CHILD HEALTH

Case presentation on :
NURSING
FREQUENT RELAPSE
NEPHROTIC SYNDROME
Submitted To: Submitted By:
Respected Madhu Ma`am Rashi
Faculty 00750306620
College of Nursing, VMMC & SJH 3rd year, BSc.(H)Nursing
VMMC & SJH
INTRODUCTION
Nephrotic Syndrome is a group of
symptoms that include protein in the
urine, low protein levels in the blood,
high cholesterol level, high risk for
clotting of blood, and edema in the
body
DEFINITION
Nephrotic syndrome is a common chronic disorder characterized by
alterations in permeability at the glomerular capillary wall resulting in
massive proteinuria, hypoalbuminemia, edema, and
hyperlipidemia.

Nephrotic range – Protein excretion of >40mg/m2/ hr and >35gm/day

Physiology of Glomerular
Filtration:
The glomerulus is a network of tiny blood vessels located within the renal corpuscle. It
plays a crucial role in the filtration of blood to form urine. The glomerular filtration barrier
comprises three layers:

1.Endothelium: The glomerular endothelium is fenestrated, meaning it has pores that

allow the passage of water and small solutes such as electrolytes and waste products.
However, it prevents the filtration of large proteins and blood cells.

2.Basement Membrane: The glomerular basement membrane is a thick layer

composed of negatively charged glycoproteins. It acts as a physical barrier, limiting the
passage of negatively charged particles such as proteins.
Epithelium: The epithelial layer of the glomerulus is composed of specialized cells
called podocytes. Podocytes have foot-like projections called foot processes that
interdigitate to form filtration slits. These slits provide an additional barrier, restricting
the passage of large molecules.

The glomerular filtration rate (GFR) is a measure of the amount of plasma filtered
through the glomeruli per unit of time. The GFR is regulated by various factors,
including the hydrostatic pressure within the glomerulus, the oncotic pressure
exerted by proteins in the blood, and the constriction or dilation of the afferent and
efferent arterioles.
 INCIDENCE
Nephrotic syndrome is more common in children than in adults, with the majority
of cases occurring between the ages of 2 and 6 years.

The estimated incidence of nephrotic syndrome in children is approximately 2-7

new cases per 100,000 children per year.
ETIOLOGY
 Unknown or idiopathic cause
 Certain disease of kidney or other organs
 Genetic - congenital
TYPES OF NEPHROTIC
SYNDROME
 Types on the basis of underlying causes :
Primary/Focal Segmental Glomerulosclerosis (FSGS): FSGS is a primary
form of nephrotic syndrome, meaning it occurs without a specific underlying cause. It
is characterized by scarring (sclerosis) in some segments of the kidney's filtering units
(glomeruli), leading to protein leakage and subsequent symptoms.

Minimal Change Disease (MCD): MCD is another primary form of nephrotic

syndrome, particularly common in children. It is called "minimal change" because the
kidney tissue appears normal under a microscope. However, there are changes at the
cellular level that disrupt the filtration process, resulting in proteinuria.
Membranous Nephropathy: Membranous nephropathy is a
primary glomerular disease characterized by thickening of the
glomerular basement membrane. It is caused by the deposition of
immune complexes in the kidney, leading to proteinuria and other
symptoms.
CLINICAL MANIFESTATIONS
• Edema starting at the face and subsequently pedal edema progressing to Presacral and genital
area to generalized subcutaneous edema
In advance cases ascites, hydrocele and hydrothorax.
Edema is pitting in nature.
• Decreased urine volume
• Massive proteinuria >40mg/m2/hr
• GI symptoms – Pain in the abdomen, diarrhea
• Respiratory symptoms: Pulmonary edema, and hydrothorax may cause respiratory distress
• Pale and irritable due to subcutaneous edema
• Usually normal blood pressure
PATHOPHYSIOLOGY
 DIAGNOSTIC FINDINGS
 Health history – description of present illness, chief complaints, onset,
progression of symptoms, any past illness
 Physical examination – generalized swelling, periorbital swelling,
peripheral edema, ascites, pale skin
 Urine analysis –
• Nephrotic range proteinuria –

Urine protein: creatinine ratio > 2

Proteinuria: 40mg/m^2/hr
Urinary dipstick showing +3/+4
 CBC – Anemia, Raised platelet count
 Serum proteins – Total protein, Hypoproteinemia (<2.5gm/dl)
 USG - Help identify underlying cause of the Nephrotic Syndrome
 Ascitic tap – for the presence of any pus cells, bacteria, blood cells
 Renal biopsy – for histology examination of renal tissue to confirm the
diagnosis
PHARMACOLOGICAL
MANAGEMENT
 Corticosteroids: Prednisolone is the most commonly prescribed corticosteroid
to reduce proteinuria and control inflammation. It is usually given as an initial
treatment for several weeks, followed by a tapering dose over several months.

• For initial episode – Corticosteroid therapy – Prednisolone 2mg/kg/day

(maximum 60 mg) in single or divided doses for 6 weeks followed by
1.5mg/kg/day (maximum 40mg) as a single morning dose every alternate day for
next 6weeks.
• For relapse – Prednisolone 2mg/kg/day as a single or divided dose until albumin
is nil or trace for 3 consecutive days followed by 1.5mg/kg/day as a single
morning dose every alternative day for the next 4 weeks and then stopped
• Frequent relapse and Steroid dependant - Alternate day since morning dose
of Prednisolone at 0.5-0.7mg\kg for 9-18 months
 Immunomodulators: In cases of steroid-resistant or frequently relapsing nephrotic syndrome,
medications such as cyclophosphamide, cyclosporine, mycophenolate mofetil, or rituximab may
be prescribed to suppress the immune system and reduce proteinuria.
 Angiotensin-converting enzyme inhibitors (ACE inhibitors) or angiotensin receptor
blockers (ARBs): These medications help control blood pressure and reduce proteinuria.
 Diuretics: Diuretics such as furosemide or spironolactone may be prescribed to reduce edema by
promoting urine production and removing excess fluid from the body.
• Aldactone -PO 3.3 mg/kg/d in single or divided doses and Frusemide – 1-3mg\kg\day
 Cholesterol-lowering medications: High cholesterol levels are common in nephrotic syndrome.
Medications like statins may be prescribed to lower cholesterol and reduce the risk of
cardiovascular complications.
• For refractory edema, albumin (0.5-1g/kg) over 2-4hr
infusion is given on alternate days followed by IV
Frusemide.
 PATIENT`S EDUCATION
 Advise the patient/family not to stop taking prednisone abruptly. Teach the adverse effects
of abruptly discontinuing therapy.

 Be aware of potential side effects: Prednisolone can cause various side effects, especially
when used for a prolonged period. These may include increased appetite, weight gain, fluid
retention, mood changes, insomnia, increased blood sugar levels, and increased
susceptibility to infections.

 Educate the patient to avoid exposure to contagious infections because he/she is at higher
risk of acquiring infection due to immunosuppression.

 Take the medication with food if needed: Prednisolone can sometimes cause stomach
irritation
 COMPLICATIONS
• Higher risk of infection
• Blood clots
• Hypertension
• High cholesterol
• Brief or long-lasting kidney problems
• Malnutrition
 NURSING DIAGNOSIS
• Acute pain related to the disease condition as evidenced by the facial grimace of the
child.
• Fluid volume excess related to water retention as evidenced by the generalized
swelling.
• Risk for infection related to immunosuppressive therapy
• Risk for fluid volume deficit (intravascular) related to proteinuria and diuresis.
• Imbalanced nutrition less than body requirement related to excretion of protein and
other nutrients.
• Ineffective tissue perfusion (renal) related to increased glomerular permeability.
• Impaired Skin Integrity related to edema and increased risk of skin breakdown as
evidenced by swelling, skin tightness, and skin discoloration.
• Deficient Knowledge regarding nephrotic syndrome and its management as evidenced
by patient/family questions, lack of understanding about dietary restrictions, and
medication regimen.
 NURSING MANAGEMENT
 Maintaining fluid volume
1.Assess for ascites, dependant venous pooling
2.Monitoring sodium and fluid intake orally and intravenously
3.Checking body weight and measuring the abdominal girth daily
4.Measurement of Blood Pressure daily
5.Administration of diuretics as prescribed
6.Watch for pulmonary edema by assessing rhonchi and cough
Infection Prevention:
1.Educate the patient and their family about the importance of hand hygiene and infection
control practices.
2.Implement appropriate precautions, such as standard precautions, to minimize the risk of
infections.
3.Monitor the patient for signs of infection and promptly report any concerns to the healthcare
team.
4.Provide an adequate balanced diet
5.Restrict visitors with infection
6.Administer antibiotics as prescribed
 Maintaining adequate nutrition
1.Monitor the patient’s weight daily
2.Assessment of child`s food preference
3.The diet provided to the child should be a high-calorie diet rich in protein
4.The diet provided must be low in Sodium.
5.Provide nutritional supplements as needed
Preventing fluid volume deficit
1. Monitor vital signs and report any variance
2. Maintain Intake Output charting and Report if the child has urine output less than 1-2ml/kg/hr
3. Monitor laboratory values including hemoglobin and hematocrit
4. Observe for any signs of dehydration
Providing Family Education
1. Should be explained the disease condition and the usual outcomes of the treatment.
2. Parents should be taught about how to maintain a urine protein diary.
3. Importance of high-calorie diet and low sodium diet.
4. Educate parents about the importance of adherence to the treatment even if the
child`s symptoms got reduced