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Home  Notes  Pediatric Nursing

Notes Pediatric Nursing

Nephrotic Syndrome
By Marianne Belleza, R.N. - Updated on August 29, 2018  0
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Maggie has been aware that her 3-year old son’s face has become quite so puffy lately. She ignored it thinking
it is just due to his plumpness. Days pass and Maggie’s son has turned from an adorable, playful toddler to an
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irritable child. When the swelling reached her son’s extremities, Maggie rushed her son to the hospital. He was
diagnosed with nephrotic syndrome.

1. Description
2. Pathophysiology
3. Statistics and Incidences
4. Causes
5. Clinical Manifestations
6. Assessment and Diagnostic Findings
7. Medical Management
7.1. Pharmacologic Management
8. Nursing Management
8.1. Nursing Assessment
8.2. Nursing Diagnoses
8.3. Nursing Care Planning and Goals
8.4. Nursing Interventions
8.5. Evaluation
8.6. Documentation Guidelines
9. Quiz: Nephrotic Syndrome

Description

Nephrotic syndrome has a course of remissions and exacerbations that usually lasts for months.

Nephrotic syndrome, or nephrosis, is defined by the presence of nephrotic-range proteinuria, edema,

hyperlipidemia, and hypoalbuminemia.
While nephrotic-range proteinuria in adults is characterized by protein excretion of 3.5 g or more per
day, in children it is defined as protein excretion of more than 40 mg/m2/h or a first-morning urine
protein/creatinine of 2-3 mg/mg creatinine or greater.

Pathophysiology

In a healthy individual, less than 0.1% of plasma albumin may traverse the glomerular filtration barrier.
Amounts above 500 mg/day point to glomerular disease.

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Nephrotic Syndrome - Overview (Sign and symptoms, pathophysiology)

The glomerular capillaries are lined by a fenestrated endothelium that sits on the glomerular basement
membrane, which in turn is covered by glomerular epithelium, or podocytes, which envelops the
capillaries with cellular extensions called foot processes.
In between the foot processes are the filtration slits; these three structures—the fenestrated
endothelium, glomerular basement membrane, and glomerular epithelium—are the glomerular filtration
barrier.
Filtration of plasma water and solutes is extracellular and occurs through the endothelial fenestrae and
filtration slits.
The importance of the podocytes and the filtration slits is shown by genetic diseases: in congenital
nephrotic syndrome of the Finnish type, the gene for nephrin, a protein of the filtration slit, is mutated,
leading to nephrotic syndrome in infancy; similarly, podocin, a protein of the podocytes, may be
abnormal in a number of children with steroid-resistant focal glomerulosclerosis.
The glomerular structural changes that may cause proteinuria are damage to the endothelial surface,
the glomerular basement membrane, or the podocytes; one or more of these mechanisms may be seen
in any one type of nephrotic syndrome.
Albuminuria alone may occur or, with greater injury, leakage of all plasma proteins (ie, proteinuria) may
take place.
 There are two current hypotheses for the formation of edema in nephrotic syndrome: the underfill
hypothesis holds that the loss of albumin leading to lower plasma colloid pressure is the cause; the
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overfill hypothesis states that the edema is due to primary renal sodium retention.

Statistics and Incidences

Nephrotic syndrome is present in as many as 7 children per 100, 000 population younger than 9 years of
age.

The average age of onset is 2.5 years, with most cases occurring between the ages of 2 and 6 years.
In the United States, the reported annual incidence rate of nephrotic syndrome is 2-7 cases per 100,000
children younger than 16 years.
In children younger than 8 years at onset, the ratio of males to females varies from 2:1 to 3:2 in various
studies.
In children, nephrotic syndrome may occur at a rate of 20 cases per million children.
Because diabetes is major cause of nephrotic syndrome, American Indians, Hispanics, and African
Americans have a higher incidence of nephrotic syndrome than do white persons.
There is a male predominance in the occurrence of nephrotic syndrome, as for chronic kidney disease
in general.

Causes

There are two causes of nephrotic syndrome: primary and secondary.

Primary. Common primary causes of nephrotic syndrome include kidney diseases such as minimal-‐
change nephropathy, membranous nephropathy, and focal glomerulosclerosis.
Secondary. Secondary causes include systemic diseases such as diabetes mellitus, lupus
erythematosus, and amyloidosis.

Clinical Manifestations

The first sign of nephrotic syndrome in children is usually swelling of the face; this is followed by swelling
of the entire body.
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MedComic.com

Edema. Edema is the salient feature of nephrotic syndrome and initially develops around the eyes and
legs; with time, the edema becomes generalized and may be associated with an increase in weight, the
development of ascites, or pleural effusions.
Malnutrition. Malnutrition may become severe, however, the generalized edema masks the loss of body
tissue, causing the child to present a chubby appearance and to double his or her weight.
Irritability and loss of appetite. Anorexia, irritability, and loss of appetite develop.
Immunosuppression. These children are generally susceptible to infection, and repeated acute
respiratory conditions are the usual pattern.
Proteinuria. Albumin leaks out due to structural damage, leading to proteinuria.
Respiratory tract infection. A history of a respiratory tract infection immediately preceding the onset of
nephrotic syndrome is frequent.
Allergy. Approximately 30% of children with nephrotic syndrome have a history of allergy.

Assessment and Diagnostic Findings

In order to establish the presence of nephrotic syndrome, laboratory tests should confirm (1) nephrotic-
range proteinuria, (2) hypoalbuminemia, and (3) hyperlipidemia. Therefore, initial laboratory testing should
include the following:

Urine studies. First morning urine protein/creatinine is more easily obtained than 24-hour urine studies,
is possibly more reliable, and excludes orthostatic proteinuria; a urine protein/creatinine ratio of more
 than 2-3 mg/mg is consistent with nephrotic-range proteinuria.
Blood studies. Serum albumin levels in nephrotic syndrome are generally less than 2.5 g/dL; serum
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sodium levels are low in patients with INS because of hyperlipidemia (pseudohyponatremia), as well as
dilution due to water retention; on the CBC, an increased hemoglobin and hematocrit indicate
hemoconcentration and intravascular volume depletion; the platelet count is often increased.
Genetic testing. Patients with infantile or congenital nephrotic syndrome should have testing for
mutations in NPHS1 and WT1; if test results are normal, then testing for mutations in NPHS2 and PLCE1
should be considered.

Medical Management

The management of nephrotic syndrome is a long process with remissions and recurrence of symptoms
common.

Corticosteroid therapy. The general consensus now is daily induction steroid treatment for 6 weeks,
followed by alternate-day maintenance therapy for another 6 weeks.
Diuretic therapy. Diuretic therapy may be beneficial, particularly in children with symptomatic edema;
loop diuretics, such as furosemide (starting at 1-2 mg/kg/d) may improve edema; their administration,
however, should be handled with care because plasma volume contraction may already be present, and
hypovolemic shock has been observed with overly aggressive therapy.
Home monitoring. Home monitoring of urine protein and fluid status is an important aspect of
management; all patients and parents should be trained to monitor first morning urine proteins at home
with urine dipstick; urine testing at home is also useful in monitoring response (or non-response) to
steroid treatment.
Diet. A sodium-restricted diet should be maintained while a patient is edematous and until proteinuria
remits; during severe edema, careful and modest fluid restriction may be appropriate, but the patient
must be monitored closely for excessive intravascular volume depletion.
Activity. A normal activity plan is recommended.

Pharmacologic Management

Prednisone is the first-line therapy for children with nephrotic syndrome. Other immunosuppressive
medications may be useful in those whose symptoms fail to respond to standard corticosteroid therapy or
in those who have frequent relapses.

Glucocorticoids. All glucocorticoids are effective; however, prednisone or prednisolone is used most
commonly; their specific mode of action in nephrotic syndrome is unknown.
 Diuretics. Diuretics promote excretion of water and electrolytes by the kidneys; these agents are used
to treat heart failure or hepatic, renal, or pulmonary disease when sodium and water retention has
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resulted in edema or ascites.
Plasma protein. This agent is used to supplement diuresis in patients with edema; it increases oncotic
pressure and thereby promotes a fluid shift from interstitial tissues.
Immunosuppressive agents. This agent is used to supplement diuresis in patients with edema; it
increases oncotic pressure and thereby promotes a fluid shift from interstitial tissues.

Nursing Management

The nursing management of a child with nephrotic syndrome include the following:

Nursing Assessment

Assess for the following:

Edema. Observe for edema when performing physical examination of the child with nephrotic
syndrome.
Weigh and measure. Weigh the child and record the abdominal measurements to serve as a baseline.
Vital signs. Obtain vital signs, including blood pressure.
Pitting edema. Note any swelling about the eyes or the ankles and other dependent parts.
Skin. Inspect the skin for pallor, irritation, or breakdown; examine the scrotal area of the male child for
swelling, redness, and irritation.

Nursing Diagnoses

Based on the assessment data, the major nursing diagnoses are:

Excess fluid volume related to fluid accumulation in tissues and third spaces.
Risk for imbalanced nutrition: less than body requirements related to anorexia.
Risk for impaired skin integrity related to edema.
Fatigue related to edema and disease process.
Risk for infection related to immunosuppression.
Deficient knowledge of the caregiver related to disease process, treatment, and home care.
Compromised family coping related to care of a child with chronic illness.

Nursing Care Planning and Goals

The major nursing care planning goals for the child with nephrotic syndrome are:

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Relieving edema.
Improving nutritional status.
Maintaining skin integrity.
Conserving energy.
Preventing infection.

Nursing Interventions

Nursing interventions for a child with nephrotic syndrome are:

Monitoring fluid intake and output. Accurately monitor and document intake and output; weigh the
child at the same time every day, on the same scale in the same clothing; measure the child’s abdomen
daily at the level of the umbilicus.
Improving nutritional intake. Offer a visually appealing and nutritious diet; consult the child and the
family to learn which foods are appealing to the child; serving six small meals my help increase the
child’s total intake better.
Promoting skin integrity. Inspect all skin surfaces regularly for breakdown; turn and position the child
every 2 hours; protect skin surfaces from pressure by means of pillows and padding; protect
overlapping skin surfaces from rubbing by careful placement of cotton gauze; bathe the child regularly;
a sheer dusting of cornstarch ma be soothing to the skin.
Promoting energy conservation. Bed rest is common during the edema stage of the condition; balance
the activity with rest periods and encourage the child to rest when fatigued; plan quiet, age-appropriate
activities that interest the child.
Preventing infection. Protect the child from anyone with an infection: staff, family, visitors, and other
children; handwashing and strict medical asepsis are essential; and observe for any early signs of
infection.

Evaluation

Goals are met as evidenced by:

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Relief from edema.

Improvement of nutritional status.
Maintainance of skin integrity.
Conservation of energy.
Prevention of infection.

Documentation Guidelines

Documentation in a patient with nephrotic syndrome include:

Temperature and other assessment findings, including vital signs.

Causative and contributing factors.
Impact of condition on personal image and lifestyle.
Plan of care.
Teaching plan.
Responses to interventions, teaching, and actions performed.
Attainment or progress towards desired outcomes.
Modifications to plan of care.

Quiz: Nephrotic Syndrome

Here’s a 5-item quiz about the study guide:

EXAM MODE
In Exam Mode: All questions are shown but the results, answers, and rationales (if any) will only be
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given after you’ve finished the quiz.

Practice Quiz: Nephrotic Syndrome

Start

PRACTICE MODE

Practice Mode: This is an interactive version of the Text Mode. All questions are given in a single
page and correct answers, rationales or explanations (if any) are immediately shown after you have
selected an answer. No time limit for this exam.

Practice Quiz: Nephrotic Syndrome

Start

TEXT MODE

Text Mode: All questions and answers are given on a single page for reading and answering at your
own pace. Be sure to grab a pen and paper to write down your answers.

1. Alaric was diagnosed with minimal-change nephrotic syndrome; which of the following signs
and symptoms are characteristics of the said disorder?

A. Hypertension, edema, hematuria.

B. Hypertension, edema, proteinuria.
C. Gross hematuria, fever, proteinuria.
D. Poor appetite, edema, proteinuria.

1. Answer: D. Poor appetite, edema, proteinuria.

 Option D: Clinical manifestations of nephrotic syndrome include loss of appetite due to edema of
intestinal mucosa, proteinuria, and edema.
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Options A, B: Hypertension alone or accompanied by hematuria is associated with
glomerulonephritis.
Option C: Gross hematuria is not associated with nephrotic syndrome. Fever will occur only if
infection also existed.

2. 12-year-old Caroline has recurring nephrotic syndrome; which of the following areas of potential
disturbances should be a prime consideration when planning ongoing nursing care?

A. Body image.
B. Sexual maturation.
C. Muscle coordination.
D. Intellectual development.

2. Answer: A. Body image

A: Because of edema associated with nephrotic syndrome, potential self-concept and body
image disturbances related to changes in appearance and social isolation should be considered.
B, C, D: Sexual maturation, muscle coordination, and intellectual function are not affected.

3. Nurse Jeremy is evaluating a client’s fluid intake and output record. Fluid intake and urine output
should relate in which way?

A. Fluid intake should be double the urine output.

B. Fluid intake should be approximately equal to the urine output.
C. Fluid intake should be half the urine output.
D. Fluid intake should be inversely proportional to the urine output.

3. Answer: B. Fluid intake should be approximately equal to the urine output.

Option B: Normally, fluid intake is approximately equal to the urine output. Any other relationship
signals an abnormality.
Option A: Fluid intake that is double the urine output indicates fluid retention
Option C: Fluid intake that is half the urine output indicates dehydration.
Option D: Normally, fluid intake isn’t inversely proportional to the urine output.
 4. Which of the following conditions most commonly causes acute glomerulonephritis?

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A. A congenital condition leading to renal dysfunction.
B. Prior infection with group A Streptococcus within the past 10-14 days.
C. Viral infection of the glomeruli.
D. Nephrotic syndrome.

4. Answer: B. Prior infection with group A Streptococcus within the past 10-14 days.

Acute glomerulonephritis is most commonly caused by the immune response to a prior upper
respiratory infection with group A Streptococcus. Glomerular inflammation occurs about 10-14 days
after the infection, resulting in scant, dark urine and retention of body fluid. Periorbital edema
and hypertension are common signs at diagnosis.

5. Dr. Jones prescribes corticosteroids for a child with nephritic syndrome. What is the primary
purpose of administering corticosteroids to this child?

A. To increase blood pressure.

B. To reduce inflammation.
C. To decrease proteinuria.
D. To prevent infection.

5. Answer: C. To decrease proteinuria.

Option C: The primary purpose of administering corticosteroids to a child with nephritic

syndrome is to decrease proteinuria.
Option A: Corticosteroids have no effect on blood pressure.
Option B: Although they help reduce inflammation, this is not the reason for their use in patients
with nephritic syndrome.
Option D: Corticosteroids may predispose a patient to infection.

See Also

Related topics to this study guide:

Pediatric Nursing Study Guides

 Nursing Notes: Study Guides for Various Topics
Pediatric Nursing NCLEX Practice Questions
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Further Reading

Recommended resources and books for pediatric nursing:

1. PedsNotes: Nurse's Clinical Pocket Guide (Nurse's Clinical Pocket Guides)

2. Pediatric Nursing Made Incredibly Easy
3. Wong's Essentials of Pediatric Nursing
4. Pediatric Nursing: The Critical Components of Nursing Care
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TAGS Kidney kidney disease Nephrotic Syndrome proteinuria Urinary System

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Marianne Belleza, R.N.

Marianne is a staff nurse during the day and a Nurseslabs writer at night. She is a registered nurse since 2015
and is currently working in a regional tertiary hospital and is finishing her Master's in Nursing this June. As an
outpatient department nurse, she is a seasoned nurse in providing health teachings to her patients making her
also an excellent study guide writer for student nurses. Marianne is also a mom of a toddler going through the
terrible twos and her free time is spent on reading books!

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