GU+Pediatric+Round+2

=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 <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Proteinuria <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Hypertension <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Diminished Glomerular filtration rate <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">*Elevated sodium levels <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">*Elevated potassium

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 140%;">***All these symptoms are related to the inflammation which changes the permeability of the glomerular membrane, this can lead to progressive kidney damage***

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 140%;">Diagnosis:

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Urinalysis demonstrates hematuria, proteinuria, and increased specific gravity, <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">WBC with differential, antistreptolysin O titer, serum complement, culture of original infection site

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 140%;">Treatment: <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">To identify and treat the infection <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Maintain fluid and electrolytes <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Maintain blood pressure <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Prevent complications

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 140%;">***Children with generalized edema, oliguria, hypertension, hematuria are hospitalized and treated with diuretics, antihypertensives and possibly antibiotics. Sodium, potassium, and fluids may be restricted***

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 140%;">***Children with normal BP and urinary output can be managed at home note care instructions below*** <span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 140%;">Care: <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Mild cases can be treated at home if they have normal output and blood pressure <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Caregivers need to be aware of worsening symptoms <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Dietary and fluid restrictions (Low sodium, low potassium- apples, pears, cherries, grapes and plums) <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Avoid high-potassium fruits, including bananas, strawberries and oranges. <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Avoid high sodium, canned foods, canned vegetables, prepared sauces, food should have no more than 20% of daily requirement <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Skin integrity, reposition every 2 hours <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Elevation of dependent extremities <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Rest periods <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Signs of dehydration

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Worsening = increased hematuria, edema, fatigue, restlessness, respiratory changes

=<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 150%;">Case Study 3: Acute Glomerulonephritis =

====<span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">//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.// ====

====<span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">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? ====

<span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">What is Michael's long-term prognosis?
<span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">What dietary considerations are important? (low sodium, low potassium)

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 140%;">Acute Glomerulonephritis

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= = <span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 19.5px;">Nephrotic syndrome:

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Massive proteinuria <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Hypoalbuminemia (low albumin in blood) <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Leads to edema and hyperlipidemia

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Primary- glomerular disease of the kidney, most common <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Secondary-renal malfunctioning due to systemic disease, hepatitis, lupus, toxins,

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 19.5px;">Incidence: <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Higher in males, African-American, Native American, and Hispanic <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Etiology- immune response alters the structure of the glomerulus

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 19.5px;">Clinical Manifestations: <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Periorbital edema upon awakening <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Anorexia <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Abdominal pain, swelling caused by inflammation of the kidney <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Fatigue <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">History of recent respiratory infection <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Rapid weight gain <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Hyperlipidemia <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Normal vital signs at first

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 19.5px;">Diagnosis: <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Dependent on proteinuria <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Serum albumin is decreased (hypoalbuminemia)

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 19.5px;">Lab tests: <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Urinalysis for protein, red blood cell casts <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Serum albumin levels (decreased) <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Serum cholesterol, triglycerides (increased) <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Hemoglobin, hematocrit (decreased) <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Platelet count (decreased) <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Electrolytes (altered) <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">BUN, creatinine <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Complement levels <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Antistreptolysin O titer (ASO) rule out

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 19.5px;">Treatment: <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Reducing proteinuria <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Controlling edema <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Preventing infection <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Corticosteroid treatment to decrease inflammation and the loss of proteins <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Treatment continues until free from proteinuria for three months

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 19.5px;">*Relapse rate- 60-70% often triggered by upper respiratory infection* <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Treated with high dose steroids until free from proteinuria for 3 days <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Diuretics are only used to treat severe edema <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Albumin may be given, helps to move interstitial fluid back to intravascular space <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Albumin is followed by furosemide to reduce possible fluid overload

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 19.5px;">Care: <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Maintain fluid and electrolyte balance <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Administer medications <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Prevent infection, skin breakdown <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Family education <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">I&O <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Daily weights <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Assess edema, dehydration <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Breath sounds <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Observe for signs and symptoms of infection <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Serum and urine electrolytes <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Good hand washing, no sick visitors

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 19.5px;">Family teaching: <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Expected course <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Teach to dip urine <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Daily weights <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Identifying relapses <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Hand washing and infection protection <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Nutritious snacks in response to steroid hunger <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Notify caregiver if exposed to chickenpox <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">No live viruses may be administered during steroid treatment

=<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 27.299999237060547px;">Case Study 1: Nephrotic Syndrome =

===<span style="font-family: 'Times New Roman',Times,serif;">//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// .===

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 * 1) =====<span style="font-family: 'Times New Roman',Times,serif; font-size: 17.457700729370117px;">How does Tyler’s case match the profile for nephrotic syndrome? =====
 * 2) =====<span style="font-family: 'Times New Roman',Times,serif; font-size: 17.457700729370117px;">What is the treatment of choice? =====
 * 3) =====<span style="font-family: 'Times New Roman',Times,serif; font-size: 17.457700729370117px;">What are some possible side effects of the treatment? =====
 * 4) =====<span style="font-family: 'Times New Roman',Times,serif; font-size: 17.457700729370117px;">What are some important nursing considerations to consider? =====
 * 5) =====<span style="font-family: 'Times New Roman',Times,serif; font-size: 17.457700729370117px;">Name some possible complications of this syndrome for Tyler. =====
 * 6) =====<span style="font-family: 'Times New Roman',Times,serif; font-size: 17.457700729370117px;">Name some topics for teaching for this family. =====

The Answer:

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<span style="color: #d22828; font-family: 'Times New Roman',Times,serif; font-size: 22.100000381469727px;">Wilms Tumor Nephroblastoma

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<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">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.

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Symptoms: <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Most children present with abdominal swelling. It is firm, nontender and confined to one side. <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Other symptoms common with a Wilms tumor include: hematuria, fatigue, malaise, hypertension, weight loss and fever.

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">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.

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">The tumor can be staged I-V. Survival rates are 90% for grades I and II.


 * <span style="color: #d22828; font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">*Do not palpate the abdomen! This can lead to shedding and spreading of cells. **

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">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.

<span style="color: #d22828; font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Meet Sydney!

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">media type="youtube" key="YHLuQmM9waM" height="377" width="672"

=<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 27px;">Renal Failure and dialysis = =media type="youtube" key="mi34xCfmLhw" width="560" height="315"=

=media type="youtube" key="Lreqo-teOhk" width="560" height="315"=

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Kidneys filter waste, excess fluid and electrolytes <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">When they don't toxins accumulate causing edema, hypertension, bone or blood problems
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 20.799999237060547px;">Acute kidney failure: **

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Low back pain in kidney area <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Painful frequent, urination, pressure <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Urine color changes, foamy, concentrated, blood in urine <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Skin itching, rashes, and dryness <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Edema face, joint and limbs <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Decreased erythropoiten leads to decrease in RBC <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Shortness of breath due to decreased RBC <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Metalic taste in the mouth <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Bad concentration and dizziness
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Symptoms: **


 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Common labs to assess kidney function: **

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">**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.

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">**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.

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">**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.

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">**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.

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">**Microalbuminuria:** This is a sensitive test that can detect a small amount of protein in the urine.

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">**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.

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">**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.

=<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 27px;">Word Match: =


 * ===<span style="font-family: 'Times New Roman',Times,serif; font-size: 1.1em;">1. Dysuria ===

<span style="font-family: 'Times New Roman',Times,serif; font-size: 1.1em;">14. Hydronephrosis
|| ===<span style="font-family: 'Times New Roman',Times,serif; font-size: 1.1em;">A. involuntary voiding of urine ===

<span style="font-family: 'Times New Roman',Times,serif; font-size: 1.1em;">N. bladder infection
||

<span style="color: #d12e2e; font-family: 'Times New Roman',Times,serif; font-size: 17px;">References:

<span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Hockenberry, M. J., & Wilson, D. (2009). Wong's essentials of pediatric nursing (8th ed.). St. Louis, MO: Mosby Elsevier.

<span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">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

<span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Sydney https://youtu.be/YHLuQmM9waM

Dialysis https://youtu.be/mi34xCfmLhw

https://youtu.be/Lreqo-teOhk