210424Renal disorders.pdf

Child with renal conditions: - Urinary Tract Infections - Acute Glomerulo-nephritis - Nephrotic Syndrome Dr Saraswathy Thangarajoo Chan KG, UNIMAS, 1.4.24 Learning outcomes: At the end of the session, students should be able to Describe...

Child with renal conditions: - Urinary Tract Infections - Acute Glomerulo-nephritis - Nephrotic Syndrome Dr Saraswathy Thangarajoo Chan KG, UNIMAS, 1.4.24 Learning outcomes: At the end of the session, students should be able to Describe the clinical manifestation of children with urinary tract infections, acute glomerulonephritis & nephrotic syndrome conditions Relate the pathophysiologic process of children with the renal conditions Describe the management for the renal conditions. Formulate nursing care plan to meet the health needs of hospitalized children with the renal conditions. 2  Review: Genito-urinary tract: Components: Kidneys’ main functions: Urine formation - processes: Glomerular filtration; Tubular reabsorption; Tubular secretion Excretion Urinary tract infection / inflammation Acute Glomerulonephritis Nephrotic Syndrome  Urinary tract infection (UTI) Clinical conditions with presence of microorganisms anywhere within the urinary tract (lower-urethra, bladder and upper tract- ureters,renal pelvis,,calyces); Classified as: o Asymptomatic/symptomatic bacteriuria, o Recurrent/persistent UTI; o Cystitis; o Urethritis; o Pyelonephritis; o Urosepsis  Incidence: 2-6 years old, Girls > Boys; o Microorganisms: E. Coli (80%); Other gram -ve enteric organisms; common to the anal, perianal, perineal regions; Contributing factors: Anatomic factors Urinary stasis Ascending infection Anatomic factors: Females’ lower urinary tract: shorter urethra; easy pathway for bacteria invasion *Males: presence of foreskins contribute to UTI; > in uncircumcised infant boys Urinary stasis: related to: vesico-ureteric reflux Anatomic abnormalities which lead to ureteric/bladder compression Habit of holding back bladder despite the urge to void; tight clothing Ascending infection: related to catheterization, diapers use and poor hygiene. Vesico ureteric reflux Clinical manifestation (i): Newborns: - may have hypothermia as sign of sepsis; - frequent/infrequent voiding; - irritability; - strong-smelling urine; - persistent diaper rash; infants - 2 years old: - non-specific signs; - Failure to thrive; - feeding problems; diarrhea, vomiting; abdominal distension; jaundice; *could be missed, thus maybe treated as GIT / respiratory disorders. Clinical manifestation (ii): Children >2 years old: -daytime incontinence in a child who has been toilet- trained; -fever, foul-smelling urine; increased urination frequency; -dysuria, urgency; maybe abdominal/flank pain; -Maybe: haematuria; dribbling urine; Clinical manifestation (iii): Adolescents: Lower UTI: dysuria; small amount; absent of fever; Upper UTI: fever; chills; flank pain. Diagnostic evaluation History; Physical exam; U/FEME: pus cells gram strain; 5- 8 WBC; maybe normal if asymptomatic bacteriuria; Urine C/S; Urine inspection: Colour ? Cloudy, hazy; Odor? fishy, unpleasant; Content? strands of mucus, pus; Amount? Less; Therapeutic management Objectives: Eliminate current infection; Identify contributing factors to reduce risk of recurrence; Prevent urosepsis- systemic infection- leading to septic shock; Preserve renal functions. Medical management: Antibiotic therapy after blood and urine C/S; could be Penicillin, sulfonamide; cephalosporin.  Nursing care management Objectives: Identification of child with UTI; -child may not verbalize discomfort due to dysuria; education of parents: - observe for clue of UTI: strong smelling urine, frequency or urgency; incontinence in a toilet-trained child; irritability; -prevention: perineal hygiene: females: wipe from front to back; avoid tight clothing/diapers; -Avoid ‘holding’ urine; -increase fluid intake; ACUTE GLOMERULONEPHRITIS A common childhood condition, sudden onset of hematuria, proteinuria, and red blood cell (RBC) casts; often accompanied by hypertension, edema, uremia (due to decreased glomerular filtration rate); Pathophysiology (1) History of streptococcal infection about 2 weeks ago. formation of anti-streptococcal antibodies; antigen-antibody complex lodges in the glomerular capillaries. activates the complement system to cause an inflammatory response in the glomeruli of both kidneys. Pathophysiology (2) increased capillary permeability and cell proliferation → leakage of some protein and large numbers of erythrocytes into the filtrate. immunoglobulin G and C3 (complement) are present in glomerular tissue and serum C3 is reduced. When the inflammatory response is severe, the congestion and cell proliferation interfere with filtration in the kidney. Pathophysiology (3) loss of filtration function of the nephron: reduced glomerular filtration rate → fluid and wastes product retention; decreased blood flow in the kidney - trigger renin secretion which leads to elevated blood pressure and edema. Severe prolonged inflammation - scarring of kidneys. Laboratory Investigations ▪ Urinanlysis-hematuria, proteinuria ▪ Cultures of pharynx – positive for streptococci ▪ Serologic tests ▪ Antistreptolysin O (ASO) ▪ Antistreptokinase (ASKase) ▪ Serum Complement level (C3) Incidence Glomerulonephritis is most common in school-aged children. Ages of peak incidence: 2 to 6 years. predominantly in boys; 60% to 80% have a history of a preceding upper respiratory tract infection or otitis media ; Clinical features (1) Dark brown-colored / “coke” urine (from blood and protein); hematuria (blood in urine); may be microscopic or macroscopic. Proteinuria (primary albumin): due to injury in the glomerular membrane & ↑ permeability of glomerular membrane. Urinalysis: turbid; presence of pus, RBC and protein; specific gravity: >1.035; Oliguria- diminished urine output, reduced GFR due to inflammation of glomerular membrane. Clinical features (2) ⚫Fluid overload; may have shortness of breath or exercise intolerance from fluid overload; tachycardia and tachypnea; ⚫High blood pressure: may have alteration in mental status; headaches, visual disturbances , signs of hypertensive encephalopathy; ⚫ Labtests: ↑ urea and serum creatinine level (Renal insufficiency) Complications kidney failure - Loss of function in the filtering part of the nephron may cause waste products to accumulate rapidly; Medical Management Goal : Reduce inflammation in the kidney, reduce fluid overload & control blood pressure. Fluid restriction. Low protein, low salt & potassium diet. Pharmacological interventions: - diuretics ; - anti-hypertensives - ACE inhibitors Nursing Interventions Nursing diagnosis Risk for electrolyte imbalance Risk for ineffective renal perfusion Risk for poor growth Risk for anemia Expected outcome Risk of injury related to progression of disease (hypertension) Goal: Patient will gradually have stable BP and not experience any related injury (due to hypertensive encephalopathy). ⚫ Monitoring: - blood pressure closely using appropriate cuff size; - mental status; ⚫ fluid restriction; ⚫administer medication as ordered; anti- hypertensives; diuretics e.g. oral hydrochlorothiazide ,to help in reducing fluid overload; ⚫ Restrict dietary sodium to reduce water retention; ⚫Inform doctor for further management if BP maintains high.  Activity Intolerance related to fluid access Goal: To manage patients’ daily activity needs effectively without exceeding their capabilities. Plan daily activities to reduce the exertions on patient. Provide sufficient rest opportunities to the patient between activities. Excess fluid volume related to accumulation of fluids secondary to renal dysfunction Goal: Patient will have a balance amount of fluid and reduced in oedema 1. Monitor: -vital signs, intake and output to monitor the progress of disease and detect complication that may appear during the course of disease; - daily body weight to assess fluid balance; 2. Restrict: - sodium intake - to prevent worsening oedema; - fluid intake - if significantly reduced urine output < 0.5cc/ kg/hr. Parental deficit in knowledge about disease and treatment Goal: parents will be able to demonstrate an understanding of disease and treatment. 1. Explain to family the disease condition in the way that they able to understand to gain cooperation; 2. Allow parents and the child to participate in care. 3. Explain to family about the progression of the child’s condition; 4. Make sure family understand the purpose of treatment and consequences if non compliance.  Nephrotic Syndrome - a collection of symptoms due to kidney damage: -proteinuria, edema, hyperlipidemia, and hypoalbuminemia most common among boys between ages 2 and 6 years old; Nephrotic-range proteinuria = > 2 g protein/dl /24 hrs; (dipstick 3+ = 2 - 5 g/24hrs) Clinical features include:  Generalized edema: on the extremities, abdomen, or genitals; periorbital edema on waking up that resolves during the day; Massive proteinuria; Hypoalbuminemia: ↓ serum albumin; Hyperlipidemia - ↑ blood cholesterol and triglycerides; urine: frothy or foamy appearance; ↓ amount; weight gain; skin: pale and shiny with prominent veins; G/C: irritability; anorexia, malaise; Pathophysiology normally, proteins are not excreted in the urine. in nephrotic syndrome, some proteins, which normally stays in the blood, gets removed along with the waste due to damage to glomeruli; on microscopic exam, glomeruli appearance greatly changed. Causes: - glomeruli inflammation (as autoimmune response); - Minimal change nephritis; Pathophysiology  Laboratory investigation: Urinalysis: ⚫Protein level is > or equal to 2 g/dL/24hrs ⚫Micro-hematuria ⚫Elevated specific gravity Serum albumin level < 25 g/dL; (hypoalbuminemia) Medical management Medication Action Nursing Implication 1. Corticosteroid Stimulate Observe major side effects therapy remission. such as weight gain, moon - Prednisone @ (Urine face, gastrointestinal 2mg/kg/day till no albumin nil bleeding, hyperglycemia, more proteinuria or trace hypertension & etc. for 3 consequence less) days; Reduce Delay administration of live excretion of vaccines (eg: mumps & then protein in urine. rubella vaccines) until child is no longer 1.5mg/kg EoD immunosuppressed. for 4-5 weeks;  Medication Action Nursing Implication 2. Diuretics - Used for severe Assess for tachycardia 0.5mg/kg stat; depends edema. & hypotension. on severity of edema. Prevent reabsorption Monitor for of water, sodium & hyponatremia & potassium by renal hypokalemia. tubules. Blocks sodium chloride transporter in distal tubule.  Medication Action Nursing Implication 3. Antibiotics; Routine prophylaxis Assess signs of penicillin V in nephrotic infection. syndrome not Monitor WBC count. effective. To treat infection. Complications (I) 1. Venous Thrombosis: -due to leak of anti-thrombin 3 (protein), which helps prevent thrombosis. -hypercoagulopathy due to loss of fluid from the blood vessels (oedema); 2. Infection: -due to leakage of immunoglobulins and its loss of complement components, thus low body immunity. -for a child with ascites, risk of spontaneous bacteria peritonitis. Complications (II) 3. Hypovolaemia. - ↓ fluid intravascularly - - Reduced perfusion to vital organs, esp. kidneys; - - excess of fluid in the tissue space; - capillary refill > 2 sec. - hypotension; 4. Pulmonary edema; Excess Fluid Volume related to sodium retention and renal dysfunction. Imbalanced Nutrition: Less than Body Requirements related to loss of appetite and protein loss in urine Activity intolerance related to fatigue due to fluid and electrolyte imbalance, albumin loss, altered nutrition, and renal failure. Risk for Infection related to loss of immunoglobulins in the urine and corticosteroid therapy. Risk for Impaired Skin Integrity related to oedema, lowered resistance to infection and injury, immobility, and malnutrition; Disturbed body image r/t changes in appearance Excess Fluid Volume related to sodium retention and renal dysfunction (i) Goal: The child will be able to regain normal fluid balance by maintains normal urine output of 0.5-1 ml/kg/hr. Assess child for disease progress: - Auscultate - adventitious lung sounds, increased work of breathing r/t fluid overload. Daily monitoring/assess:(Nephrotic charting): extremities, genitals, and periorbital oedema; respiratory effort, RR; urine for proteinuria & specific gravity; level of oedema @ lower extremities & abdomen ascites; measure abdominal girth; - Strict intake and output; - Daily weighing of child with same scale; Excess Fluid Volume related to sodium retention and renal dysfunction (ii) Administer prescribed medications (eg. diuretics, prednisolone) at the scheduled times. - Observe for side effects of corticosteroids (moon face, increased appetite, increased hair growth, abdominal distention and hyperglycemia); If the child is receiving albumin infusion, monitor closely for hypertension or signs of volume overload caused by fluid shifts; albumin infusion may be simultaneously with diuretics. Imbalanced Nutrition: less than body requirements r/t loss of appetite and protein loss in urine Goal: The child will be able to maintain adequate caloric intake that meets the nutritional requirements. Plan to give child’s food preferences; Encourage the child to eat by presenting attractive meals with small portions. Encourage socialization during meals- may improve the child’s appetite. (no fluids restriction except during severe edema). Serve a normal or high protein diet & reduced salt. Activity intolerance related to fatigue due to disease condition Provide opportunities for quiet play as tolerated, such as drawing, playing board games, listening to tapes, and watching videos. Adjust the child’s daily schedule to allow rest periods after activities. Explain to parents and child about the importance of rest. limiting the number of visitors during the acute phase of the illness may be necessary. Telephone contacts may be encouraged as an alternative to visitors. To provide a sense of control, encourage the child to set his own limits on activity. Risk for Infection related to loss of immunoglobulins in the urine and corticosteroid therapy. Practice careful hand-washing/strict aseptic technique during invasive procedures. Monitor TPR 4 hourly - detect early signs of infection; Advise parents and children to avoid exposure to people with respiratory infections and communicable diseases. Emphasize the importance of avoiding public areas - reduce risk of exposure to infections. Educate caregivers to look up for signs of infection. Risk for Impaired Skin Integrity related to oedema, lowered immunity and altered nutrition Goal: child will not get any skin breakdown Assess the skin repeatedly for redness or other signs of pressure injury. Turn the child frequently, and use therapeutic mattresses (e.g. airflow) to help prevent skin breakdown if needed to. Keep the skin clean and dry. Disturbed body image r/t changes in appearance 2nd to disease condition and treatment Goal: Child will be able to discuss feelings and concerns Explore feelings and concerns regarding appearance. Explain to child about the positive aspects of appearance and evidence of diminished edema. Explain to child and family that the s/s assoc. with steroid therapy will subside when medication is discontinued. Encourage socialization with other child in the ward apart from family members. Explore area of interest and encourage their pursuit. Case scenario 1 A 5-year-old boy was admitted to the paediatric medical ward. The mother gave the history that her child had swelling of his whole body especially upon wake up in the morning for the past 3 days; his urine was frothy and straw-coloured. He appeared to be tired easily lately. He has been on monthly follow-up at the specialist clinic. On examination, his blood pressure is normal. Urinalysis shows albumin 4+. The most likely diagnosis of this child is. Case scenario 2 ⦁ Four-year old Anita was brought to the A & E by her mother with a history of passing less urine than usual which was cola-coloured for 2 days; her face was puffy and her legs were swollen for 3 days. She has recovered from a sore throat 10 days ago. On examination by the doctor, she has peri-orbital oedema and her blood pressure was 160/100 mm Hg. Her most probable diagnosis is