CONCEPT ANALYSIS: Nephrotic Syndrome

Case Scenario:
Patient C, a Hispanic woman 48 years of age, presents to a medical office complaining of
persistent swelling of her feet and ankles, to the degree that she cannot put on her shoes. She first
noted mild ankle swelling approximately two to three months previously. She borrowed some
diuretic pills from a friend, and the pills seemed to help, but now she has run out. She also
reports that she has gained 20 pounds over the last few months, despite regular exercise and
trying to adhere to a healthy diet. Her medical history is significant for type 2 diabetes, for which
she takes a sulfonylurea agent. She neither sees a physician regularly nor monitors her blood
glucose at home. She denies dysuria, urinary frequency, or urgency, but she does report that her
urine has appeared foamy. She has had no fever, joint pain, skin rashes, or gastrointestinal
symptoms.
Her physical examination is significant for mild periorbital edema, multiple hard
exudates, and dot hemorrhages on funduscopic examination. She also has pitting edema of her
hands, feet, and legs. Her heart rhythm is regular without murmurs, and her abdominal
examination is benign. She has diminished sensation to light touch in her feet and legs to
mid-calf. A urine dipstick performed in the office shows 2+ glucose, 3+ protein, and negative
leukocyte esterase, nitrates, and blood.
The presumed diagnosis is nephrotic syndrome secondary to diabetic nephropathy. A
24-hour urine collection is taken to measure proteinuria and to verify the diagnosis. Usual causes
in adults include diabetes, hepatitis B, amyloidosis, lupus erythematosus, and drugs such as
penicillamine and captopril.
Maintenance of glycosylated hemoglobin (HbA1c) to 7.0% or lower is recommended,
and Patient C is started on diabetes care (with regular follow-up and screening). To address the
nephrotic syndrome, an ACE inhibitor is prescribed to control her blood pressure. In order to
meet her blood pressure targets more quickly, a diuretic is also prescribed. Patient C is instructed
to limit her intake of fluids and protein (to less than 2 g/day). She is asked to return in several
weeks for additional screening and to call if the edema does not resolve.
 Concept Map Components

Risk Factors (modifiable/non-modifiable)

1. Modifiable risk factors
● Diabetes - diabetes can lead to kidney damage (diabetic nephropathy) that affects
the glomeruli.

2. Non - modifiable risk factors

● Age - Nephrotic syndrome can affect children and adults of all ages.
● Race - Hispanics along with African Americans have a higher incidence of
nephrotic syndrome than do white persons.
● Genetics - it can be inherited by an autosomal recessive gene and can happen to
genetic disorders that affect the kidneys.

Disease Progression/Pathophysiology

Nephrotic Syndrome Pathophysiology

 Nephrotic Syndrome is a kidney disorder that can be indicated and characterized by an
increase in the glomerular permeability of an individual, and manifests with severe proteinuria.
Nephrotic syndrome can be inherited by an autosomal recessive gene. Although it can occur at
later ages, it is commonly diagnosed in children. Individuals who are diagnosed with diabetes are
more likely to develop nephrotic syndrome, since these conditions can cause a risk for damage in
the glomerulus in the kidneys. The disease starts to manifest and progress when the damage in
the glomerulus starts. In clients diagnosed with diabetic neuropathy, the risk for the progression
of this damage is much higher than those individuals without this condition. This will then lead
to the increasing protein in the urine, which is termed as proteinuria. It will now result in a
decreased oncotic pressure and compensatory protein synthesis in the liver, which will now
further lead to the development of nephrotic syndrome.

Signs and Symptoms

● Swelling (edema) in legs, feet, and hands

● Foamy urine, result of excess protein in your urine
● Weight gain due to retaining too much fluid
● Diminished sensation to light touch from legs to feet
● Exudates and dot hemorrhages in the skin

Complications
Possible complications of nephrotic syndrome include:
● Blood clots - the inability of glomeruli to filter blood properly can lead to loss of proteins
that help prevent clotting. This increases your risk of developing a blood clot in your
veins
● High blood cholesterol and elevated blood triglycerides - When the level of the protein
albumin in your blood falls, your liver makes more albumin. At the same time, your liver
releases more cholesterol and triglycerides.
● High blood pressure - Damage to your glomeruli and the resulting buildup of excess
body fluid can raise your blood pressure.
● Acute kidney injury - If your kidneys lose their ability to filter blood due to damage to
the glomeruli, waste products can build up quickly in your blood. If this happens you
might need emergency dialysis- an artificial means of removing extra fluids and waste
from your blood - typically with an artificial kidney machine.
● Chronic kidney disease - Nephrotic syndrome can cause your kidneys to lose their
function over time. If kidney function falls low enough, you might need dialysis or a
kidney transplant.
● Infections - people with nephrotic syndrome have an increased risk of infections due to a
deficient immune response.
Nursing Diagnosis Prioritization
No. Nursing Diagnosis
1 Excess fluid volume related to decreased
kidney function and fluid accumulation as
evidenced by foamy urine and pitting
edema of hands, feet, and legs.
2 Imbalanced nutrition: more than body
requirements related to greater intake than
metabolic needs as evidenced by gaining 20
pounds over the last few months despite
regular exercise and adhering to a healthy
diet.
3 Altered sensory perception related to
accumulation of fluid in the lower
extremities secondary to nephrotic
syndrome, as evidenced by diminished
sensation to light touch from legs to feet.
Justification
This is considered as the top priority
because according to ABC
prioritization, this falls under the
circulation where fluid overload could
compromise regulatory mechanisms for
sodium and water as seen commonly in
heart failure (CHF), kidney failure, and
liver failure. It could also cause venous
insufficiency because the veins are
having trouble transporting enough
blood all the way to the feet and back to
the heart.
This problem falls under the
Physiological needs in Maslow’s
Hierarchy of Needs, in which the client
has an imbalanced nutrition, and is
evident by weight gain of 20 pounds in
the previous months. According to
Maslow’s Hierarchy of needs,
physiological needs is one of the top
priorities. The client also has type 2
diabetes which makes it more crucial to
manage. If not treated immediately, this
can cause the client to furthermore gain
weight, which causes a great risk for the
client’s condition, since she is also
diagnosed to have diabetes.
Client C is suffering from diminished
sensory perception from light touches in
her lower extremity, which might be
caused by the accumulation of fluid
secondary to her condition. According
to MAAUAR’s method of problem
prioritization, this problem falls under
the Mental status changes and
Alterations, in which Patient C is having
alterations in her perception, wherein
she cannot feel light touches in her
lower extremities, making it one of the
priority problems in the client.
 4 Impaired skin integrity and mobility related
to low protein levels in the blood secondary
to nephrotic syndrome, as evidenced by
exudates and dot hemorrhages in the skin.
The client is having exudates and dot
hemorrhages in her skin that might have
been caused by the decreased protein
levels in the blood, secondary to
nephrotic syndrome. According to
MAAUAR’s method of prioritization,
this problem falls in the Unaddressed
and Untreated Problems that requires
attention, making it one of the a priority
problems since these exudates and dot
hemorrhages cause inflammation in the
client’s skin, which might lead to
infection and furthermore discomfort for
the client.

Nursing Management

Excess fluid volume

Independent
● Obtain intake & output and daily weight of the client
● Obtain vital signs
● Assess lung sounds, edema, and other symptoms
● Monitor responses to medications like diuretics
● Position client to semi-fowler’s position for orthopnea
● Turn client every 2 hrs to prevent bedsores
● Instruct client to limit sodium as prescribed
Dependent
● Take diuretics as prescribed by the physician
Collaborative
● Cooperate with the pharmacist to maximally concentrate IV fluids and medications

Imbalanced nutrition
Independent
● Monitor client’s weight daily
● Assess nutritional daily patterns including food preference, caloric intake, and diet
history.
● Encourage high potassium, low-fat, low sodium diet with moderate amounts of protein.
● Provide a comfortable and delightful environment during meal times.
● Consider six small nutrient-dense meals instead of three larger meals daily to reduce the
feeling of fullness.
Dependent
 ● Schedule medications in such a way that they are not administered immediately prior to
meals.
Collaborative
● Refer to a dietitian for a comprehensive nutrition assessment and methods for nutritional
support.

Altered Sensory Perception

Independent
● Assess ability to speak, hear, interpret and respond to simple commands.
● Maintain blood glucose levels within the normal range.
● Monitor vital signs and mental status.
● Evaluate sensory awareness. stimulus of hot cold dull/sharp smell, taste, hearing and
location/function in the body.
● Determine response to painful stimuli.
● Keep the patient’s routine as consistent as possible. Encourage participation in activities
of daily living (ADLs) as possible.
● Assist patients with ambulation or position changes.
Dependent
● Carry out the prescribed regimen for correcting DKA as indicated.

Impaired Skin integrity and Mobility:

Independent
● Assess the patient’s range of motion
● Assess and monitor the patient’s skin integrity
● Assist the patient in moving to prevent accidents and falls.
● Raise the siderails of the bed.
● Assess the patient’s nutritional status.
● Assist the patient in feeding.
● Encourage the patient to rest and avoid strenuous activities
● Evaluate the patient’s need for use of assistive devices.
● Educate the patient and her family members about the use of assistive devices.
Dependent
● Administer the medications ordered by the physician
● Monitor therapeutic effect of the medications that has been administered
● Submit the ordered laboratory findings to the physician