Nursing Care Plan for Nephrotic Syndrome

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 is also attributed with 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

  1. Monitor vitals

  2. 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

  3. 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

  4. Insert indwelling catheter unless contraindicated for infection

  5. Indwelling catheter will provide more accurate measurement of urine output

  6. Monitor diagnostic studies

    • Lab
    • Ultrasound
    • Kidney biopsy (as indicated)
  7. 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 be helpful in determining etiology

     
    Ultrasound

    • Can help determine severity and cause of nephrotic syndrome

     
    Kidney biopsy

    • Typically not needed, but may be  indicated in diabetic patients

  8. Assess for skin integrity

  9. Lack of protein in the blood reduces the integrity of skin and increases the risk of breakdown and ulceration.

  10. Assess dependent and periorbital  edema

  11. Evaluate and report degree of edema (+1 – +4)

    There may be a gain of up to 10lbs of fluid before pitting is noticed

  12. Administer medications and evaluate response

    • ACE Inhibitors or ARBs: (benazepril, losartan)  reduce 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 fluid from the body to the bloodstream to treat hypovolemia and replace low serum protein

  13. Monitor for volume depletion with use of diuretics

  14. 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

  15. Monitor for corticosteroid toxicity for ongoing use

  16. 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.

  17. Assist with Rest / Ambulation

  18. 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

  19. 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 dietitian as needed


References

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