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الموضوع: Nephrotic Syndrom

  1. #1
    تاريخ التسجيل
    Feb 2006
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    877

    افتراضي Nephrotic Syndrom

    السلام عليكم ورحمة الله وبركاته

    اعضاء طبيب دوت كوم

    اهلا وسهلا بكم بلتقى طلاب كلية التمريض التي يسرها تقديم كل ماهو جديد ومفيد

    لاعضائها الكرام


    تقدم اليكم مرض

    NEPHROTIC SYNDROM

    بالتفصيل مع الخطة التمريضية المتبعة

    تمنياتنا ان ينال على رضاكم


    ودمتم بالف صحة وعافية


    اعداد وتنفيذ مركز التديب و التعليم

  2. #2
    تاريخ التسجيل
    Feb 2006
    الدولة
    قلب امي
    المشاركات
    877

    افتراضي

    NEPHROTIC SYNDROME



    Nephrotic syndrome is characterized by heavy proteinuria, hypoalbuminemia, and edema. The syndrome can be subdivided into congenital, primary (idiopathic), and secondary types. Approximately 85% to 95% of primary cases in preadolescents are minimal change nephrotic syndrome (MCNS) and are associated with minimal histologic change in the glomeruli. Nephrotic syndrome annually afflicts approximately 16 children per 100,000 younger than age 16 in the United States; it is slightly more common in males than females in young children, but this disappears in teenagers and adults. Mean age at onset is 2 آ½.


    Pathophysiology and Etiology

    Primary (idiopathic, minimal change, childhood) nephrotic syndrome

    • Underlying defect is thought to be caused by the loss of charge selectivity of the glomerular basement membrane, which permits negatively charged proteins, primarily albumin, to pass easily through the capillary walls into the urine.
    • Excessive urinary loss of protein and catabolization by the kidney of circulating albumin leads to a decrease in serum protein (hypoalbuminemia).
    • The colloidal osmotic pressure that holds water in the vascular compartments is reduced because of the decrease in the amount of serum albumin. This allows fluid to flow from the capillaries into the interstitial spaces, thus producing edema.
    • The shift of fluid from the plasma to the interstitial spaces reduces the vascular fluid volume (hypovolemia), which in turn stimulates the renin-angiotensin system and the secretion of antidiuretic hormone and aldosterone.
    • Tubular reabsorption of sodium and water is increased to increase intravascular volume.
    • The loss of proteins, particularly immunoglobulins, predisposes the child to infection.


    Clinical Manifestations

    • Onset is insidious thought to be caused by immune system disturbances because it commonly occurs after a mild URI.
    • Edema is typically the presenting symptom.
      • Edema may be minimal or massive.
      • Edema is usually first apparent around the eyes.
      • Dependent edema occurs in areas of the body, such as the hands, ankles, feet, and genitalia.
      • Fluid that accumulates in the body spaces may give rise to ascites and pleural effusions.
      • Striae may appear on the skin from overstretching.

    • Profound weight gain caused by edema; the child may actually double normal weight.
    • Decreased urine output during the edematous phase urine appears concentrated and frothy.
    • Pallor, irritability, lethargy, and fatigue.
    • GI disturbances, including vomiting, diarrhea, and anorexia caused by edema of intestinal mucosa.


    Diagnostic Evaluation

    • Urinalysis:
      • Protein usually 2+ or greater
      • Blood absent or transient

    • 24-hour urine protein frequently greater than 2 g/m2 per day.
    • Blood:
      • Total protein reduced
      • Albumin less than 2 g/dL
      • Cholesterol Mgreater than 200 mg/dL with edema

    • Renal biopsy is indicated if patient is steroid resistant (has failed to achieve remission after 28 days of steroid therapy).


    Management

    Steroid Therapy

    Preferred approach to treatment.

    • Prednisone is usually the drug of choice because it is less likely to induce salt retention and potassium loss and is the least expensive.
    • No standard program of therapy exists, but most children receive 60 mg/m2 per day for induction of remission.
      • The steroid dosage may also be calculated on ideal body weight with an equivalent dose being 2 mg/kg per day.
      • Practice varies; however, the maximum steroid dosage is up to 80 mg/day for 4 weeks.

    • After daily steroid therapy, the prednisone should be discontinued slowly to avoid complications of steroid withdrawal, particularly benign intracranial hypertension. Practice varies; however, most centers recommend tapering using alternate-day prednisone over 6 to 8 weeks.
    • Children with nephrotic syndrome may respond to steroid therapy in several ways:
      • Steroid sensitive: achieving a remission within 28 days of the start of prednisone therapy for the initial presentation of nephrotic syndrome.
      • Steroid dependent: two consecutive relapses, occurring during prednisone therapy, or within 14 days after its cessation.
      • Steroid resistant: failure to achieve response in spite of 4 weeks of prednisone therapy at 60 mg/m2 per day.

    • Children with steroid-responsive MCNS have a favorable long-term prognosis.


    Alternative Drug Therapies

    • Should be considered when children relapse frequently (four to five per year), become steroid resistant or steroid dependent, or demonstrate unacceptable adverse effects of steroid therapy (steroid toxicity). The decision to use alternative therapy in conjunction with steroids should be made by an experienced pediatric nephrologist.
    • Immunosuppressants
      • Cyclophosphamide (Cytoxan, Neosar)
      • Cyclosporin A (Neoral, Sandimmune)
      • Tacrolimus (Prograf)



    I.V. Albumin 25%

    • To shift fluid from interstitial space into the vascular system.
    • This is only a temporary treatment to relieve edema but may be used in severe cases of edema that causes respiratory distress or severe discomfort due to edema.
    • Diuretic therapy is used in combination with I.V. albumin to help relieve edema. In cases of hypovolemia, diuretics may not be indicated.


    Complications

    • Infections:
      • Peritonitis, most commonly caused by Streptococcus pneumoniae, but may also be caused by Escherichia coli and Haemophilus influenzae
      • Gram-negative septicemia
      • Staphylococcal cellulitis

    • Thrombosis
    • Hyperlipidemia
    • Acute renal failure


    Nursing Assessment

    • Obtain history of onset of illness and symptoms.
      • Precipitating events
      • Recent immunizations
      • Recent URIs
      • Flulike symptoms
      • Time of onset and location of edema
      • Urinary pattern changes

    • Perform physical examination focusing on vital signs; auscultation of breath sounds to determine adventitious sounds; areas and extent of edema, especially periorbital region, extremities, genitalia, abdomen; and peripheral perfusion, including pulses, color, warmth of extremities
    • Nursing Diagnoses
    • Excess Fluid Volume related to fluid accumulation in tissues
    • Risk for Infection related to urinary loss of proteins and chronic steroid use
    • Imbalanced Nutrition: Less Than Body Requirements related to loss of proteins through urine and anorexia
    • Interrupted Family Processes related to childhood illness
    • .


    التعديل الأخير تم بواسطة نجمه ; 06-21-2008 الساعة 06:50 PM

  3. #3
    تاريخ التسجيل
    Feb 2006
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    قلب امي
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    877

    افتراضي

    Nursing Interventions

    Relieving Excess Fluid

    • Administer corticosteroids as recommended by the health care provider.
      • Observe for adverse effects and complications of therapy such as Cushing's syndrome increased body hair (hirsutism), rounding of the face (moon face*), abdominal distention, striae, increased appetite with weight gain, cataracts, and aggravation of adolescent acne.
      • Stress that these physical changes are not harmful or permanent and that they will disappear after the steroid treatment is stopped.
      • Observe for serious adverse effects and uncommon complications of corticosteroids

    • Administer immunosuppressive drugs as prescribed.
      • Make sure that patient and parents understand the desired and adverse effects of therapy.
      • Observe for complications of therapy, such as decreased white blood cell (WBC) count, increased susceptibility to infection, hair loss or increased hair growth (hirsutism), gingival hyperplasia, hemorrhagic cystitis.

    • Administer diuretics as prescribed.
      • Be aware of those diuretics that may cause potassium depletion.
      • Offer foods high in potassium, such as orange juice, bananas, and dried fruits (eg, raisins, apricots).
      • Administer supplemental potassium chloride as ordered and if the urine output is adequate.

    • Encourage activity as tolerated.
    • Restrict fluids as ordered (usually only during the extreme edematous phases).
      • Restriction is carefully calculated at frequent intervals, based on the urine output of the previous day plus estimated insensible losses.
      • Offer small amounts of fluids spaced at regular intervals throughout the day and evening. Use a cup of appropriate size for the amount of fluid being offered.
      • Measure fluids accurately in graduated containers. Do not estimate fluid intake or output.
      • Place a sign on the child's bed to make sure that no urine is accidentally discarded and that all intake is recorded.
      • Determine total intake and output every 8 hours. In children who are not toilet trained, a fairly accurate record of output can be obtained by weighing diapers before and after voiding.
      • Record other causes of fluid loss, such as the number of stools per day, perspiration.

    • Assist with abdominal paracentesis; this may be required because of marked ascites. During the procedure, fluid is withdrawn from the peritoneal cavity to relieve pressure symptoms and respiratory distress.
    • Restrict sodium as ordered (usually done while the child is proteinuric). A starting point is 2 to 3 g/day.
      • Use a low-sodium menu when ordering meals from the hospital.
      • Assist family in making food choices that are low in sodium.
      • Foods that should be limited include cured, salted, canned, or smoked meats; processed cheese; regular canned or frozen soups and bouillon cubes; salted crackers and other snack foods.



    ALERT

    No live vaccinations or immunizations should be given during active episodes of nephrosis or while the child receives immunosuppressive therapy.

    ALERT

    Administer cyclophosphamide in the morning, with large volumes of fluid, to prevent concentration of the drug in the urine and increased susceptibility to cystitis.

    Preventing Infection

    • Monitor complete blood count for decreased WBC count and neutropenia.
    • Closely observe the child who takes corticosteroids for signs of infection. Be aware that fever and other symptoms may be masked.
    • Provide meticulous skin care to the edematous areas of the body.
      • Bathe the child frequently and apply powder. Areas of concern are moist parts of the body and edematous male genitalia. Support the scrotum with a cotton pad held in place by a T-binder, if necessary, for the child's comfort.
      • Position the child so that edematous skin surfaces are not in contact. Place a pillow between the child's legs when lying on side.
      • Elevate the child's head to reduce edema.

    • If possible, avoid invasive procedures, such as femoral venipunctures and I.M. injections, to decrease the chance of introducing pathogens. Venipuncture of the lower extremities may also predispose the child to thromboembolism because of the hypovolemia, stasis, and increased plasma concentration of clotting factors.
    • Educate parents regarding signs and symptoms of possible infections.


    Enhancing Nutritional Status

    • Assess nutritional intake, growth, and development as appropriate for age.
    • Provide a diet low in sodium, fat, and sugar. Place a sign on the child's bed that indicates dietary restrictions, so that everyone will be aware of special needs.
    • Provide food choices that appeal to the child and that are easy to eat according to stage of development.
    • Provide nutritional supplements as needed.


    Providing Emotional Support

    • Encourage frequent visiting and allow as much parental participation in the child's care as possible. Hospitalization, if necessary, is usually brief.
    • Allow the child as much activity as tolerated.
      • Balance periods of rest, recreation, and quiet activities during the convalescent phase.
      • Allow the child to eat meals with family or other children.

    • Encourage the child and family to verbalize fears, frustrations, and questions.
      • Be aware that young children frequently fear abandonment by their parents.
      • Allow parents to express frustrations regarding the uncertainties associated with the cause of the disease, the clinical course, and prognosis.
      • Explain the difference between nephritis and nephrosis if parents have questions.

    • Help the child adjust to changes in body image, such as cushingoid appearance, by explaining changes ahead of time.
    • Discuss the problems of discipline with the parents. Encourage them to set consistent limits and reasonable expectations of their child's behavior.
    • Suggest parents get involved with a support group for families of children with chronic illnesses, as needed.


    Family Education and Health Maintenance

    • Prepare the family for home management of the child's care plan.
      • Have the dietitian discuss special diets with the parents.
      • Teach the parents about the child's medication the desired effects and the potential adverse effects.
      • Demonstrate urine testing for protein.
      • Initiate a community health nursing referral if necessary for reassessment and reinforcement of teaching.

    • Encourage continued medical follow-up visits.
    • Emphasize the necessity of taking medication according to the prescribed schedule and for an extended time. Discuss complications encountered with steroid therapy.
    • Teach prevention and recognition of signs and symptoms of infection.
    • Advise family on activity restrictions necessary.
    • Teach signs and symptoms of relapse (proteinuria on urine dipstick at home, increased edema, decreased urine output) and whom and when to call with questions.
    • Teach signs and symptoms of fluid imbalances (excess or dehydration).


    Evaluation: Expected Outcomes

    • Decreased edema and ascites; adequate urine output
    • Exhibits no signs of infection
    • Family verbalizes and follows dietary restrictions as demonstrated by appropriate weight gain/loss
    • Family verbalizes concerns regarding child's illness as demonstrated by open communication with staff and other family members



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