A
ntonio Cruise, a 7-year-old boy, is brought to the clinic by his mother for his annual examination. During your assessment the mother brings up concerns that Antonio continues to wet the bed at night. She states,“I was hoping this would end on its own, but now I’m concerned that there is a problem.”
What further assessment information would you obtain?
What education and interventions may be necessary for this child and family?
What can you do to provide support and encour- agement for Antonio and his family?
(Flynn & Tullus, 2009). Nurses must be adept at accurately measuring blood pressure in children.
Nephrotic Syndrome
Nephrotic syndrome occurs as a result of increased glo- merular basement membrane permeability, which allows abnormal loss of protein in the urine. Nephrotic syn- drome generally occurs in three forms—congenital, idio- pathic, and secondary.
Congenital nephrotic syndrome is an inherited dis- order; it is rare and occurs primarily in families of Finnish descent. The prognosis is poor, though some success has occurred with early, aggressive treatment and with the advances in kidney transplantation in infants ( Jalanko, 2009). Nephrotic syndrome may also occur secondary to another condition such as systemic lupus erythematosus, Henoch-Schönlein purpura, or diabetes.
Idiopathic nephrotic syndrome is the most com- monly occurring type in children and is often termed min- imal change nephrotic syndrome (MCNS) (Lane, 2011).
MCNS occurs more frequently in males than females, with 70% of cases occurring by age 5 years (Lane, 2011).
This discussion will focus primarily on MCNS. Complica- tions of nephrotic syndrome include anemia, infection, poor growth, peritonitis, thrombosis, and renal failure.
Pathophysiology
Increased glomerular permeability results in the pas- sage of larger plasma proteins through the glomeru- lar basement membrane. This results in excess loss of protein (albumin) in the urine (proteinuria) and decreased protein and albumin (hypoalbuminemia) in the bloodstream. Protein loss in nephrotic syndrome tends to be almost exclusively albumin. Hypoalbumin- emia results in a change in osmotic pressure, and luid shifts from the bloodstream into the interstitial tissue (causing edema). This decrease in blood volume trig- gers the kidneys to respond by conserving sodium and water, leading to further edema. The liver senses the protein loss and increases production of lipoproteins.
Hyperlipidemia then develops as the excess lipids can- not be excreted in the urine. Hyperlipidemia associated with nephrotic syndrome may be quite severe, yet cho- lesterol levels may decrease when the nephrotic syn- drome is in remission, only to rise signiicantly again with a relapse.
Children with nephrotic syndrome are at increased risk for clotting (thromboembolism) because of the decreased intravascular volume. They are also at increased risk for the development of serious infection, most com- monly pneumococcal pneumonia, sepsis, or spontane- ous peritonitis. Steroid-resistant nephrotic syndrome may result in acute renal failure.
When behavioral and motivational therapies are unsuccessful, particularly in the older child, medications may be prescribed. Teach the child and parents about the use of medications such as oxybutynin, imipramine, and desmopressin (DDAVP) if these are prescribed (refer to Drug Guide 43.1).
Take Note!
Enuresis is a source of shame and embarrassment for children and adolescents. It afects the child’s life emotionally, behaviorally, and socially. The family’s life is also signiicantly afected. Treatment failures for enuresis have been correlated with adolescent low self-esteem (Martin &
Volkmar, 2007).
Acquired Disorders Resulting in Altered Renal Function
A number of acquired disorders are responsible for alterations in renal function. They may occur as an auto- immune response or in relation to a bacterial infection.
Renal dysfunction may also occur as a result of obstruc- tive disorders or repeated VUR, as discussed earlier. Left untreated, these disorders may lead to renal failure. Even when treated appropriately, sometimes the appropri- ate response is not achieved and acute or chronic renal failure develops. Renal disorders are the most frequent cause of hypertension in children.
Take Note!
Severe hypertension (blood pressure higher than the 99th percentile for age and sex) may lead to damage of the eye or vital organs (kidney, brain, or heart), or even death
FIGURE 43.5 Some children and fami- lies ind great success with the use of an enuresis alarm. The alarm wakes the child at the irst sign of wetness. Over time, the child learns to awaken at night in response to the sensation of a full bladder.
either normal or decreased unless the child is progress- ing to renal failure. Auscultate heart and lung sounds, noting abnormalities related to luid overload. Palpate the skin, noting tautness. Palpate the abdomen and doc- ument the presence of ascites.
Laboratory and Diagnostic Tests
Urine dipstick will reveal marked proteinuria. Infre- quently, mild hematuria is also present. Serum protein and albumin levels will be low (often markedly so).
Serum cholesterol and triglyceride levels are elevated.
With continued nephrotic syndrome, creatinine and BUN may become elevated.
Nursing Management
Goals for nursing management include promoting diure- sis, preventing infection, promoting adequate nutrition, and educating the parents about ongoing care at home.
As with other chronic disorders, provide ongoing emo- tional support to the child and family.
Promoting Diuresis
Administer corticosteroids as ordered. Tapering or wean- ing doses are required when the time comes to stop corticosteroid therapy. Administer diuretics if ordered, usually furosemide (Lasix). Children may develop hypo- kalemia because of potassium loss as an adverse effect of furosemide. Those children may require potassium sup- plementation or a diet higher in potassium-containing foods. Monitor urine output and the amount of protein in the urine (by dipstick). Weigh the child daily on the same scale either naked or wearing the same amount of clothing. Assess for resolution of edema. Measure pulse
Therapeutic Management
Medical management of MCNS usually involves the use of corticosteroids. Intravenous albumin may be used in the severely edematous child. Diuretics are also required in the edematous phase. Long-term therapy is usually required to induce remission. The nephrologist will determine the length of therapy based on the child’s response. Children who have steroid-responsive MCNS generally have a favorable prognosis. Some children with MCNS exhibit a minimal response to steroid therapy or experience remissions and the MCNS is steroid resistant (Lane, 2011). Immunosuppressive therapy such as cyclo- phosphamide, cyclosporine A, or mycophenolate mofetil may be necessary.
Nursing Assessment
For a full description of the assessment phase of the nursing process, refer to page 1551. Assessment indings pertinent to MCNS are discussed below.
Health History
Elicit a description of the present illness and chief com- plaint. Common signs and symptoms reported during the health history might include:
• Nausea or vomiting (may be related to ascites)
• Recent weight gain
• History of periorbital edema upon waking, progress- ing to generalized edema throughout the day
• Weakness or fatigue
• Irritability or fussiness
Explore the child’s current and past medical history for risk factors such as:
• Intrauterine growth retardation
• Young age (younger than 3 years)
• Male sex
Physical Examination
The physical assessment of the child with nephrotic syn- drome includes inspection and observation, auscultation, and palpation.
Observe the child for edema (periorbital, general- ized [anasarca], or abdominal ascites). As the disease progresses, the edema also progresses to become more generalized, eventually becoming severe. Inspect the skin for a stretched, tight appearance; pallor; or skin break- down related to signiicant edema (Fig. 43.6). Document height (or length) and weight. Note increased respiratory rate or increased work of breathing related to ascites and edema.
Note the blood pressure; it may be elevated in the child with nephrotic syndrome, though it is most often
FIGURE 43.6 Note marked edema associated with nephrotic syndrome.
of relapse and remission takes an emotional toll on the child and family. Frequent hospitalizations require the child to miss school and the parents to miss work; this creates further stress for the family. The child may experi- ence social isolation because he or she must avoid expo- sure to infections or because of self-esteem problems.
The child may be dissatisied with his or her appearance because of edema and weight gain, short stature, and the classic “moon face” associated with chronic steroid use.
Provide emotional support to the child and family.
Encourage them in their efforts to maintain the treatment plan. Introduce the child to other youngsters with chronic renal conditions. Refer families to the National Kidney Foundation, a link to which can be found on , for information about local support groups and resources.
Acute Poststreptococcal Glomerulonephritis
Acute poststreptococcal glomerulonephritis (APSGN) is a condition in which immune processes injure the glomeruli. Immune mechanisms cause inlammation, which results in altered glomerular structure and func- tion in both kidneys. It often occurs following an infec- tion, usually an upper respiratory or skin infection.
APSGN is caused by an antibody–antigen reaction sec- ondary to an infection with a nephritogenic strain of group A β-hemolytic streptococcus. APSGN occurs more frequently in males than females and with a peak preva- lence occurring around 5 to 6 years of age (Bhimma, 2011). The most serious complication is progression to uremia and renal failure (either acute or chronic).
There is no speciic medical treatment for APSGN.
Treatment is aimed at maintaining luid volume and man- aging hypertension. If there is evidence of a current strep- tococcal infection, antibiotic therapy will be necessary.
Nursing Assessment
For a full description of the assessment phase of the nurs- ing process, refer to page 1551. Assessment indings per- tinent to acute glomerulonephritis are discussed below.
Health History
Elicit a description of the present illness and chief com- plaint. Common signs and symptoms reported during the health history might include:
• Fever
• Lethargy
• Headache
• Decreased urine output
• Abdominal pain
• Vomiting
• Anorexia rate and blood pressure every 4 hours to detect hypovo-
lemia resulting from excessive luid shifts. Enforce oral luid restrictions if ordered.
In cases of severe hypoalbuminemia, intravenous albumin may be administered. Increases in the serum albumin level cause luid to shift from the subcutane- ous spaces back into the bloodstream. A diuretic such as furosemide administered immediately after the albumin infusion allows for optimal diuresis and prevents luid overload. Refer to Drug Guide 43.1 for the nursing impli- cations related to use of these medications.
Preventing Infection
Monitor the child’s temperature. Administer pneumococ- cal vaccine as prescribed (see Chapter 31 for information on immunizations). Administer prophylactic antibiotics, if prescribed. Delay administering live vaccines until at least 2 weeks after corticosteroid or other immunosup- pressive medication therapy ceases. Teach parents that if the child is unimmunized and is exposed to chickenpox, the parents should notify the child’s pediatrician, nurse practitioner or nephrologist immediately so that the child may receive varicella zoster immunoglobulin.
Encouraging Adequate Nutrition and Growth
Encourage a nutrient-rich diet within prescribed restric- tions. Fluid restriction is reserved for children with massive edema. Sodium intake may be restricted in the edematous child in an effort to prevent further luid retention. Consul- tation with the dietitian is often helpful in meal planning because many of the foods that children like are high in sodium. Encourage protein-rich snacks. Consult with the child and family in planning meals and snacks that the child likes and will be likely to consume. Use of nutritional supplement shakes may be helpful for some children.
Educating the Family
Teach parents how to give medications and monitor for adverse effects. Demonstrate the urine dipstick technique for detecting protein, and encourage the family to keep a chart of dipstick results. The child may return to school but should avoid contact with sick playmates. If the child is exposed to another child with an infectious illness, explain to the parents that they should monitor temperature and urine dipstick results more frequently to identify a relapse in nephrotic syndrome early so that treatment can begin.
Providing Emotional Support
Nephrotic syndrome is often a chronic condition, and children who are responsive to steroid treatment may enter remission only to experience relapse. This cycle
illness. Other causes of HUS include idiopathic, inherited, drug-related, association with malignancies, transplanta- tion, and malignant hypertension. This discussion will focus on typical HUS, the type preceded by a diarrheal illness. Watery diarrhea progresses to hemorrhagic colitis, then to the triad of HUS. The features of HUS, as well as effects on other organs, are caused primarily by micro- thrombi and ischemic changes within the organs. The thrombotic events in the small blood vessels of the glom- erulus lead to occlusion of the glomerular capillary loops and glomerulosclerosis, resulting in renal failure.
A verotoxin-producing strain of E. coli, O157:H7, causes the majority of cases, though Streptococcus pneu- moniae, Shigella dysenteriae, and other bacteria may also be the cause (Tan & Silverberg, 2010). It is thought that antibiotic treatment for the bacteria may contribute to release of the verotoxin. Undercooked ground beef accounts for most cases of E. coli O157:H7 infection, but it is also transmitted via the feces of numerous ani- mals as well as unpasteurized dairy and fruit products.
Transmission also occurs via human feces, and cases have been linked to public swimming pools. HUS occurs most often in children age 6 months to 4 years (Tan &
Silverberg, 2010). Complications include chronic renal failure, seizures and coma, pancreatitis, intussusception, rectal prolapse, cardiomyopathy, congestive heart failure, and acute respiratory distress syndrome.
Therapeutic management of HUS is directed toward maintaining luid balance; correcting hypertension, aci- dosis, and electrolyte abnormalities; replenishing circu- lating red blood cells; and providing dialysis if needed.
Nursing Assessment
For a full description of the assessment phase of the nursing process, refer to page 1551. Assessment indings pertinent to HUS are discussed below.
Health History
Elicit a description of the present illness and chief com- plaint. Common signs and symptoms reported during the health history might include watery diarrhea accompanied by cramping and sometimes vomiting. After several days, the diarrhea becomes bloody and eventually improves.
Explore the child’s current and past medical history for risk factors such as ingestion of ground beef, visits to a water park or to a petting zoo before the onset of the diarrheal illness, or use of antidiarrheal medications or antibiotics.
Physical Examination
Observe the child for pallor, toxic appearance, edema, oliguria (decreased urine output), or anuria (absent urine output). Assess for elevated blood pressure and Assess the child’s current and past medical history for
risk factors such as a recent episode of pharyngitis or other streptococcal infection, age older than 2 years, or male sex.
Physical Examination and Laboratory and Diagnostic Tests
Assess the child’s blood pressure for elevation, which is common. Note the presence of mild edema. Observe for signs of cardiopulmonary congestion such as increased work of breathing or cough. Auscultate the lungs for crack- les and the heart for gallop. The urine dipstick test will reveal proteinuria as well as hematuria. Inspect the urine for gross hematuria, which will cause the urine to appear tea colored, cola colored, or even a dirty green color.
Serum creatinine and BUN may be normal or elevated, the serum complement level is depressed, and the erythrocyte sedimentation rate is elevated. Laboratory indings speciic to streptococcus include an elevated antistreptolysin (ASO) titer and an elevated DNAase B antigen titer.
Nursing Management
Administer antihypertensives such as labetalol or nife- dipine and diuretics as ordered. Monitor blood pressure frequently. Maintain sodium and luid restrictions as pre- scribed during the initial edematous phase. Weigh the child daily on the same scale wearing the same amount of clothing. Monitor increasing urine output and note improvement in the urine color. Document resolution of edema. Provide a careful neurologic evaluation, as hyper- tension may cause encephalopathy and seizures. Children with APSGN generally are fatigued and choose bed rest during the acute phase. Provide the child with age-appro- priate activities and cluster care to allow rest periods.
Some children may be managed at home if edema is mild and they are not hypertensive. Teach the family to monitor urine output and color, take blood pressure mea- surements, and restrict the diet as prescribed. The child cared for at home should not participate in strenuous activ- ity until proteinuria and hematuria are resolved. If renal involvement progresses, dialysis may become necessary.
Take Note!
Avoid use of nonsteroidal anti-inlammatory drugs (NSAIDs) in children with questionable renal function, as the antiprostaglandin action of NSAIDs may cause a further decrease in the glomerular iltration rate (Solomon, 2012).
Hemolytic-Uremic Syndrome
Hemolytic-uremic syndrome (HUS) is deined by three features—hemolytic anemia, thrombocytopenia, and acute renal failure. Typical HUS features an antecedent diarrheal
Preventing Hemolytic-Uremic Syndrome
Proper hand washing is necessary. Teach children to wash their hands after using the bathroom, before eat- ing, and after petting farm animals. Encourage the use of “swim diapers,” which contain feces, for children who are not toilet trained. Teach parents to thoroughly cook all meats to a core temperature of 155ºF, or until the meat is gray or brown throughout and the juices from the meat are clear rather than pink. Wash all fruits and vegetables thoroughly. Ensure that drinking water and water used for recreation are treated appropriately. Avoid unpasteur- ized dairy products and fruit juices (including cider).
Renal Failure
Renal failure is a condition in which the kidneys cannot concentrate urine, conserve electrolytes, or excrete waste products. As in adults, renal failure in children may occur as an acute or chronic condition. Some cases of acute renal failure resolve without further complications, while dialy- sis is necessary in other children. When acute renal failure continues to progress, it becomes chronic (also known as end-stage renal disease [ESRD]). Dialysis and kidney trans- plantation are treatment modalities used for ESRD.
Acute Renal Failure
Acute renal failure is deined as a sudden, often revers- ible, decline in renal function that results in the accu- mulation of metabolic toxins (particularly nitrogenous wastes) as well as luid and electrolyte imbalance. Fluid overload may lead to hypertension, pulmonary edema, and congestive heart failure. Additional complications include hyperkalemia, metabolic acidosis, hyperphos- phatemia, and uremia. In children, acute renal failure most commonly occurs as a result of decreased renal perfusion, as occurs in hypovolemic or septic shock. It may also occur in children with hemolytic anemia or as a result of nephrotoxicity from medications. Com- plications include anemia, hyperkalemia, hyperten- sion, pulmonary edema, cardiac failure, and altered level of consciousness or seizures. In addition, acute renal failure may also progress to a chronic state.
Therapeutic management is aimed at treating the underlying cause, managing the luid and electrolyte dis- turbances, and decreasing blood pressure.
Take Note!
Medications commonly used in children can reduce renal function. Cephalosporins may cause a transient increase in BUN and creatinine. Truly nephrotoxic drugs often used in children include aminoglycosides, sulfonamides, vanco- mycin, and NSAIDs. Make sure that potentially nephrotoxic tenderness in the abdomen. Assess the child for neu-
rologic involvement, which may include irritability, altered level of consciousness, seizures, posturing, or coma.
Laboratory and Diagnostic Tests
Urinalysis may reveal the presence of blood, protein, pus, and/or casts. Serum laboratory abnormalities are numerous and may include:
• Elevated BUN and creatinine
• Moderate to severe anemia (with the presence of Burr cells, schistocytes, spherocytes, or helmet cells), mild to severe thrombocytopenia
• Increased reticulocyte count
• Increased bilirubin and lactic dehydrogenase (LDH) levels
• Negative Coombs test (except in cases of Streptococ- cus pneumoniae infection)
• Leukocytosis with left shift
• Hyponatremia
• Hyperkalemia
• Hyperphosphatemia
• Metabolic acidosis
Nursing Management
Nursing management of the child with HUS focuses on close observation and monitoring of the child’s status.
Institute and maintain contact precautions to prevent spread of E. coli O157:H7 to other children (bacteria are shed for up to 17 days after resolution of the diar- rhea). Close attention must be paid to luid volume sta- tus. Prevention of HUS is also an important nursing function.
Maintaining Appropriate Fluid Volume Balance
Maintain strict intake and output monitoring and record- ing to evaluate the progression toward renal failure.
Carefully monitor intravenous infusions and blood chem- istries. Administer diuretics as ordered. Assess blood pressure frequently and report elevations to the physi- cian or nurse practitioner. Administer antihypertensives as ordered and monitor their effectiveness. Encourage adequate nutritional intake within the constraints of pre- scribed dietary restrictions. Monitor for bleeding as well as for fatigue and pallor. Follow the institutional protocol for transfusion of packed red blood cells and/or platelets (platelets are usually transfused only if active bleeding or severe thrombocytopenia occurs). Report progressive deterioration in laboratory indings to the physician or nurse practitioner. Some children with HUS will require dialysis for at least several days.