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CASE STUDY

NCM 109 RLE CLINICAL

Wednesday 7:00 AM – 12:00 PM

Submitted by:
REGALA, BIANCA YSABELLE M.
BSN II – B
Group 3
DIARRHEA

Diarrhea is an increase in the frequency of bowel movements, as well as the water content and
volume of the waste. It may arise from a variety of factors, including malabsorption disorders, increased
secretion of fluid by the intestinal mucosa, and hypermotility of the intestine. It may also due to
infection, inflammatory bowel diseases, side effects of drugs, increased osmotic loads, radiation, or
increased intestinal motility.

Diarrhea can be an acute or a severe problem. Mild cases can be recovered in a few days.
However, severe diarrhea can lead to dehydration or severe nutritional problems. Problems associated
with diarrhea include fluid and electrolyte imbalances, impaired nutrition, and altered skin integrity.
Additionally, nurses and the members of the healthcare team must take precautions to prevent
transmission of infection associated with some causes of diarrhea.

Pathophysiology
Diarrhea is an increase in the volume of stool or frequency of defecation. It is one of the most
common clinical signs of gastrointestinal disease, but also can reflect primary disorders outside of the
digestive system. Certainly, disorders affecting either the small or large bowel can lead to diarrhea.
For many people, diarrhea represents an occasional inconvenience or annoyance, yet at least 2
million people in the world, mostly children, die from the consequences of diarrhea each year.
There are numerous causes of diarrhea, but in almost all cases, this disorder is a manifestation
of one of the four basic mechanisms described below. It is also common for more than one of the four
mechanisms to be involved in the pathogenesis of a given case.

Causes
The following are the common causes of diarrhea:
 Anxiety  Motor disorders: irritable bowel
 Alcohol abuse  Mucosal inflammation: Crohn’s disease
 Chemotherapy or ulcerative colitis
 Disagreeable dietary intake  Radiation
 Enteric infections: viral, bacterial, or  Short bowel syndrome
parasitic  Side effects of medication use
 Gastrointestinal disorders  Stress
 Increased secretion  Surgical procedures: bowel resection,
 Laxative abuse gastrectomy
 Malabsorption (e.g., lactase deficiency)  Tube feedings
 Viruses. Viruses that can cause diarrhea include Norwalk virus, cytomegalovirus and viral
hepatitis. Rotavirus is a common cause of acute childhood diarrhea. The virus that causes
 coronavirus disease 2019 (COVID-19) has also been associated with gastrointestinal symptoms,
including nausea, vomiting and diarrhea.
 Bacteria and parasites. Contaminated food or water can transmit bacteria and parasites to your
body. When traveling in developing countries, diarrhea caused by bacteria and parasites is often
called traveler's diarrhea. Clostridium difficile is another type of bacteria that can cause serious
infections that cause diarrhea, and it can occur after a course of antibiotics or during a
hospitalization.
 Medications. Many medications, such as antibiotics, can cause diarrhea. Antibiotics destroy
both good and bad bacteria, which can disturb the natural balance of bacteria in your intestines.
Other drugs that cause diarrhea are cancer drugs and antacids with magnesium.
 Lactose intolerance. Lactose is a sugar found in milk and other dairy products. People who have
difficulty digesting lactose have diarrhea after eating dairy products. Lactose intolerance can
increase with age because levels of the enzyme that helps digest lactose drop after childhood.
 Fructose. Fructose is a sugar found naturally in fruits and honey. It's sometimes added as a
sweetener to certain beverages. In people who have trouble digesting fructose, it can lead to
diarrhea.
 Artificial sweeteners. Sorbitol and mannitol — artificial sweeteners found in chewing gum and
other sugar-free products — can cause diarrhea in some otherwise healthy people.
 Surgery. Abdominal or gallbladder removal surgeries can sometimes cause diarrhea.
 Other digestive disorders. Chronic diarrhea has a number of other causes, such as Crohn's
disease, ulcerative colitis, celiac disease, microscopic colitis and irritable bowel syndrome.

Signs and Symptoms

A patient with diarrhea may report the following signs and symptoms:
 Abdominal pain
 Cramping
 Frequency of Stools (more than 3 times a day)
 Hyperactive bowel sounds or sensations
 Loose or liquid stools
 Urgency.

Complications
Diarrhea can cause dehydration, which can be life-threatening if untreated. Dehydration is
particularly dangerous in children, older adults and those with weakened immune systems.
If you have signs of serious dehydration, seek medical help.
Indications of dehydration in adults
These include:
 Excessive thirst
 Dry mouth or skin
 Little or no urination
  Weakness, dizziness or lightheadedness
 Fatigue
 Dark-colored urine
Indications of dehydration in infants and young children
These include:
 Not having a wet diaper in three or more hours
 Dry mouth and tongue
 Fever above 102 F (39 C)
 Crying without tears
 Drowsiness, unresponsiveness or irritability
 Sunken appearance to the abdomen, eyes or cheeks

Medical Management
Treatment
Most cases of diarrhea clear on their own within a couple of days without treatment. If the client tried
lifestyle changes and home remedies for diarrhea without success, tge doctor might recommend
medications or other treatments.
Antibiotics
Antibiotics might help treat diarrhea caused by bacteria or parasites. If a virus is causing the diarrhea,
antibiotics won't help.
Treatment to replace fluids
The doctor likely will advise to replace the fluids and salts. For most adults, that means drinking water,
juice or broth. If drinking liquids upsets the stomach or causes vomiting, the doctor might recommend
getting IV fluids.
Water is a good way to replace fluids, but it doesn't contain the salts and electrolytes — minerals such
as sodium and potassium — that are essential for the body to function. Electrolytes level can maintain
by drinking fruit juices for potassium or eating soups for sodium. But certain fruit juices, such as apple
juice, might make diarrhea worse.
For children, ask the doctor about using an oral rehydration solution, such as Pedialyte, to prevent
dehydration or replace lost fluids.
Treating underlying conditions
If the diarrhea is caused by a more serious condition, such as inflammatory bowel disease, the doctor
will work to control that condition. The client might be referred to a specialist, such as a
gastroenterologist, who can help devise a treatment plan.

Diagnostic Test
Your doctor will ask about your medical history, review the medications you take, conduct a physical
exam and may order tests to determine what's causing your diarrhea. Possible tests include:

 Blood test. A complete blood count test can help indicate what's causing your diarrhea.
  Stool test. Your doctor might recommend a stool test to see if a bacterium or parasite is causing
your diarrhea.

 Flexible sigmoidoscopy or colonoscopy. Using a thin, lighted tube that's inserted in your

rectum, your doctor can see inside your colon. The device is also equipped with a tool that
allows your doctor to take a small sample of tissue (biopsy) from your colon. Flexible
sigmoidoscopy provides a view of the lower colon, while colonoscopy allows the doctor to see
the entire colon.

Nursing Management
 Weigh patient daily and note decreased weight.
 Have patient keep a diary that includes the following: time of day defecation occurs; usual
stimulus for defecation; consistency, amount, and frequency of stool; type of, amount of, and
time food consumed; fluid intake; history of bowel habits and laxative use; diet; exercise
patterns; obstetrical/gynecological, medical, and surgical histories; medications; alterations in
perianal sensations; and present bowel regimen.
 Avoid using medications that slow peristalsis. If an infectious process is occurring, such as
Clostridium difficile infection or food poisoning, medication to slow down peristalsis should
generally not be given.
 Give antidiarrheal drugs as ordered. Most antidiarrheal drugs suppress gastrointestinal motility,
thus allowing for more fluid absorption.
 Provide the following dietary alterations:
o Bulk fiber (e.g., cereal, grains, Metamucil).
o “Natural” bulking agents (e.g., rice, apples, matzos, cheese)
o Avoidance of stimulants (e.g., caffeine, carbonated beverages)
 Record number and consistency of stools per day; if desired, use a fecal incontinence collector
for accurate measurement of output.
 Evaluate dehydration by observing skin turgor over sternum and inspecting for longitudinal
furrows of the tongue. Watch for excessive thirst, fever, dizziness, lightheadedness, palpitations,
excessive cramping, bloody stools, hypotension, and symptoms of shock.
 Encourage fluids 1.5 to 2 L/24 hr plus 200 mL for each loose stool in adults unless
contraindicated; consider nutritional support.
 Monitor and record intake and output; note oliguria and dark, concentrated urine. Measure
specific gravity of urine if possible.
 Evaluate the appropriateness of protocols for bowel preparation on basis of age, weight,
condition, disease, and other therapies.
 Provide perianal care after each bowel movement.
o Cleanse with a mild cleansing agent (perineal skin cleanser).
o Apply protective ointment prn.
o If skin is still excoriated and desquamated, apply a wound hydrogel.
  Avoid the use of rectal Foley catheters.
 If diarrhea is associated with cancer or cancer treatment, once infectious cause of diarrhea is
ruled out, provide medications as ordered to stop diarrhea.
 For patients with enteral tube feeding, employ the following:
o Change feeding tube equipment according to institutional policy, but no less than every
24 hours.
o Administer tube feeding at room temperature.
o Initiate tube feeding slowly.
o Decrease the rate or dilute feeding if diarrhea persists or worsens.
 If diarrhea is chronic and there is an indication of malnutrition, discuss with primary care
practitioner for a dietary consult and possible use of a hydrolyzed formula to maintain nutrition
while the gastrointestinal system heals.
 Encourage patient to eat small, frequent meals and to consume foods that normally cause
constipation and are easy to digest.
 Educate the patient or caregiver about the following dietary measures to control diarrhea:
o Avoid spicy, fatty foods, alcohol, and caffeine.
o Broil, bake, or boil foods; avoid frying.
o Avoid foods that are disagreeable.
 Allow the patient to communicate with caregiver if diarrhea occurs with prescription drugs.
 Educate patient or caregiver the proper use of antidiarrheal medications as ordered.
 Discuss the importance of fluid replacement during diarrheal episodes.
 Impart to patient the importance of good perianal hygiene.
 Educate patient and SO on how to prepare food properly and the importance of good food
sanitation practices and handwashing.
 Provide emotional support for patients who are having trouble controlling unpredictable
episodes of diarrhea.

DEHYDRATION
Dehydration occurs when you use or lose more fluid than you take in, and your body doesn't
have enough water and other fluids to carry out its normal functions. If you don't replace lost fluids, you
will get dehydrated. Anyone may become dehydrated, but the condition is especially dangerous for
young children and older adults.
The most common cause of dehydration in young children is severe diarrhea and vomiting.
Older adults naturally have a lower volume of water in their bodies, and may have conditions or take
medications that increase the risk of dehydration. This means that even minor illnesses, such as
infections affecting the lungs or bladder, can result in dehydration in older adults. Dehydration also can
occur in any age group if you don't drink enough water during hot weather — especially if you are
exercising vigorously.
Pathophysiology
The negative fluid balance that causes dehydration results from decreased intake, increased
output (renal, gastrointestinal [GI], or insensible losses), or fluid shift (ascites, effusions, and capillary
leak states such as burns and sepsis). The decrease in total body water causes reductions in both the
intracellular and extracellular fluid volumes. Clinical manifestations of dehydration are most closely
related to intravascular volume depletion and the physiologic compensation attempts that takes place.
As dehydration progresses, hypovolemic shock ultimately ensues, resulting in end organ failure and
death.

Causes
Sometimes dehydration occurs for simple reasons: You don't drink enough because you're sick
or busy, or because you lack access to safe drinking water when you're traveling, hiking or camping.
Other dehydration causes include:
 Diarrhea, vomiting. Severe, acute diarrhea — that is, diarrhea that comes on suddenly and violently
— can cause a tremendous loss of water and electrolytes in a short amount of time. If you have
vomiting along with diarrhea, you lose even more fluids and minerals.
 Fever. In general, the higher your fever, the more dehydrated you may become. The problem
worsens if you have a fever in addition to diarrhea and vomiting.
 Excessive sweating. You lose water when you sweat. If you do vigorous activity and don't replace
fluids as you go along, you can become dehydrated. Hot, humid weather increases the amount you
sweat and the amount of fluid you lose.
 Increased urination. This may be due to undiagnosed or uncontrolled diabetes. Certain medications,
such as diuretics and some blood pressure medications, also can lead to dehydration, generally
because they cause you to urinate more.

Signs and Symptoms

Thirst isn't always a reliable early indicator of the body's need for water. Many people,
particularly older adults, don't feel thirsty until they're already dehydrated. That's why it's important to
increase water intake during hot weather or when you're ill.
The signs and symptoms of dehydration also may differ by age.
Infant or young child Adult
 Dry mouth and tongue  Extreme thirst
 No tears when crying  Less frequent urination
 No wet diapers for three hours  Dark-colored urine
 Sunken eyes, cheeks  Fatigue
 Sunken soft spot on top of skull  Dizziness
 Listlessness or irritability  Confusion

Risk factors
Anyone can become dehydrated, but certain people are at greater risk:
 Infants and children. The most likely group to experience severe diarrhea and vomiting, infants and
children are especially vulnerable to dehydration. Having a higher surface area to volume area, they
also lose a higher proportion of their fluids from a high fever or burns. Young children often can't tell
you that they're thirsty, nor can they get a drink for themselves.
 Older adults. As you age, your body's fluid reserve becomes smaller, your ability to conserve water
is reduced and your thirst sense becomes less acute. These problems are compounded by chronic
illnesses such as diabetes and dementia, and by the use of certain medications. Older adults also
may have mobility problems that limit their ability to obtain water for themselves.
 People with chronic illnesses. Having uncontrolled or untreated diabetes puts you at high risk of
dehydration. Kidney disease also increases your risk, as do medications that increase urination. Even
having a cold or sore throat makes you more susceptible to dehydration because you're less likely to
feel like eating or drinking when you're sick.
 People who work or exercise outside. When it's hot and humid, your risk of dehydration and heat
illness increases. That's because when the air is humid, sweat can't evaporate and cool you as
quickly as it normally does, and this can lead to an increased body temperature and the need for
more fluids.

Complications
Dehydration can lead to serious complications, including:
 Heat injury. If you don't drink enough fluids when you're exercising vigorously and perspiring
heavily, you may end up with a heat injury, ranging in severity from mild heat cramps to heat
exhaustion or potentially life-threatening heatstroke.
 Urinary and kidney problems. Prolonged or repeated bouts of dehydration can cause urinary tract
infections, kidney stones and even kidney failure.
 Seizures. Electrolytes — such as potassium and sodium — help carry electrical signals from cell to
cell. If your electrolytes are out of balance, the normal electrical messages can become mixed up,
which can lead to involuntary muscle contractions and sometimes to a loss of consciousness.
 Low blood volume shock (hypovolemic shock). This is one of the most serious, and sometimes life-
threatening, complications of dehydration. It occurs when low blood volume causes a drop in blood
pressure and a drop in the amount of oxygen in your body.

Prevention
To prevent dehydration, drink plenty of fluids and eat foods high in water such as fruits and
vegetables. Letting thirst be your guide is an adequate daily guideline for most healthy people.
People may need to take in more fluids if they are experiencing conditions such as:

 Vomiting or diarrhea. If your child is vomiting or has diarrhea, start giving extra water or an oral
rehydration solution at the first signs of illness. Don't wait until dehydration occurs.
 Strenuous exercise. In general, it's best to start hydrating the day before strenuous exercise.
Producing lots of clear, dilute urine is a good indication that you're well-hydrated. During the
 activity, replenish fluids at regular intervals and continue drinking water or other fluids after you're
finished.
 Hot or cold weather. You need to drink additional water in hot or humid weather to help lower your
body temperature and to replace what you lose through sweating. You may also need extra water in
cold weather to combat moisture loss from dry air, particularly at higher altitudes
 Illness. Older adults most commonly become dehydrated during minor illnesses — such as influenza,
bronchitis or bladder infections. Make sure to drink extra fluids when you're not feeling well.

Medical Management
Treatment
The only effective treatment for dehydration is to replace lost fluids and lost electrolytes. The
best approach to dehydration treatment depends on age, the severity of dehydration and its cause. For
infants and children who have become dehydrated from diarrhea, vomiting or fever, use an over-the-
counter oral rehydration solution. These solutions contain water and salts in specific proportions to
replenish both fluids and electrolytes.
Start with about a teaspoon (5 milliliters) every one to five minutes and increase as tolerated. It
may be easier to use a syringe for very young children. Older children can be given diluted sports drinks.
Use 1 part sports drink to 1 part water.
Most adults with mild to moderate dehydration from diarrhea, vomiting or fever can improve
their condition by drinking more water or other liquids. Diarrhea may be worsened by full-strength fruit
juice and soft drinks.
If you work or exercise outdoors during hot or humid weather, cool water is your best bet.
Sports drinks containing electrolytes and a carbohydrate solution also may be helpful.
Children and adults who are severely dehydrated should be treated by emergency personnel
arriving in an ambulance or in a hospital emergency room. Salts and fluids delivered through a vein
(intravenously) are absorbed quickly and speed recovery.

Diagnostic Test
The doctor can often diagnose dehydration on the basis of physical signs and symptoms. If the
client is dehydrated, he/she is likely to have low blood pressure, especially when moving from a lying to
a standing position, a faster than normal heart rate and reduced blood flow to your extremities.
To help confirm the diagnosis and pinpoint the degree of dehydration, other tests may be
conducted, such as:
 Blood tests. Blood samples may be used to check for a number of factors, such as the levels of your
electrolytes — especially sodium and potassium — and how well your kidneys are working.
 Urinalysis. Tests done on your urine can help show whether you're dehydrated and to what degree.
They also can check for signs of a bladder infection.

Nursing Management
 Urge the patient to drink prescribed amount of fluid.
 Aid the patient if he or she is unable to eat without assistance, and encourage the family or SO to
assist with feedings, as necessary.
 If patient can tolerate oral fluids, give what oral fluids patient prefers. Provide fluid and straw at
bedside within easy reach. Provide fresh water and a straw.
 Emphasize importance of oral hygiene.
 Provide comfortable environment by covering patient with light sheets.
 Plan daily activities.
For more severe hypovolemia:
 Insert and IV catheter to have IV access.
 Administer parenteral fluids as prescribed. Consider the need for an IV fluid challenge with
immediate infusion of fluids for patients with abnormal vital signs.
 Administer blood products as prescribed.
 Maintain IV flow rate. Stop or delay the infusion if signs of fluid overload transpire, refer to physician
respectively.
 Assist the physician with insertion of central venous line and arterial line, as indicated.
 Provide measures to prevent excessive electrolyte loss (e.g., resting the GI tract, administering
antipyretics as ordered by the physician).
 Begin to advance the diet in volume and composition once ongoing fluid losses have stopped.
 Encourage to drink bountiful amounts of fluid as tolerated or based on individual needs.
 Educate patient about possible cause and effect of fluid losses or decreased fluid intake.
 Enumerate interventions to prevent or minimize future episodes of dehydration.
 Emphasize the relevance of maintaining proper nutrition and hydration.
 Teach family members how to monitor output in the home. Instruct them to monitor both intake
and output.
 Refer patient to home health nurse or private nurse in able to assist patient, as appropriate.
 Identify an emergency plan, including when to ask for help.

ACUTE GLOMEROLUNEPHRITIS
Glomerulonephritis (gloe-mer-u-low-nuh-FRY-tis) is inflammation of the tiny filters in the
kidneys (glomeruli). Glomeruli remove excess fluid, electrolytes and waste from the bloodstream and
pass them into your urine. Glomerulonephritis can come on suddenly (acute) or gradually (chronic).
Glomerulonephritis occurs on its own or as part of another disease, such as lupus or diabetes.
Severe or prolonged inflammation associated with glomerulonephritis can damage the kidneys.
Treatment depends on the type of glomerulonephritis the patient have.
Acute glomerulonephritis (GN) comprises a specific set of renal diseases in which an
immunologic mechanism triggers inflammation and proliferation of glomerular tissue that can result in
damage to the basement membrane, mesangium, or capillary endothelium.

Pathophysiology
 Acute Glomerulonephritis involves both structural changes and functional changes.
 Structurally, cellular proliferation leads to an increase in the number of cells in the glomerular tuft
because of the proliferation of endothelial, mesangial, and epithelial cells.
 The proliferation may be endocapillary (i.e., within the confines of the glomerular capillary tufts) or
extracapillary (ie, in the Bowman space involving the epithelial cells).
 In extracapillary proliferation, proliferation of parietal epithelial cells leads to the formation of
crescents, a feature characteristic of certain forms of rapidly progressive GN.
 Leukocyte proliferation is indicated by the presence of neutrophils and monocytes within the
glomerular capillary lumen and often accompanies cellular proliferation.
 Glomerular basement membrane thickening appears as thickening of capillary walls on light
microscopy.
 Electron-dense deposits can be subendothelial, subepithelial, intramembranous, or mesangial, and
they correspond to an area of immune complex deposition.
 Hyalinization or sclerosis indicates irreversible injury.
 These structural changes can be focal, diffuse or segmental, or global.
 Functional changes include proteinuria, hematuria, reduction in GFR (ie, oliguria or anuria), and
active urine sediment with RBCs and RBC casts.
 The decreased GFR and avid distal nephron salt and water retention result in expansion of
intravascular volume, edema, and, frequently, systemic hypertension.

Causes
Many conditions can cause glomerulonephritis. Sometimes the disease runs in families and
sometimes the cause is unknown. Conditions that can lead to inflammation of the kidneys' glomeruli
include:
 Infectious. The most common infectious cause of acute GN is infection by Streptococcus species (ie,
group A, beta-hemolytic).
 Noninfectious. Noninfectious causes of acute GN may be divided into primary renal diseases,
systemic diseases, and miscellaneous conditions or agents.
Infections
 Post-streptococcal glomerulonephritis. Glomerulonephritis may develop a week or two after
recovery from a strep throat infection or, rarely, a skin infection (impetigo). To fight the infection,
your body produces extra antibodies that can eventually settle in the glomeruli, causing
inflammation.
Children are more likely to develop post-streptococcal glomerulonephritis than are adults, and
they're also more likely to recover quickly.
 Bacterial endocarditis. Bacteria occasionally can spread through your bloodstream and lodge in your
heart, causing an infection of one or more of your heart valves. You're at greater risk of this
condition if you have a heart defect, such as a damaged or artificial heart valve. Bacterial
endocarditis is associated with glomerular disease, but the connection between the two is unclear.
 Viral infections. Viral infections, such as the human immunodeficiency virus (HIV), hepatitis B and
hepatitis C, can trigger glomerulonephritis.
Immune diseases
 Lupus. A chronic inflammatory disease, lupus can affect many parts of your body, including your
skin, joints, kidneys, blood cells, heart and lungs.
 Goodpasture's syndrome. A rare immunological lung disorder that can mimic pneumonia,
Goodpasture's syndrome causes bleeding in your lungs as well as glomerulonephritis.
 IgA nephropathy. Characterized by recurrent episodes of blood in the urine, this primary glomerular
disease results from deposits of immunoglobulin A (IgA) in the glomeruli. IgA nephropathy can
progress for years with no noticeable symptoms.
Vasculitis
 Polyarteritis. This form of vasculitis affects small and medium blood vessels in many parts of your
body, such as your heart, kidneys and intestines.
 Granulomatosis with polyangiitis. This form of vasculitis, formerly known as Wegener's
granulomatosis, affects small and medium blood vessels in your lungs, upper airways and kidneys.
Conditions likely to cause scarring of the glomeruli
 High blood pressure. This can damage your kidneys and impair their ability to function normally.
Glomerulonephritis can also lead to high blood pressure because it reduces kidney function and can
influence how your kidneys handle sodium.
 Diabetic kidney disease (diabetic nephropathy). This can affect anyone with diabetes, usually taking
years to develop. Good control of blood sugar levels and blood pressure might prevent or slow
kidney damage.
 Focal segmental glomerulosclerosis. Characterized by scattered scarring of some of the glomeruli,
this condition can result from another disease or occur for no known reason.

Infrequently, chronic glomerulonephritis runs in families. One inherited form, Alport syndrome, also
might impair hearing or vision.
In addition to the causes listed above, glomerulonephritis is associated with certain cancers, such as
multiple myeloma, lung cancer and chronic lymphocytic leukemia.

Signs and Symptoms

Signs and symptoms of glomerulonephritis depend on whether you have the acute or chronic
form and the cause. Your first indication that something is wrong might come from symptoms or from
the results of a routine urinalysis.
Glomerulonephritis signs and symptoms include:
 Pink or cola-colored urine from red blood cells in your urine (hematuria). Usually the presenting
symptom is grossly bloody urine; the caregiver may describe the urine as smoky or bloody.
 Foamy urine due to excess protein (proteinuria)
 Fluid retention (edema) with swelling evident in your face, hands, feet and abdomen. Periorbital
edema. Periorbital edema and/or pedal edema may accompany or precede hematuria.
 Fever. Fever may be 103°F to 104°F at the onset but decreases in a few days to about 100°F.
 Hypertension. Hypertension occurs in 60% to 70% of patients during the first 4 or 5 days.
 Oliguria. Oliguria (production of a subnormal volume of urine) is usually present, and the urine has a
high specific gravity and contains albumin, red and white blood cells, and casts.
 Fluid overload. Observe for periorbital and/or pedal edema; edema and hypertension due to fluid
overload (in 75% of patients); crackles (ie, if pulmonary edema); elevated jugular venous pressure;
ascites and pleural effusion (possible).
 Cerebral symptoms. Cerebral symptoms consisting mainly of headache, drowsiness, convulsions,
and vomiting occur in connection with hypertension in a few cases.

Complications
Glomerulonephritis can damage your kidneys so that they lose their filtering ability. As a result,
dangerous levels of fluid, electrolytes and waste build up in your body.
Possible complications of glomerulonephritis include:

 Acute kidney failure. Loss of function in the filtering part of the nephron can result in rapid
accumulation of waste products. You might need emergency dialysis — an artificial means of
removing extra fluids and waste from your blood — typically by an artificial kidney machine.
 Chronic kidney disease. Your kidneys gradually lose their filtering ability. Kidney function that
deteriorates to less than 10 percent of normal capacity results in end-stage kidney disease, which
requires dialysis or a kidney transplant to sustain life.
 High blood pressure. Damage to your kidneys and the resulting buildup of wastes in the
bloodstream can raise your blood pressure.
 Nephrotic syndrome. With this syndrome, too much protein in your urine results in too little protein
in your blood. Nephrotic syndrome can be associated with high blood cholesterol and swelling
(edema) of the eyelids, feet and abdomen.

Prevention
There may be no way to prevent most forms of glomerulonephritis. However, here are some
steps that might be beneficial:
 Seek prompt treatment of a strep infection with a sore throat or impetigo.
 To prevent infections that can lead to some forms of glomerulonephritis, such as HIV and hepatitis,
follow safe-sex guidelines and avoid intravenous drug use.
 Control high blood pressure, which lessens the likelihood of damage to your kidneys from
hypertension.
 Control your blood sugar to help prevent diabetic nephropathy.

Medical Management
Treatment
 Treatment of glomerulonephritis and your outcome depend on:
 Whether you have an acute or chronic form of the disease
 The underlying cause
 The type and severity of your signs and symptoms
Some cases of acute glomerulonephritis, especially those that follow a strep infection, might
improve on their own and require no treatment. If there's an underlying cause, such as high blood
pressure, an infection or an autoimmune disease, treatment will be directed to the underlying cause. In
general, the goal of treatment is to protect your kidneys from further damage.
Treatment of acute glomerulonephritis (AGN) is mainly supportive, because there is no specific
therapy for renal disease.
• Diet. Sodium and fluid restriction should be advised for treatment of signs and symptoms of
fluid retention (eg, edema, pulmonary edema); protein restriction for patients with azotemia should be
advised if there is no evidence of malnutrition.
• Activity. Bed rest is recommended until signs of glomerular inflammation and circulatory
congestion subside as prolonged inactivity is of no benefit in the patient recovery process.
• Long term monitoring. Long-term studies on children with AGN have revealed few chronic
sequelae.
Therapies for associated kidney failure
For acute glomerulonephritis and acute kidney failure, dialysis can help remove excess fluid and
control high blood pressure. The only long-term therapies for end-stage kidney disease are kidney
dialysis and kidney transplant. When a transplant isn't possible, often because of poor general health,
dialysis is the only option.

Pharmacologic Management
The goals of pharmacotherapy are to reduce morbidity, to prevent complications, and to
eradicate the infection.
 Antibiotics. In streptococcal infections, early antibiotic therapy may prevent antibody response to
exoenzymes and render throat cultures negative, but may not prevent the development of AGN.
 Loop diuretics. Loop diuretics decrease plasma volume and edema by causing diuresis. The
reductions in plasma volume and stroke volume associated with diuresis decrease cardiac output
and, consequently, blood pressure.
 Vasodilators. These agents reduce systemic vascular resistance, which, in turn, may allow forward
flow, improving cardiac output.
 Calcium channel blockers. Calcium channel blockers inhibit the movement of calcium ions across
the cell membrane, depressing both impulse formation (automaticity) and conduction velocity.

Diagnostic Test
Glomerulonephritis often comes to light when a routine urinalysis is abnormal. Tests to assess
the kidney function and make a diagnosis of glomerulonephritis include:
 Urine test. A urinalysis might show red blood cells and red cell casts in your urine, an indicator of
possible damage to the glomeruli. Urinalysis results might also show white blood cells, a common
 indicator of infection or inflammation, and increased protein, which can indicate nephron damage.
Other indicators, such as increased blood levels of creatinine or urea, are red flags. The urine is dark;
its specific gravity is greater than 1.020; RBCs and RBC casts are present; and proteinuria is
observed.
 Imaging tests. If the doctor detects evidence of damage, he or she may recommend diagnostic
studies that allow visualization of your kidneys, such as a kidney X-ray, an ultrasound exam or a CT
scan.
 Kidney biopsy. This procedure involves using a special needle to extract small pieces of kidney tissue
for microscopic examination to help determine the cause of the inflammation. A kidney biopsy is
almost always necessary to confirm a diagnosis of glomerulonephritis.
 Initial blood tests. A CBC is performed; a decrease in the hematocrit may demonstrate a dilutional
anemia; in the setting of an infectious etiology, pleocytosis may be evident; electrolyte levels are
measured (particularly the serum potassium), along with BUN and creatinine (to allow estimation of
the glomerular filtration rate [GFR]); the BUN and creatinine levels will exhibit a degree of renal
compromise and GFR may be decreased.
 Complement levels. Differentiation of low and normal serum complement levels may allow the
physician to narrow the differential diagnosis.
 Streptozyme tests. The streptozyme tests test includes many streptococcal antigens that are
sensitive for screening but are not quantitative, such as DNAase, streptokinase, streptolysin O, and
hyaluronidase; the antistreptolysin O (ASO) titer is increased in 60-80% of patients; increasing ASO
titers or streptozyme titers confirm recent infection.
 Blood and tissue cultures. Blood culture is indicated in patients with fever, immunosuppression,
intravenous (IV) drug use history, indwelling shunts, or catheters; cultures of throat and skin lesions
to rule out Streptococcus species may be obtained.

Nursing Management
The nurses’ role in the care of a child with AGN is crucial.
Nursing Assessment
Assessment of a child with AGN include:
 Physical examination. Obtain complete physical assessment
 Assess weight. Monitor daily weight to have a measurable account on the fluid elimination.
 Monitor intake and output. Monitor fluid intake and output every 4 hours to know progressing
condition via glomerular filtration.
 Assess vital signs. Monitor BP and PR every hour to know progression of hypertension and basis for
further nursing intervention or referral.
 Assess breath sounds. Assess for adventitious breath sounds to know for possible progression in the
lungs.
Nursing Diagnoses
Based on the assessment data, the major nursing diagnoses are:
 Ineffective breathing pattern related to the inflammatory process.
 Altered urinary elimination related to decreased bladder capacity or irritation secondary to
infection.
 Excess fluid volume related to a decrease in regulatory mechanisms (renal failure) with the potential
of water.
 Risk for infection related to a decrease in the immunological defense.
 Imbalanced nutrition less than body requirements related to anorexia, nausea, vomiting.
 Risk for impaired skin integrity related to edema and pruritus.
 Hyperthermia related to the ineffectiveness of thermoregulation secondary to infection.
Nursing Care Planning and Goals
Nursing care planning goals for a child with acute glomerulonephritis are:
 Excretion of excessive fluid through urination.
 Demonstration of behaviors that would help in excreting excessive fluids in the body.
 Improvement of distended abdominal girth.
 Improvement of respiratory rate.
 Participation and demonstration of various ways to achieve effective tissue perfusion.
Nursing Interventions
Nursing care of a child with AGN includes the following interventions:
 Activity. Bed rest should be maintained until acute symptoms and gross hematuria disappear.
 Prevent infection. The child must be protected from chilling and contact with people with
infections.
 Monitor intake and output. Fluid intake and urinary output should be carefully monitored and
recorded; special attention is needed to keep the intake within prescribed limits.
 Monitor BP. Blood pressure should be monitored regularly using the same arm and a properly fitting
cuff.
 Monitor urine characteristics. The urine must be tested regularly for protein and hematuria using
dipstick tests.

NEPHROTIC SYNDROME
Nephrotic syndrome is a kidney disorder that causes your body to pass too much protein in your
urine. Nephrotic syndrome is usually caused by damage to the clusters of small blood vessels in your
kidneys that filter waste and excess water from your blood. The condition causes swelling, particularly in
your feet and ankles, and increases the risk of other health problems.
Treatment for nephrotic syndrome includes treating the condition that's causing it and taking
medications. Nephrotic syndrome can increase your risk of infections and blood clots. Your doctor might
recommend medications and dietary changes to prevent complications.
Nephrotic syndrome has a course of remissions and exacerbations that usually lasts for months.
Nephrotic syndrome, or nephrosis, is defined by the presence of nephrotic-range proteinuria, edema,
hyperlipidemia, and hypoalbuminemia. While nephrotic-range proteinuria in adults is characterized by
protein excretion of 3.5 g or more per day, in children it is defined as protein excretion of more than 40
mg/m2/h or a first-morning urine protein/creatinine of 2-3 mg/mg creatinine or greater.

Pathophysiology
In a healthy individual, less than 0.1% of plasma albumin may traverse the glomerular filtration
barrier. Amounts above 500 mg/day point to glomerular disease.

 The glomerular capillaries are lined by a fenestrated endothelium that sits on the glomerular
basement membrane, which in turn is covered by glomerular epithelium, or podocytes, which
envelops the capillaries with cellular extensions called foot processes.
 In between the foot processes are the filtration slits; these three structures—the fenestrated
endothelium, glomerular basement membrane, and glomerular epithelium—are the glomerular
filtration barrier.
 Filtration of plasma water and solutes is extracellular and occurs through the endothelial fenestrae
and filtration slits.
 The importance of the podocytes and the filtration slits is shown by genetic diseases: in congenital
nephrotic syndrome of the Finnish type, the gene for nephrin, a protein of the filtration slit, is
mutated, leading to nephrotic syndrome in infancy; similarly, podocin, a protein of the podocytes,
may be abnormal in a number of children with steroid-resistant focal glomerulosclerosis.
 The glomerular structural changes that may cause proteinuria are damage to the endothelial
surface, the glomerular basement membrane, or the podocytes; one or more of these mechanisms
may be seen in any one type of nephrotic syndrome.
 Albuminuria alone may occur or, with greater injury, leakage of all plasma proteins (ie, proteinuria)
may take place.
 There are two current hypotheses for the formation of edema in nephrotic syndrome: the underfill
hypothesis holds that the loss of albumin leading to lower plasma colloid pressure is the cause; the
overfill hypothesis states that the edema is due to primary renal sodium retention.

Causes
There are two causes of nephrotic syndrome: primary and secondary.
 Primary. Common primary causes of nephrotic syndrome include kidney diseases such as minimal--
change nephropathy, membranous nephropathy, and focal glomerulosclerosis.
 Secondary. Secondary causes include systemic diseases such as diabetes mellitus, lupus
erythematosus, and amyloidosis.
Nephrotic syndrome is usually caused by damage to the clusters of tiny blood vessels (glomeruli)
of the kidneys. The glomeruli filter the blood as it passes through your kidneys, separating things
your body needs from those it doesn't. Healthy glomeruli keep blood protein (mainly albumin) —
which is needed to maintain the right amount of fluid in your body — from seeping into the urine.
When damaged, glomeruli allow too much blood protein to leave the body, leading to nephrotic
syndrome.
Many possible causes
 Many diseases and conditions can cause glomerular damage and lead to nephrotic syndrome,
including:
 Diabetic kidney disease. Diabetes can lead to kidney damage (diabetic nephropathy) that affects the
glomeruli.
 Minimal change disease. This is the most common cause of nephrotic syndrome in children.
Minimal change disease results in abnormal kidney function, but when the kidney tissue is examined
under a microscope, it appears normal or nearly normal. The cause of the abnormal function
typically can't be determined.
 Focal segmental glomerulosclerosis. Characterized by scarring of some of the glomeruli, this
condition can result from another disease, a genetic defect or certain medications or occur for no
known reason.
 Membranous nephropathy. This kidney disorder is the result of thickening membranes within the
glomeruli. The thickening is due to deposits made by the immune system. It can be associated with
other medical conditions, such as lupus, hepatitis B, malaria and cancer, or it can occur for no known
reason.
 Systemic lupus erythematosus. This chronic inflammatory disease can lead to serious kidney
damage.
 Amyloidosis. This disorder occurs when amyloid proteins accumulate in the organs. Amyloid buildup
often damages the kidneys' filtering system.

Signs and Symptoms

The first sign of nephrotic syndrome in children is usually swelling of the face; this is followed by
swelling of the entire body.
 Weight gain due to fluid retention
 Fatigue
 Edema. Edema is the salient feature of nephrotic syndrome and initially develops around the eyes
and legs; with time, the edema becomes generalized and may be associated with an increase in
weight, the development of ascites, or pleural effusions.
 Malnutrition. Malnutrition may become severe, however, the generalized edema masks the loss of
body tissue, causing the child to present a chubby appearance and to double his or her weight.
 Irritability and loss of appetite. Anorexia, irritability, and loss of appetite develop.
 Immunosuppression. These children are generally susceptible to infection, and repeated acute
respiratory conditions are the usual pattern.
 Proteinuria. Albumin leaks out due to structural damage, leading to proteinuria.
 Respiratory tract infection. A history of a respiratory tract infection immediately preceding the
onset of nephrotic syndrome is frequent.
 Allergy. Approximately 30% of children with nephrotic syndrome have a history of allergy.

Risk Factors
Factors that can increase your risk of nephrotic syndrome include:
 Medical conditions that can damage your kidneys. Certain diseases and conditions increase your
risk of developing nephrotic syndrome, such as diabetes, lupus, amyloidosis, reflux nephropathy and
other kidney diseases.
 Certain medications. Medications that might cause nephrotic syndrome include nonsteroidal anti-
inflammatory drugs and drugs used to fight infections.
 Certain infections. Infections that increase the risk of nephrotic syndrome include HIV, hepatitis B,
hepatitis C and malaria.

Complications
Possible complications of nephrotic syndrome include:
 Blood clots. The inability of the glomeruli to filter blood properly can lead to loss of blood 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.
 Poor nutrition. Loss of too much blood protein can result in malnutrition. This can lead to weight
loss, which can be masked by edema. You may also have too few red blood cells (anemia), low blood
protein levels and low levels of vitamin D.
 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 (dialyzer).
 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.

Medical Management

The management of nephrotic syndrome is a long process with remissions and recurrence of
symptoms common.

 Corticosteroid therapy. The general consensus now is daily induction steroid treatment for 6
weeks, followed by alternate-day maintenance therapy for another 6 weeks.
 Diuretic therapy. Diuretic therapy may be beneficial, particularly in children with symptomatic
edema; loop diuretics, such as furosemide (starting at 1-2 mg/kg/d) may improve edema; their
administration, however, should be handled with care because plasma volume contraction may
already be present, and hypovolemic shock has been observed with overly aggressive therapy.
 Home monitoring. Home monitoring of urine protein and fluid status is an important aspect of
management; all patients and parents should be trained to monitor first morning urine proteins
 at home with urine dipstick; urine testing at home is also useful in monitoring response (or non-
response) to steroid treatment.
 Diet. A sodium-restricted diet should be maintained while a patient is edematous and until
proteinuria remits; during severe edema, careful and modest fluid restriction may be
appropriate, but the patient must be monitored closely for excessive intravascular volume
depletion.
 Activity. A normal activity plan is recommended.

Pharmacologic Management

Prednisone is the first-line therapy for children with nephrotic syndrome. Other
immunosuppressive medications may be useful in those whose symptoms fail to respond to standard
corticosteroid therapy or in those who have frequent relapses.

 Glucocorticoids. All glucocorticoids are effective; however, prednisone or prednisolone is used

most commonly; their specific mode of action in nephrotic syndrome is unknown.
 Diuretics. Diuretics promote excretion of water and electrolytes by the kidneys; these agents
are used to treat heart failure or hepatic, renal, or pulmonary disease when sodium and water
retention has resulted in edema or ascites. These help control swelling by increasing your
kidneys' fluid output. Diuretic medications typically include furosemide (Lasix). Others include
spironolactone (Aldactone, Carospir) and thiazides, such as hydrochlorothiazide or metolazone
(Zaroxolyn).
 Plasma protein. This agent is used to supplement diuresis in patients with edema; it increases
oncotic pressure and thereby promotes a fluid shift from interstitial tissues.
 Immunosuppressive agents. This agent is used to supplement diuresis in patients with edema; it
increases oncotic pressure and thereby promotes a fluid shift from interstitial tissues.
Medications to control the immune system, such as corticosteroids, can decrease the
inflammation that accompanies some of the conditions that can cause nephrotic syndrome.
Medications include rituximab (Rituxan), cyclosporine and cyclophosphamide.
 Blood pressure medications. Drugs called angiotensin-converting enzyme (ACE) inhibitors
reduce blood pressure and the amount of protein released in urine. Medications in this category
include lisinopril (Prinvil, Qbrelis, Zestril), benazepril (Lotensin), captopril and enalapril
(Vasotec).
Another group of drugs that works similarly is called angiotensin II receptor blockers (ARBs) and
includes losartan (Cozaar) and valsartan (Diovan). Other medications, such as renin inhibitors,
also might be used, though ACE inhibitors and ARBs are generally used first.
 Cholesterol-reducing medications. Statins can help lower cholesterol levels. However, it's not
clear whether cholesterol-lowering medications can improve the outcomes for people with
nephrotic syndrome, such as avoiding heart attacks or decreasing the risk of early death.
 Statins include atorvastatin (Lipitor), fluvastatin (Lescol XL), lovastatin (Altoprev), pravastatin
(Pravachol), rosuvastatin (Crestor, Ezallor) and simvastatin (Zocor).
  Blood thinners (anticoagulants). These might be prescribed to decrease your blood's ability to
clot, especially if you've had a blood clot. Anticoagulants include heparin, warfarin (Coumadin,
Jantoven), dabigatran (Pradaxa), apixaban (Eliquis) and rivaroxaban (Xarelto).

Diagnostic Test

Tests and procedures used to diagnose nephrotic syndrome include:

 Urine tests. A urinalysis can reveal abnormalities in your urine, such as large amounts of protein.
You might be asked to collect urine samples over 24 hours.
 Blood tests. A blood test can show low levels of the protein albumin and often decreased levels
of blood protein overall. Loss of albumin is often associated with an increase in blood
cholesterol and blood triglycerides. The creatinine and urea nitrogen levels in your blood also
might be measured to assess your overall kidney function.
 Kidney biopsy. Your doctor might recommend removing a small sample of kidney tissue for
testing. During a kidney biopsy, a needle is inserted through your skin and into your kidney.
Kidney tissue is collected and sent to a lab for testing.

Nursing Management
The nursing management of a child with nephrotic syndrome include the following:
Nursing Assessment
Assess for the following:
 Edema. Observe for edema when performing physical examination of the child with nephrotic
syndrome.
 Weigh and measure. Weigh the child and record the abdominal measurements to serve as a
baseline.
 Vital signs. Obtain vital signs, including blood pressure.
 Pitting edema. Note any swelling about the eyes or the ankles and other dependent parts.
 Skin. Inspect the skin for pallor, irritation, or breakdown; examine the scrotal area of the male
child for swelling, redness, and irritation.
Nursing Diagnoses
Based on the assessment data, the major nursing diagnoses are:
 Excess fluid volume related to fluid accumulation in tissues and third spaces.
 Risk for imbalanced nutrition: less than body requirements related to anorexia.
 Risk for impaired skin integrity related to edema.
 Fatigue related to edema and disease process.
 Risk for infection related to immunosuppression.
 Deficient knowledge of the caregiver related to disease process, treatment, and home care.
 Compromised family coping related to care of a child with chronic illness.
Nursing Care Planning and Goals
The major nursing care planning goals for the child with nephrotic syndrome are:
  Relieving edema.
 Improving nutritional status.
 Maintaining skin integrity.
 Conserving energy.
 Preventing infection.
Nursing Interventions
Nursing interventions for a child with nephrotic syndrome are:
 Monitoring fluid intake and output. Accurately monitor and document intake and output;
weigh the child at the same time every day, on the same scale in the same clothing; measure the
child’s abdomen daily at the level of the umbilicus.
 Improving nutritional intake. Offer a visually appealing and nutritious diet; consult the child and
the family to learn which foods are appealing to the child; serving six small meals my help
increase the child’s total intake better.
 Promoting skin integrity. Inspect all skin surfaces regularly for breakdown; turn and position the
child every 2 hours; protect skin surfaces from pressure by means of pillows and padding;
protect overlapping skin surfaces from rubbing by careful placement of cotton gauze; bathe the
child regularly; a sheer dusting of cornstarch ma be soothing to the skin.
 Promoting energy conservation. Bed rest is common during the edema stage of the condition;
balance the activity with rest periods and encourage the child to rest when fatigued; plan quiet,
age-appropriate activities that interest the child.
 Preventing infection. Protect the child from anyone with an infection: staff, family, visitors, and
other children; handwashing and strict medical asepsis are essential; and observe for any early
signs of infection.