Acute

Glomerulonephritis
Etiology:
Immune complex reaction from a previous infection.
Most often from URI and skin infections.
Children 2 6 years of age.
Occurs after the previous infection has resolved.
NOT an infections, dont treat with antibiotics

Patho:
Capallaries in the glomeruli are obstructed by damaged tissue cells-
blood flow is then reduced to the glomeruli
GFR is reduced and vascular permeability is increased
This allows proteins and RBCs to pass through glomeruli
Sodium and water are retained
Fluid overload with both intravascular and interstitial compartments

Clinical manifestations:
Many children are asymptomatic but if symptoms occur
Abrupt onset
Flank or abdominal pain
Hematuria smokey, tea-colored
Edema midperiorbital edema, dependent edema- feet/ankles
o Could progress to pulmonary effusion crackles, cough,
dyspnea or ascites
Acute HTN- may cause encephalopathy headache, n/v, lethargy,
and seizures
Oliguria may or may not be present

Diagnostic Tests:
Urinalysis reveals hematuria, proteinuria, red & white cell casts
BUN and CR elevated
CBC increased WBCs
ASO titer elevated due to the presence of antibodies from a
recent strep resp infection, but the ASO level associated with
recent skin infection is low.
ESR elevated
-Serum lipids are increased and serum protein are decreased as
result of proteinuria
Nursing Assessment and Management:
Assess:
Careful monitoring of Fluid and Electrolytes
Close monitoring of BP- May need antihypertensives
Fluid volume excess monitoring
Lung sounds
Daily weights
Urine for output and protein and hematuria

Manage:
Fatigue cluster care for uninterrupted sleep time, quiet activities
Fluid restriction edema and mild to moderate HTN should be
treated with sodium restriction no added salt, and a diuretic such
as furosemide.
Skin integrity bedrest in acute phase, areas with edema and other
susceptible areas should be protected, turn child frequently, elevate
extremities on pillows, make sure childs bed if free of crumbs or toys,
and keep sheets wrinkle free. Maintain proper hygiene and dry skin
Nutrition no added salt and low protein diet, increase childs
appetite by having family bring foods the child likes and also
encourage family to eat with child; medicine cups can be used so
child doesnt take large sips
Anxiety parents commonly feel guilty, may blame themselves for
not noticing or responding quick enough, discuss the etiology of the
disease and the treatment and that it is not possible to predict which
of the few children with strep infection will develop APIGN.

Discharge Teaching:
Blood pressure monitoring, urine dipstick
No added sodium diet
Activities with frequent rest periods
Strenuous activity restricted until no protein or blood in urine- no
gym class
Weekly followed by monthly UA
Prevent infection dont being child around sick people and do
screenings on family with suspected strep, etc.
Recovery phase if usually complete without relapse, no risk for
relapse like Nephrotic syndrome.
 Hemolytic Uremic Syndrome HUS

*Rare, occurs most often to children under 4 years of age
*Triad of symptoms
Hemolytic anemia
Thrombocytopenia
Acute renal failure
*Increased risk for chronic renal failure

Etiology:
Endotoxins from ecoli, shigella, salmonella= undercooked meats,
alfalfa sprouts, public pools, petting zoos
Associated with viral infections

Patho:
Toxin attached to glomeruli, collecting ducts and distal tubules
Injury to endothelial lining of glomerular arterioles
Endothelium swells and becomes occluded with deposits of platelets
and fibrin clots (intravascular coagulation)
Red blood cells are damaged, become fragmented and are removed
by the spleen

Clinical Manifestations:
Hemolytic anemia
HTN
Pallor
Bruising
Purpura non blanch lesions
Neurologic changes irritability, lethargy, seizures
Acute renal failure- 50% (requires period of dialysis)
Proceeded by apparent viral illness within last 7 days
Gastroenteritis w/ bloody diarrhea, URI, UTI

Diagnostic Tests HUS:
Urinalysis hematuria, casts (cells from lining of kidneys),
proteinuria
CBC decreased hgb, hct, plt
BUN and serum CR elevated
 Electrolytes decreased Na, increased K+
Decreased serum albumin
Decreased calcium
Increased phosphorus
ABG metabolic acidosis


Management HUS:
Supportive
Fluid management
High-calorie diet low in protein, K+, Na, phos likely enteral
Calcium gluconate to replace Ca
Kayexalate to remove K+
Aluminum hydroxide to remove phos by binding to it
Antihypertensives
Transfusion PRBC; platelets to treat severce anemia; if child needs
surgery or is beeding
Dialysis

Nursing Care HUS:
Fluid volume excess strict I&O, daily weights
Risk for impaired skin integrity positions changes, dry linens, skin
care
Risk for injury r/t low platelet count avoid invasive procedures,
monitor neuro status
Altered family coping support, encourage participation in care













 Nephrotic Syndrome

Glomerular membrane injury
Most common type is minimal change nephrotic syndrome or primary- can
be from glomerulonephritis
Secondary nephrotic syndrome related to systemic disease, drugs or toxins
Prognosis 85% will fully recover, no renal damage
o 50% will experience relapses, most common in children 2-7 years of
age
TEACH parents how to watch for relapses and what to do


Patho:
Thought to be related to immune system
o Increased glomerular permeability albumin excreted into
urine
o Decreased osmotic pressure in vascular space
o Edema third space shifting can occur
o Hyperlipidemia the liver stimulates to make more albumin
which also makes more lipid proteins (does this because low
serum protein)
o Hypercoagulabilty

Clinical Manifestations:
Edema
o periorbital, dependent areas lower extremities, abd, scrotum
Abdominal pain
o pressure from fluid in the stomach
Fatgiue
o r/t fluid and electrolyte imbalance, albumin loss, altered
nutrition, and renal failure
Anorexia
o r/t loss of appetite and protein loss in urine
Pallor
Irritability
Decreased UO
o Malaise


Diagnostic Tests:
Urinalysis 3-4+ protein
Serum albumin Less than 2.5
CBC
Source of infection (wont find)
Electrolytes
Cholesterol and triglycerides elevated
Kidney Biopsy
o Not a routine test, but if they dont respond to therapy they will
do it

Management/Treat:
Pednisone
o High dose, minimum of 6 weeks or until no protein in the
urine, then wean off, may take up to 6 months
Diet High protein
Diuretic therapy Monitor electrolytes carefully
Albumin
Fluid restriction
Bedrest if severe edema
Immunosuppressant therapy

Nursing Care:
Assessment
o Vital signs, intake/output, daily weights, daily urine for protein
Skin integrity
Prevent infection
o Provide meticulous skin care, and monitor temp

Fluid Volume Management:
Intravascular fluid volume deficit
o Careful I&O
o Monitor for s/s of dehydration
o Albumin
Extravascular fluid volume excess
o I&O, daily weight, measure abdominal girth, BP (low b/c no
enough vascular fluid), diuretic if ordered, pulmonary
assessment (fluid could move into lungs)
Discharge Teaching:
Infection prevention
o High dose of prednisone
No live virus immunizations
o Ex: MMR and varicella
UA dipstick
o Protein
Blood pressures
Weights
o Relapse signs are increase in weight or tightness (with clothes,
shoes)
Follow-up
Tapering off of prednisone
Symptoms of relapse





























 Enuresis
Repeated involuntary voiding by a child old enough that bladder control is
expected, usually about 5 to 6 years of age
Can occurs either at night (nocturnal), during the day (diurnal), or both
Primary enuresis
o Child has never had a dry night, attributed to maturational delay and
small functional bladder; not associated with stress or psychiatric
cause
Secondary enuresis
o Child who has been reliably dry for at least 6 months begins
bedwetting; associated with stress, infections, and sleep disorders

Enuresis may result from neurologic or congenital structural disorders, illness,
preoccupation with concerns, or stress. Nocturnal enuresis occurs most often in
children whose parents have a HX of bed-wetting.

Diagnosis:
Patient history
Family history
Urinalysis and urine culture
o Looking for infections
Pinworms
o How to DX: Put tape across rectum before bed; before daylight
use flashlight to check for them
KUB
Ultrasound, VCUG
Bladder sonography
NOTES:
- About only 50% of kids are potty trained before the age of 4.
- Alot of enuresis is tied to sleep, not bladder, may be over tired.

Management of Enuresis:
Reassurance
Bladdder exercises, timed voiding
Limit fluids after dinner
Void at HS and before parents go to bed
Reward systems
Bedwetting alarms
Medications
Combination most effective
How to promote the childs self-esteem:
Combination therapy works the best
Focus on parent and childs awareness that enuresis cannot be
controlled by the child
Encourage parents to not focus on wet bed, but help the child to
change cloths and sheets and go back to bed matter of fact
Short-term camp/overnights

Medications to treat Nocturnal Enuresis:
Desmopressin
(ADH) given at night, may be used nightly or as needed has
diuretic effect
Imipramine
Tricyclic antidepressant antcholinergic and antispasmodic
effects risk of accidental overdose
Oxybutynin
Anticholinergic has antispasmodic effects, effective for overactive
detrusor muscle
























 Urinary Tract Infection (UTI)

Risk Factors for UTIs:
Neurogenic bladder Sexual Abuse
Infrequent voiding Sexual Activity
Irritated perineum Obstruction
Constipation Masturbation

Clinical Manifestations:

Infants Children
Poor feeding irritable Fever
Vomiting Poor appetite
Fever +/- - not usually in neonate Vomiting
Poor wt gain- particularly w/ Poor growth
recurrent UTIs Incontinence
Irritability Frequency
Diarrhea loose stools Hematuria frank
Urgency dysuria, enuresis
USUALLY with recurrent UTIs


Risks with UTI:
Eliminate infection
Preserve renal function

Diagnosis of UTI:
Urine culture
o Catheterization is the most reliable

Treatment of UTI:
Antibiotic therapy Sulfamethoxazole-trimethoprim (oral
antibiotic) in children over the age of 2 months
o If urine show WBC or nitrate
If febrile or suspect pyelonephritis
o IV, and increase fluids (also IV antibiotics given)
o Suspicious of kidney problems with fever so HOSPITALIZE
ALWAYS send urine for a culture
Follow-up:
Recheck urine after antibiotic (usually 7-10 days)
o Ultrasound is recommended after first UTI
o VCUG recommended after second or if ultrasound is abnormal
Give a careful explanation of equipment
Allow preschooler to handle catheter
Use dolls to demonstrate, therapeutic play
Adequate staff to restrain
TALK through the procedure and offer privacy
Have parents for comfort
Follow-up cultures

Parent/Patient teaching:
Careful explanation of risks of UTI
Push po fluids
Void at regular intervals
Important of follow-up
Wiping from front to back
Cotton underwear
Avoid tight clothing
No bubble baths
Sexually active adolescents
o Void before and after intercourse


















 Polycystic Kidney Disease PKD

Inherited
Autosomal recessive and dominant forms
Cellular hyperplasia causes collecting ducts to dilate, cells form fluid
filled sacs, obstructing urinary flow
As cysts fill with fluid, nephron functions decrease


Clinical Manifestations:
Hypertension diuretic
Hematuria
Polyuria
Poor growth high protein diet
UTI antibiotic
Proteinuria


Diagnosis & Treatment:
Renal ultrasound
Often diagnosed prenatally by US
Supportive care, screen the family
HTN
o Diuretics
UTI
o Antibiotics
Poor growth
o Prevent renal failure, prevent UTI, high protein diet
Renal dialysis or transplant (still will have liver impairment)
Genetic counseling
o Autosomal dominant, each child has 50% risk of child
inheriting disease







 Wilms Tumor (renal tumor)
Nephroblastoma
Most common renal tumor
Peak incidence 3 years of age
Slightly increases incidence in boys
More common in Caucasians
More common on left kidney
Tumor doubles in size every 11 days, rapidly growing


Clinical Manifestations:
Asymptomatic
Nontender swelling or mass in abdomen
May be palpated by parent during bath or diaper change, or by
provider during a routine physical exam
6-7% of all childhood cancers


Diagnosis:
Careful history and physical
Abdominal ultrasound
CT scan check for metastasis
Bone marrow aspiration
Kidney function tests of uninvolved kidney
o B/C we are removing bad kidney, must check to see if the other
one is healthy
MRI metastasis


National Wilms Tumor Staging:
Stage I tumor is limited to kidney and completely excised
Stage II tumor extends beyond kidney but is completely excised
Stage III nonhematogenous spread to joining organs but not
through blood system
Stage IV hematogenous metastasis
Stage V bilateral renal involvement



Therapeutic Management:
Surgery w/in 24-48 hours of diagnosis
Biopsy regional lymph nodes
Chemotherapy after surgery
Radiation based on staging
Bilateral involvement
o Partial nephrectomy (and adrenal glands) vs total,
transplant if possible (to maintain kidney function), chemo
and radiation

Nursing Care:
DO NOT PALPATE ABDOMEN
Anxiety child and parent
o Parents will get a binder to read about disease during hospital time
Risk for infection
Pain
Risk for fluid imbalance related to renal impairment
o Need second kidney to be functional
Knowledge deficit related to care and follow-up
o Caregiver role strain related to severity of illness
Acute to chronic
o Risk for inadequate nutrition