR


E. white blood cells in the urine


F. urethral meatus on the ventral (underside) of the penis


G. downward curvature of the penis and an incomplete foreskin


H. CRP


I. collection of peritoneal fluid in the scrotal sac


J. scrotal or inguinal swelling that contains abdominal contents


K. common bacterial organism


L. undescended testes


M. painful urination


N. bladder infection







References:

Hockenberry, M. J., & Wilson, D. (2009). Wong's essentials of pediatric nursing (8th ed.). St. Louis, MO: Mosby Elsevier.


Montagnino, B. A., & Ring, P. A. (2009). Chapter 27: The child with genitourinary dysfunction. In M. J. Hockenberry & D. Wilson (Eds.), Wong's essentials of pediatric nursing (8th ed., pp. 949-973). St. Louis, MO: Mosby Elsevier.

Wilm's Tumor
https://youtu.be/5Jfh3AxUHz0

Sydney
https://youtu.be/YHLuQmM9waM

Dialysis
https://youtu.be/mi34xCfmLhw

https://youtu.be/Lreqo-teOhk