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acuteglomerulonephritisagn-170704144802.pptx

1. Acute glomerulonephritis is a common kidney disease in children that often presents with red urine caused by blood in the urine. It typically results from a prior streptococcal infection of the throat or skin. 2. The disease is characterized by sudden onset of hematuria, decreased urine output, edema, and high blood pressure. It involves inflammation of the capillary loops in the kidneys caused by antigen-antibody complexes depositing in the glomeruli. 3. Treatment focuses on monitoring for hematuria, edema, and hypertension. Fluid intake is restricted if urine output decreases significantly. Antibiotics may be given if a streptococcal infection preceded the acute glomerulone

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BY -YOGESH ADENGALE 2nd M.Sc Nsg
⦁ Acute glomerulonephritis is a common disease in children and it is one of the diseases that are presented commonly with hematuria which means red urine (blood in urine). Acute Glomerulo Nephritis in all probabilities results secondary to a proceeding streptococcal (beta-hemolyticus type 12) infection of throat or skin.Ahistory of upper respiratory infection.
⦁ Acute Nephritis or glomerulonephritis is an infective renal disease characterized by sudden onset of hematuria, oliguria, edema and hypertension.
⦁ Acute glomerulonephritis is an immune – mediated inflammatory disease of the capillary loops in the renal glomeruli. The antigen – antibody complex deposition within the glomeruli results in glomerular injury which is manifested as hematuria, oliguria, edema and hypertension.
⦁ The Kidneys are paired reddish and bean shaped organs located in the peritoneum and the posterior wall of the abdomen. The kidneys are located between the levels of the last thoracic and third lumbar vertebrae, a position where they are partially protected by the eleventh and twelfth pairs of ribs. The right kidney is slightly lower than the left because the liver occupies considerable space on the right side superior to the kidney.
1.Homostasis function- ⦁ Excreting wastes and foreign substances ⦁ Maintenance of water balance ⦁ Maintenance of electrolyte balance ⦁ Maintenance of acid base balance 2.Hemopoietic function 3.Endocrine function 4.Regulation of blood pressure 5.Regulation of blood calcium level
⦁ More common in male than females. ⦁ Most common in preschool and early school age children with a peak age of onset of 6-7 years. ⦁ Rare in children under two years of age. ⦁ On average responsible for 2 to 4% of pediatric admissions in India. ⦁ Accounts for about 90% of renal diseases in childhood ⦁ Varies with the prevalence of nephritogenic strains of streptococci and the likelihood of cross – infection.
1.Presumed cause – antigen – antibody reaction secondary to an infection in the body. 2.Initial infection: ⦁ Usually either an upper respiratory infection or a skin infection, usually one to 3 weeks before the onset of symptoms ⦁ Most frequent causative agent – nephritogenic strains of group - A beta – haemolytic streptococcus (type 12), acute post – streptococcal glomerulonephritis (APSGN) is the most common.
⦁ Most cases are post infectious and have been associated with -Pneumococcal -Viral infection -Acute post streptococcal glomerulonephritis is the most common of the post infectious renal disease in childhood. -Streptococcal pharyngitis is more common in the winter.
Urinary symptoms: ⦁ Decreased urine output ⦁ Bloody or brown – coloured urine. Oedema: ⦁ Present in most patients Usually mild. ⦁ Often manifested by Periorbital oedema in the morning ⦁ May appear only as rapid weight gain. ⦁ May be generalized and influenced by posture.
Hypertension: ⦁ Present in over 50 per cent of patients. ⦁ Usually mild. ⦁ Rise in blood pressure may be sudden. ⦁ Usually appears during the first four to five days of the illness. Malaise Mild headache ⦁ Gastrointestinal disturbances, especially anorexia and vomiting, often with abdominal and long pain. ⦁ Pallor ⦁ Irritability ⦁ Lethargy ⦁ Dysuria ⦁ Fever
⦁ History of illness and physical examination help in clinical diagnosis. ⦁ The confirmation of diagnosis is done by the following: Urine examination: It shows increased specific gravity, smoke dirty brown colour urine with reduced total amount in 24 hrs. Mild to moderate or severe albuminuria is detected. Microscopic examination reveals presence of red cells, WBCs, pus cells, epithelial cells and granular cast. Proteinuria (3+ to 4+)
Blood examination: ⦁ Blood examination demonstrates increased level of urea, creatine, ESR, ASO titer and anti – DNAase ‘B’. There is decreased level of Hb%, serum complement and albumin in blood. Hyponatremia and hyperkalemia may occur in persistent oliguria. Throat swab culture: ⦁ Throat swab culture may show presence of beta – hemolyticus streptococcus in some children. Chest X-ray: ⦁ It may show pulmonary congestion
AGN with impaired renal function as severe oliguria and azotemia needs hospitalization for special attention. Mild oliguria patients with normal blood pressure can be managed at home with OPD – based treatment. Treatment is essentially symptomatic Monitoring: ⦁ The patient should be monitored closely for the presence of hematuria, decreased urinary output, and signs of volume overload like edema, hypertension and congestive heart failure.
⦁ Daily record the general condition, edema, consciousness level, weight, heart rate, respiratory rate, blood pressure, fluid intake and urinary output. ⦁ The kidney function tests must be monitored at regular intervals. Bed rest: ⦁ It is rarely indicated except during the acute phase when complications of acute renal failure may be present. ⦁ Protect the child from fatigue and contact with other respiratory infections. ⦁ Position: ⦁ In congestive heart failure or hypertension, make the patient lie in a propped up position and provide oxygen.
Diet: ⦁ Diet should be arranged with restriction of protein, salt and fluid intake, till oliguria and increased blood urea level persist. ⦁ Carbohydrate containing food to be allowed freely. ⦁ The diet of the patient need not be restricted routinely. ⦁ Fluid intake should be allowed in a calculated amount (i.e., total amount of previous day urine output in 24 hrs plus insensible losses to be allowed to drink on that day). ⦁ Daily weight recording is important to assess the increase and decrease of edema.
Fluid balance: ⦁ Regular measurement of vital signs, body weight and intake and output is essential to monitor the disease’s progress and detect complications that may appear at any time during the course of the disease. ⦁ A record of daily weight is the most useful means to assess fluid balance and should be kept for children treated at home and for those who are hospitalized. ⦁ Sodium and water restriction is useful when the output is significantly reduced (< 2 to 3 dl/24hr.) ⦁ In these children the water allowed is equivalent to the calculated insensible loss plus the volume of urine excreted.
⦁ Diuretics are of limited value when severe renal failure is not severe, diuretic therapy (usually furosemide {lasix} is helpful if significant edema and fluid overload are present. ⦁ Rarely, children withAGN developARF with oliguria that significantly alters the fluid and electrolyte balance. ⦁ Fluid restriction is needed in case of acute renal failure when urine output is diminished.
Hypertension: ⦁ Acute hypertension must be anticipated and identified early. ⦁ Blood pressure measurements are taken every 4 to 6 hrs. ⦁ Significant but not severe hypertension is controlled with loop diuretics. ⦁ Other antihypertensive drugs, such as calcium channel blockers, beta blockers, or angiotensin – converting enzyme inhibitors, may be needed in severe cases. Dialysis: ⦁ May be required in patient with severe and prolonged oliguria or anuria,and renal failure.
Penicillin: ⦁ Administered of antibiotic (preferably Penicillin) is needed for 7 to 10 days to eradicate streptococci in the throat or skin. ⦁ Anti hypertensive (nifedipine, atenolol) and diuretics are used to control hypertension and its consequences. ⦁ Magnesium sulphate may be prescribed in the encephalopathy to reduce cerebral edema. ⦁ Sedatives (diazepam) may be required in restless patients. ⦁ Management of complication like CCF, hypertensive encephalopathy, etc should be done promptly to prevent life threatening outcome. Dopamine infusion, steroid therapy and respiratory support may require for some patients.
⦁ Impaired urinary elimination related to glomerular dysfunction. ⦁ Infection related to group A beta- haemolytic streptococcus pharyngitis, upper respiratory infection. ⦁ Fluid volume excess related to altered renal function (or) diminished glomerular filtration increased Na+ retention. ⦁ Activity intolerance related to edema. ⦁ Altered skin integrity related to edema ⦁ Altered nutritional, less than body requirement, related to albuminuria and GI disturbances. ⦁ Fear and anxiety related to disease processes. ⦁ High risk for seizure activity related to hypertensive encephalopathy. ⦁ Knowledge deficit regarding care of the child with renal disease and continuation of care at home.
1.Hypertensive encephalopathy: Manifestations: ⦁ Restlessness ⦁ Convulsions ⦁ Vomiting ⦁ Severe headache ⦁ Visual disturbance ⦁ Cause – probably ischemia secondary to vasospasm. Duration: ⦁ Usually one to two days. ⦁ Ends spontaneously with decreased blood pressure. 2.Congestive heart failure: ⦁ Cardiac failure may occur due to persistent hypertension, hypervolemia and peripheral vasoconstriction.
Manifestation: ⦁ Dyspnoea ⦁ Tachycardia ⦁ Liver engorgement. Duration: ⦁ Variable ⦁ Usually subsides rapidly with the onset the fall in blood pressure. 3.Uraemia (rare): Manifestation: ⦁ Evidence of acidosis
⦁ Drowsiness ⦁ Coma ⦁ Muscular twitching ⦁ Convulsions. 4.Anaemia: usually caused by hyperyolaemia rather than a loss of red blood cells in the urine. 5.Renal failure may occur with severe oliguria or anuria or increased B.P ⦁ It may occur in two phases:- ⦁ First phase: this stage of edema with oliguria may last for 5 – 10 days. ⦁ Second phase: this stage of dieresis starts with the increased of urine and decreased edema.
⦁ Hydronephrosis is a condition in which one or both of the kidneys become stretched and swollen. This is usually because: There is a blockage somewhere in the urinary system which is the usual cause, or urine is flowing from the bladder back to the kidneys ⦁ It can sometimes cause a pain in the side, or there may be no symptoms at all.
⦁ Hydronephrosis is distension and dilation of the renal pelvis and calyces, usually caused by obstruction of the free flow of urine from the kidney, leading to progressive atrophy of the kidney.
⦁ The signs and symptoms of Hydronephrosis depend upon whether the obstruction is acute or chronic, partial or complete, unilateral or bilateral. Unilateral Hydronephrosis may occur without any symptoms. ⦁ Asymptomatic (in some cases) ⦁ Pain is felt in the renal area ⦁ Hematuria ⦁ Urinary infection, dysuria frequency ⦁ Renal calculi ⦁ Azotemia ⦁ Some large Hydronephrosis can be palpable
⦁ History collection ⦁ Physical examination:An enlarged kidney may be palpable on examination. Suprapubic tenderness along with a palpable bladder is strongly suggestive of acute urinary retention ⦁ Blood tests can show raised Creatinine and electrolyte imbalance. ⦁ Urinalysis may show an elevated pH due to the secondary destruction of nephrons within the affected kidney. ⦁ Ultrasound allows for visualization of the ureters and kidneys and can be used to assess the presence of Hydronephrosis .
⦁ IVU (intravenous urogram) is useful for assessing the position of the obstruction. ⦁ CT 99% of stones are visible on CT and therefore CT is becoming a common choice of initial investigation.
MEDICALMANAGEMENT Treatment of Hydronephrosis focuses upon ⦁ The removal of the obstruction ⦁ Drainage of the urine that has accumulated behind the obstruction. ⦁ The antibiotics are used to prevent the Hydronephrosis from causing kidney infections.
Nephrostomy ⦁ Acute obstruction of the upper urinary tract is usually treated by the insertion of a Nephrostomy (an artificial opening created between the kidney and the skin which allows for the drainage of urine directly from the upper part of the urinary system) tube. Ureteric Stent ⦁ Chronic upper urinary tract obstruction is treated by the insertion of a Ureteric stent (a thin tube inserted into the ureter to prevent or treat obstruction of the urine flow from the kidney)
Nephrostomy Ureteric Stent
Pyeloplasty ⦁ Pyeloplasty is the surgical reconstruction of the renal pelvis to drain and decompress the kidney. Most commonly it is performed to treat an uretero-pelvic junction obstruction if residual renal function is adequate. Suprapubic Catheter ⦁ Lower urinary tract obstruction is usually treated by insertion of a urinary catheter or a suprapubic catheter. Fetal surgery for congenital Hydronephrosis. ⦁ Fetal surgical treatment is done for the correction of posterior urethral valve obstruction and ureteropelvic junction obstruction.
Pyeloplasty Suprapubic Catheter
ASSESSMENT History ⦁ Elicit a careful history about urinary patterns to determine a history of burning sensations, abnormal color, and frequency of urination. ⦁ Determine any recent history of mild or severe renal or flank pain that radiates to the groin. ⦁ Ask about vomiting, nausea, or abdominal fullness. Ask a male patient if he has had prostate difficulties and urinary difficulties. Physical Examination ⦁ Inspect the flank area for asymmetry, which indicates the presence of a renal mass. ⦁ Inspect the male urethra for stenosis, injury, or phimosis.
⦁ Inspect and palpate for vaginal, uterine, and rectal lesions in females. When the flank area is palpated, you may feel a large fluctuating soft mass in the kidney area that represents the collection of urine in the renal pelvis. ⦁ Palpate the abdomen to help identify tender areas. ⦁ If the Hydronephrosis is the result of bladder obstruction, markedly distended urinary bladder may be felt. ⦁ Gentle pressure on the urinary bladder may result in leaking urine from the urethra because of bladder overflow.
PRE-OPERATIVE NURSING DIAGNOSIS ⦁ Hyperthermia related to infectious process. ⦁ Impaired nutritional status less than body requirement related to hospitalization. ⦁ Disturbed elimination pattern incontinence of urine and related to retention of urine ⦁ Deficient knowledge of parents related to the plan of treatment, surgical procedure and prevention of complications. ⦁ Disturbed family process related to hospitalization of the child. ⦁ High risk for urinary tract infection related to presence of urinary obstruction.
POST-OPERATIVE NURSING DIAGNOSIS ⦁ Ineffective airway clearance related to effects of anesthesia, and pain ⦁ Acute pain related to incision, and the surgical procedure ⦁ Impaired physical mobility of the upper extremities related to surgery ⦁ Risk for imbalanced fluid volume related to the surgical procedure ⦁ Deficient knowledge of home care procedures ⦁ Risk for infection related to the presence of surgical wound.
⦁ Teach the importance of adequate fluids. ⦁ Explain the importance of notifying the physician at the first signs of inability to void or of urinary infection, such as burning or painful urination, cloudy urine, rusty or smoky urine, blood-tinged urine, foul odor, flank pain, or fever.
⦁ Early detection and prompt treatment has good prognosis. Left untreated, bilateral obstruction (occurring to both kidneys rather than one) has a poor prognosis.
⦁ Text book of pediatric nursing, editors by “wong and whaley’s”, published by “n.r.broyhers”, 4th edition, page no:1242-1246. ⦁ Dorothy r. marlow, “text book of pediatric nursing” 6th edition, published by elsevien, page no: 284-290. ⦁ Text book of “essential pediatric nursing”, editors by “piyush gupta”, published by “a.p. jain and co”, 1st edition, page no: 300- 301. ⦁ The short text book of “pediatric nursing”, editors by “suraj gupte”, published by “jaypee brothers”, 10th edition, page no: 433-434.
⦁ A text book of pediatric nursing, editor by “parul datta”, published by “ jaypee”, 2nd edition, page no: 362-364 ⦁ The lippincott manual of pediatric nursing, editor by “barbara f. weller”, published by “chapman and hall”, 8th edition, page no: 777-778. ⦁ Nursing care plans for newborns and children, editor by “ micheke knoll puzas”, published by “ mosby”, page no: 355 – 357. ⦁ Assuma beevi.t.m., “text book of pediatric nursing”, published by elsevien, page no: 307-308