Nursing Care Plan (NCP) for Nephrotic Syndrome

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Outline

Pathophysiology

Nephrotic syndrome is a collection of symptoms that indicates kidney damage. These symptoms include albuminuria, hyperlipidemia, hypoalbuminemia, and dependent edema. Damaged glomeruli allow proteins, most commonly albumin, to leak into the urine. As albumin leaks into the urine, the blood can no longer absorb the fluid which results in edema and leads to ascites.

Etiology

Primary nephrotic syndrome is caused by certain diseases that specifically affect the kidneys and include minimal change nephropathy, focal segmental glomerulosclerosis, which is the formation of scar tissue within the glomeruli and membranous nephropathy, which occurs when immune molecules form deposits on the glomeruli. Secondary nephrotic syndrome occurs secondary to other systemic diseases such as diabetes (most common), lupus, amyloidosis, and renal vein thrombosis. The overuse of NSAIDS and some antibiotics are also attributed to damage to the glomeruli. Infections such as HIV, hepatitis B, hepatitis C, and malaria may increase the risk of developing kidney disease.

Desired Outcome

Maintain adequate fluid balance and nutrition

Nephrotic Syndrome Nursing Care Plan

Subjective Data:

  • Weight gain
  • Fatigue
  • Loss of appetite

Objective Data:

  • Foamy urine
  • Anemia
  • Vitamin D deficiency
  • Malnutrition
  • Ascites
  • Hypertension
  • Dependent edema

Nursing Interventions and Rationales

  • Monitor vitals
  Temperature- monitor for signs of infection, especially with immunosuppressant therapy Blood pressure- hypotension may indicate hypovolemia Heart rate- tachycardia may be a sign of infection or hypovolemia
  • Monitor fluid balance
  • Measure for decreased output <400 mL/24 hr period may be evident by dependent edema
  • Daily weights at the same time on the same scale each day, >0.5kg/day is indicative of fluid retention
  • Note changes in characteristics of urine: dark, frothy or opalescent appearance, hematuria
  • Insert indwelling catheter unless contraindicated for infection
  The indwelling catheter will provide a more accurate measurement of urine output
  • Monitor diagnostic studies
    • Lab
    • Ultrasound
    • Kidney biopsy (as indicated)

  Urine test

  • 24-hour urine or single urine specimen/urinalysis
  • >30mg albumin / 1g creatinine
  • Increased protein, decreased creatinine clearance
  • Microhematuria
  • Proteinuria that does not contain albumin is indicative of multiple myeloma

Serum test

  • Serum albumin will be lower than 3.5 – 4.5 (normal range)
  • Tests for hepatitis B, hepatitis C, HIV, syphilis, and lupus may help determine etiology

Ultrasound

  • Can help determine the severity and cause of the nephrotic syndrome

Kidney biopsy

  • Typically, not needed, but maybe indicated in diabetic patients
  • Assess for skin integrity
  Lack of protein in the blood reduces the integrity of the skin and increases the risk of breakdown and ulceration.
  • Assess dependent and periorbital edema
  Evaluate and report the degree of edema (+1 – +4) There may be a gain of up to 10lbs of fluid before pitting is noticed
  • Administer medications and evaluate the response
  • ACE Inhibitors or ARBs: (benazepril, losartan) reduce the amount of protein released in urine
  • Diuretics: (furosemide, spironolactone) Increase fluid output
  • Hypolipidemics: (atorvastatin, simvastatin) reduce cholesterol in the blood
  • Anticoagulants: (warfarin, apixaban) prevent blood clots
  • Immunosuppressants: (prednisone) corticosteroids decrease inflammation from underlying conditions such as lupus and amyloidosis
  • IV Albumin infusion: as ordered, to reduce ascites; draws the fluid from the body to the bloodstream to treat hypovolemia and replace low serum protein
  • Monitor for volume depletion with use of diuretics

  Diuretics help to flush out fluid from the tissues to decrease edema. Excess urination may result in volume depletion and lead to dehydration or hypovolemia Assess symptoms

  • Daily weights
  • Pulse
  • Blood pressure
  • Monitor for corticosteroid toxicity for ongoing use

  Long term use of corticosteroids can have severe side effects. Monitor for:

  • GI bleeding- higher risk of bleeding and perforation; use antacids to prevent GI symptoms
  • Blood sugar levels may be elevated.
  • Supplement with calcium and vitamin D to prevent bone loss
  • Encourage yearly eye exam to assess for cataracts and glaucoma as corticosteroids may increase intraocular pressure and cause clumping together of proteins that result in cataracts
  • Avoid exposure to communicable diseases with immunosuppressant therapy to prevent infections and disease complications.
  • Assist with Rest / Ambulation
  Initially, bed rest is encouraged to help mobilize edema. After the first few days of treatment, encourage ambulation and elevation for venous return and prevent thromboses
  • Provide nutrition education
  • Malnutrition may occur due to excretion of protein, but may not be evident in weights due to edema
  • Diet high in lean protein (1g/kg/day) and low sodium to reduce swelling
  • Limit foods that increase blood sugar such as simple carbohydrates, refined sugars, and processed foods
  • Refer to a dietitian as needed

Writing a Nursing Care Plan (NCP) for Nephrotic Syndrome

A Nursing Care Plan (NCP) for Nephrotic Syndrome starts when at patient admission and documents all activities and changes in the patient’s condition. The goal of an NCP is to create a treatment plan that is specific to the patient. They should be anchored in evidence-based practices and accurately record existing data and identify potential needs or risks.


References

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Transcript

This is the care plan for nephrotic syndrome. So pathophysiology. Nephrotic syndrome is a collection of symptoms that indicate some type of kidney damage. The symptoms of nephrotic syndrome include albuminuria, hyperlipidemia, and hypoalbuminemia, and that’s just pretty much low albumin circulating in the blood. And dependent edema. What happens is the glomerular in the kidneys are damaged and then allows proteins, most likely albumin to leak into the urine. As the albumin leaks into the urine, the blood can no longer absorb the fluid and it results in edema, at least the third spacing in ascites. So some nursing considerations that we want to think about when we’re taking care of these patients with nephrotic syndrome, we want to assess the fluid balance. These patients can become dehydrated and lose fluid really quickly. We want to monitor their vital signs. We want to administer any medications that’s ordered, and we want to assess their skin integrity. The desired outcome for these patients is to maintain adequate fluid balance and nutrition.

So a patient comes in and they are presenting with nephrotic syndrome. So what are some things that you think that this patient is going to say or going to feel? Well, I can tell you this, that these patients are oftentimes very fatigued. They’re tired when they come in. You’ve got to think they’re losing a lot of their nutrition so they’re going to be tired. Their body is working a little extra hard to keep them going. They’re going to have a loss of appetite. That also ties into fatigue. So they’re going to have a decreased appetite. They’re not going to eat as much. Okay? When we assess these patients, there are some things that are hallmark to nephrotic syndrome. Some of the things are they’re going to have foamy urine. So the urine is going to be foamy.

And that’s just because there’s going to be a buildup of protein in the urine. They’re also going to be anemic. So you’re going to see a decrease in their hemoglobin lab values. A lot of the values are going to be down with their vitamins, such as a vitamin D deficiency, and this is going to come from malnutrition. That’s also one of the signs. They’re going to have some ascites, which is third spacing, generally around the abdomen of fluid. They’re going to have some hypotension, low BP. Let’s write that down. They’re going to have some low BP and that’s going to be, because again, while they have all this third spacing, like the dependent edema, they’re going have the dependent edema. While they have all this buildup of fluid on them, it’s not in the right place. It’s not in the vascular system.

So their BP is going to be low. Okay? Some things that we can do as nurses, when we’re taking care of these patients, we can monitor their vital signs. Let’s see what type of vitals they’re going to have their temperature. They may have a fever. So they’re going to have increased temp. That could be because of the infection process that’s going on, especially for those patients that are on some type of immunosuppressants. We are going to look at their blood pressure. Like I said, they’re going to have low BP. They’re going to be hypotensive. That’s going to be because they’re hypovolemic, they’re not going to have enough volume inside of their vascular system. Their heart rate, because of the hypovolemia, they are going to be tachycardic. So they’re going to have an increased heart rate.

The next thing we want to be mindful of, we’re going to monitor their fluid balance. We’re going to look for decreased urine output. Decreased urine output is going to be anything less than a, so decreased urine output, anything less than 400 MLs in the 24 hour period. That’s going to definitely be evident by any dependent edema. We want to insert a Foley catheter. We want to make sure that we get accurate I&Os, and we want to make sure we know any changes or characteristics of the urine such as if it’s dark or is it the foamy color. Okay? We are also going to administer any medications that are ordered, and we’re going to evaluate the response. Medications such as ACE inhibitors, ACE inhibitors, or ARBs. And that’s angiotensin receptor blockers, diuretics, hyperlipidemia, anti-coagulants, IV albumin infusion. All of these types of medications are going to work on being therapeutic for the patient with nephrotic syndrome.

And then we are also going to assess the skin integrity. Remember, these patients are holding onto fluids, third spacing. So the lack of protein in their blood dramatically reduces. So decreased protein and dramatically reduces the integrity of the skin. It increases the risk of skin breakdown and ulceration. Okay? So let’s take a look at these key points. These are some really good key points. This is what you need to focus on with nephrotic syndrome. Remember that it’s just a collection of symptoms that indicates kidney damage. Some subjective things that the patient is going to complain about though. They may have some weight gain, even though they have the loss of appetite. They’re going to be fatigued. What we’re going to notice from this patient is we’re going to notice that they are hypotensive, low BP. That we’re going to notice some ascites. We may see on the lab values that their hemoglobin is low or anemia. Frothy, concentrated, urine.

Their urine is going to be concentrated, because they’re not producing much because of the kidney damage. Our goals for these patients is fluid management. We want to make sure that these patients are adequately hydrated in their vascular space. So we’re going to insert a catheter for accurate I&Os. We may need to give some IV albumin to pull that fluid back until their vascular system. Remember, we want to report to the physician that any of your output is less than 400 MLs for the 24 hour period. We want to make sure we report that. And finally, medication management. ACE inhibitors, ARBs. Remember those things reduce the amount of protein released. Diuretics, hypolipidemic. So we want to lower that fluid volume. We want to give some anticoagulants and some IV albumin infusion, as they are ordered. We want to reduce ascites.

This was a big topic, but you all did great. We love you guys. Go out and be your best self today. And always remember, happy nursing.

 

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