“… what matters most for our internal chemical equilibrium is, not what we eat and drink, but what are kidneys retain. They are truly the master chemist of our sea within.”

- William B. Smively Jr. M.D.

NEPHROTICNEPHROTIC SYNDROME SYNDROME

I. Background of the I. Background of the studystudy

Nephrotic Syndrome is…Nephrotic Syndrome is…

^ ^ abnormal leak of proteinsabnormal leak of proteins(proteinuria= 3.5g/day)(proteinuria= 3.5g/day)

leading to decreased serum albumin leading to decreased serum albumin (hypoalbuminemia) and osmotic pressure(hypoalbuminemia) and osmotic pressure^̂ low level of protein in the blood low level of protein in the blood (leakage in protein)(leakage in protein)^ ^ swelling of body parts swelling of body parts

*puffiness in the eye*puffiness in the eye*ascites*ascites*pleural effusion*pleural effusion

^ ^ increased levels of lipidincreased levels of lipid

Nephrotic Syndrome may be Nephrotic Syndrome may be caused by an underlying cause caused by an underlying cause such as Rash associated with such as Rash associated with

SLE or neuropathy with SLE or neuropathy with diabetesdiabetes

What does diabetes do to the What does diabetes do to the Kidneys in patient with Nephrotic Kidneys in patient with Nephrotic Syndrome?Syndrome?

*the kidneys cannot clean up your *the kidneys cannot clean up your blood properly…blood properly…* your body will retain more water * your body will retain more water and salt than it should…and salt than it should…*can cause difficulty in emptying the *can cause difficulty in emptying the bladder…bladder…*you can develop an infection from *you can develop an infection from rapid growth of infections…rapid growth of infections…

General Objectives:General Objectives:At the end of the study or At the end of the study or

learning, the level 3 nursing learning, the level 3 nursing students will be able to rectify, students will be able to rectify, expound, and relate all ideas or expound, and relate all ideas or

perception to the nursing approach perception to the nursing approach in doing valid and outmost care in doing valid and outmost care with the patient experiencing an with the patient experiencing an outset of Nephrotic syndrome.outset of Nephrotic syndrome.

II. ObjectivesII. Objectives

Specific Objectives: Specific Objectives:

the level 3 student nurses will be the level 3 student nurses will be capable of:capable of:

1. Propose the over all 1. Propose the over all assessment findings with the assessment findings with the

patient experiencing a Nephrotic patient experiencing a Nephrotic syndrome. syndrome.

2. Expound thoroughly and 2. Expound thoroughly and articulately the anatomy and articulately the anatomy and physiology of the systems physiology of the systems involved in Nephrotic syndrome.involved in Nephrotic syndrome.

3. An intricate illustration and 3. An intricate illustration and explanation of the explanation of the pathophysiology of the pathophysiology of the Nephrotic syndrome with Nephrotic syndrome with regards to the patient.regards to the patient.

4. Devise a well planned, with the 4. Devise a well planned, with the principle of SMART a principle of SMART a

comprehensive nursing care plan comprehensive nursing care plan that is applicable to the patient that is applicable to the patient

with Nephrotic syndrome.with Nephrotic syndrome.

5. Inculcate health teachings for 5. Inculcate health teachings for the patient to follow and be in the patient to follow and be in great help for his condition.great help for his condition.

6. Elucidate and discuss the rationale of the different nursing interventions to the patient and to the family as well.

7. Evaluate the effectiveness and accuracy of the outcome of the nursing interventions. 8. Provided the needed information or knowledge to attain a healthy living.

III. Personal DataIII. Personal DataName: I.B.P.Name: I.B.P.Gender: MaleGender: MaleAge: 67 years oldAge: 67 years oldAddress: P5 B33 L5 Palkparan D.C.Address: P5 B33 L5 Palkparan D.C.Birthdate: July 28, 1940Birthdate: July 28, 1940Birthplace: Misamis, OrientalBirthplace: Misamis, OrientalReligion: Roman CatholicReligion: Roman Catholic

Height: 5’5’’Height: 5’5’’Civil Status: MarriedCivil Status: MarriedNationality: FilipinoNationality: FilipinoAttending Physician: Dr. MAttending Physician: Dr. MDate and time of admission: Date and time of admission: February 2, 2008; 2:57pmFebruary 2, 2008; 2:57pmChief complaint: Edema; unable to Chief complaint: Edema; unable to walkwalk

Admitting Diagnosis: Nephrotic Admitting Diagnosis: Nephrotic SyndromeSyndrome

IV. Nursing AssessmentIV. Nursing AssessmentHistory of Present IllnessHistory of Present Illness

The patient was known to have The patient was known to have type I Diabetes Mellitus and type I Diabetes Mellitus and hypertension for about 3 years. At hypertension for about 3 years. At August 2006, he was admitted at August 2006, he was admitted at Philippine General Hospital wherein his Philippine General Hospital wherein his previous diagnosis of DM Type I was previous diagnosis of DM Type I was confirmed. Catapres & Norvasc were confirmed. Catapres & Norvasc were his maintenance medication for his maintenance medication for hypertension.hypertension.

After 1 year,After 1 year,

at December 2007, he was admitted at December 2007, he was admitted at JPR Hospital in Cavite at the third at JPR Hospital in Cavite at the third floor complaining of progressive floor complaining of progressive edema on both his lower extremities; edema on both his lower extremities; inability to walk; blurring of vision inability to walk; blurring of vision and hypertensionand hypertension

After a series of laboratory tests, After a series of laboratory tests,

he was diagnosed with nephrotic he was diagnosed with nephrotic syndrome.syndrome.

A.1. Family HistoryA.1. Family History-Noted to have history of -Noted to have history of

hypertensionhypertension-Noted to have history of DM -Noted to have history of DM

from the mother’s sidefrom the mother’s side

A.2. Vital Signs (February 8, 2008, A.2. Vital Signs (February 8, 2008, 12:00pm)12:00pm)

BP: 160/ 90 mmHgBP: 160/ 90 mmHgPR: 78 beats per minutePR: 78 beats per minute

RR: 22 cycles per minuteRR: 22 cycles per minuteTemp: 37.1°CTemp: 37.1°C

•

Henderson (1996) conceptualized the Henderson (1996) conceptualized the nurses’ role as assisting sick or healthy nurses’ role as assisting sick or healthy

individuals to gain independence in meeting individuals to gain independence in meeting the 14 fundamental needs:the 14 fundamental needs:

Breathing normallyBreathing normallyEating and drinking adequatelyEating and drinking adequately

Eliminating body wastesEliminating body wastesMoving and maintaining desirable positionMoving and maintaining desirable position

A.3. Nursing TheoryA.3. Nursing TheoryHenderson’sHenderson’s

Definition of Nursing.Definition of Nursing.

Sleeping and restingSleeping and resting

Selecting suitable clothesSelecting suitable clothes

Maintaining body temperature within Maintaining body temperature within normal range by adjusting clothing normal range by adjusting clothing

and modifying the environmentand modifying the environment

Keeping the body clean and well Keeping the body clean and well groomed to protect the integumentgroomed to protect the integument

Avoiding strangers in the Avoiding strangers in the environment and avoiding injury to environment and avoiding injury to

othersothers

Communicating with others; Communicating with others; expressing emotions, needs, fears expressing emotions, needs, fears

or opinionsor opinions

Worshipping according to one’s faithWorshipping according to one’s faith

Working in such a way that one feels Working in such a way that one feels a sense of accomplishmenta sense of accomplishment

Playing or participating in various Playing or participating in various forms of recreationforms of recreation

Learning, discovering or satisfying the Learning, discovering or satisfying the curiosity that leads to normal curiosity that leads to normal

development and health, and using development and health, and using available health facilities.available health facilities.

Her emphasis on the importance of Her emphasis on the importance of nursing independence from, and nursing independence from, and

interdependence with, other health interdependence with, other health care disciplines are well recognized. care disciplines are well recognized.

A.4. Maslow’s Hierarchy of A.4. Maslow’s Hierarchy of NeedsNeeds

• Physiologic NeedsPhysiologic Needs

• Safety Needs Safety Needs • Love & BelongingnessLove & Belongingness

• Self-Esteem Needs Self-Esteem Needs • Self Actualization Self Actualization

A.5.Physical Assessment

AssessmentAssessment ResultResult AnalysisAnalysis

General Health General Health and and AppearanceAppearance

2/4 functional level (requires 2/4 functional level (requires help from another person for help from another person for assistance and supervision) & assistance and supervision) & ROM___, weakness on lower ROM___, weakness on lower extremities, ambulatory with extremities, ambulatory with assistance, oriented, no foul assistance, oriented, no foul odor, with mood swings odor, with mood swings presentpresent

There is poor There is poor circulation of blood in circulation of blood in the lower extremities the lower extremities that causes that causes weakness.  weakness. 

SkinSkin Dry, black pigmentation is Dry, black pigmentation is present on the lower present on the lower extremities, with pitting extremities, with pitting edema in both legs with edema in both legs with edema grade of +2, no edema grade of +2, no readily detectable distortion, readily detectable distortion, disappears in 10-15secsdisappears in 10-15secs

It indicates fluid It indicates fluid retention. There is retention. There is shifting of fluid from shifting of fluid from intravascular to intravascular to interstitial interstitial compartment thus, compartment thus, causing decreased causing decreased elasticity of skin.elasticity of skin.

HeadHead Rounded, absence of nodules Rounded, absence of nodules and masses upon palpations, and masses upon palpations, symmetrical facial features, symmetrical facial features, and scalp is dry; color of the and scalp is dry; color of the hair is in combination of hair is in combination of white and gray. white and gray.

____________________________

EyesEyes Change in visual field, blurred Change in visual field, blurred vision, with pink palpable vision, with pink palpable conjunctiva, cornea is without conjunctiva, cornea is without lesions, conjunctiva is clear, lesions, conjunctiva is clear, Pupils are equal, measuring Pupils are equal, measuring 2-3 mm in diameter, round 2-3 mm in diameter, round and reactive to light and and reactive to light and accommodation. accommodation.

Blurred vision Blurred vision develops as the lens develops as the lens and retina are and retina are exposed to exposed to hyperosmolar fluids. hyperosmolar fluids. It can be an indicator It can be an indicator of hyperglycemia. of hyperglycemia.

EarsEars Ears are normal in Ears are normal in appearance; normal hearing appearance; normal hearing status, auditory canal status, auditory canal appears with moderate appears with moderate amount of cerumen and amount of cerumen and without any lesions. without any lesions. Tympanic membranes are Tympanic membranes are intact. Hearing is adequate.intact. Hearing is adequate.

____________________________

NoseNose No deviation, nasal mucosa No deviation, nasal mucosa appears pink and without appears pink and without abnormal discharge, no nasal abnormal discharge, no nasal polyps or other lesions are polyps or other lesions are noted, frontal and maxillary noted, frontal and maxillary are not tender.are not tender.

____________________________

Mouth and Mouth and ThroatThroat

Lips are moist with no Lips are moist with no cyanosis or pallor; Appears to cyanosis or pallor; Appears to have an incomplete set of have an incomplete set of teeth; buccal mucosa is moist teeth; buccal mucosa is moist in appearance. Tongue shows in appearance. Tongue shows no lesions, ability to protrude, no lesions, ability to protrude, move from side to side; move from side to side; pharyngeal mucosa is pink, pharyngeal mucosa is pink, without lesions and signs of without lesions and signs of inflammationinflammation

____________________________

NeckNeck Neck is supple, no limited Neck is supple, no limited range of motion. No evidence range of motion. No evidence of tracheal deviation. Thyroid of tracheal deviation. Thyroid gland is in normal size. gland is in normal size. Palpations reveal no nodules Palpations reveal no nodules and massesand masses

RespiratoryRespiratory No chest pain, no dyspnea No chest pain, no dyspnea and cough noted. Normal and cough noted. Normal breath sounds are breath sounds are auscultated in both lung auscultated in both lung fields.fields.

____________________________

Cardiovascular Cardiovascular systemsystem

No chest pain, palpitations No chest pain, palpitations and tightness. Normal and tightness. Normal capillary refill: less than 3 capillary refill: less than 3 secs. Peripheral edema is secs. Peripheral edema is present in arms, legs and present in arms, legs and feet. Pitting edema scale is feet. Pitting edema scale is +2.+2.

____________________________

GastrointestinaGastrointestinall

No lesions or marked ridges No lesions or marked ridges in the abdomen. Symmetric in the abdomen. Symmetric movement of abdomen movement of abdomen during respiration. Abdominal during respiration. Abdominal girth is 55cms. Abdomen is girth is 55cms. Abdomen is distended. Pain in the right distended. Pain in the right hypochondriac area. Pain hypochondriac area. Pain scale is 4/10. irregular scale is 4/10. irregular elimination pattern notedelimination pattern noted

____________________________

Genitourinary Genitourinary Urine: amber, aromatic smell; Urine: amber, aromatic smell; frequency is irregular. The frequency is irregular. The patient is with condom patient is with condom cathetercatheter

____________________________

MusculoskeletaMusculoskeletall

Lacking muscle tone, Poor Lacking muscle tone, Poor muscle strength on lower muscle strength on lower extremities. Limitation of extremities. Limitation of movement is present. Pain movement is present. Pain upon movement is present upon movement is present especially in the spine. especially in the spine. Positive for edema on both Positive for edema on both extremities. Edema grade is extremities. Edema grade is +2 (Depression 5-8mm). No +2 (Depression 5-8mm). No deformities or swelling on the deformities or swelling on the joints and bonesjoints and bones

____________________________

NeurologicNeurologic Can smile, frown, clench Can smile, frown, clench teeth, turn head from side to teeth, turn head from side to side against resistance; and side against resistance; and tongue midline on protrusiontongue midline on protrusion

____________________________

V. Anatomy and Physiology, PathophysiologyV. Anatomy and Physiology, Pathophysiology

Urinary Urinary TractTract

Kidney

UretersUreters

UrethraUrethra

Bladder

PathophysiologyPathophysiology

Damaged glomerular capillary membrane

Increased permeability to protein and loss of negative (-) charge

Increased loss of plasma proteins particularly albumin in urine

(Proteinuria)

Decreased albumin in the blood(Hypoalbuminemia)

NEPHROTIC SYNDROME

Edema Pitting edemaHandsFeet (pedal edema)Puffiness around the eyesAbdomen (ascites)Pleural effusion

HypovolemiaHypokalemia

Infection

HyperlipidemiaHypertension

Anemia

Lifestyle Overweight SmokingAgeRaceFamily HistoryGender

Diabetes Mellitus

Precipitating Factor Predisposing Factors

Decrease intravascular oncotic pressure

Leakage of extracellular fluid from blood to interstitial

Intravascular volume fails

Stimulating activation of renin-angiotensin-aldosterone axis and

sympathetic nervous system,release of vasopressin

Hypovolemia

Promote renal salt and water retention and restore intravascular volume

Edema

Edema

Increased potassium excretion

Hypokalemia

Brief explanation on how the sign and symptoms occur…

Decreased albumin in the blood(Hypoalbuminemia)

Loss of transferrin (transferrin is a glycoprotein found in blood plasma

that act as carrier for iron in blood stream)

Anemia

Medical ManagementMedical Management

7.2 Laboratory Results7.2 Laboratory ResultsTable 1. Taken on (02-02-08)Table 1. Taken on (02-02-08)

CHEMISTRYCHEMISTRY RESULTSRESULTS NORMAL VALUESNORMAL VALUES INTERPRETATIONINTERPRETATION

AlbuminAlbumin 19g/L19g/L 35-50g/L35-50g/L HypoalbumineHypoalbuminemia; mia;

excretion of protein in the urine

due to kidney

damage

BUNBUN 5.6 mmol/L5.6 mmol/L 3.2-7.1 mmol/L3.2-7.1 mmol/L NormalNormal

CreatinineCreatinine 103 mmol/L103 mmol/L 71-133 mmol/L71-133 mmol/L NormalNormal

SodiumSodium 128 mmol/L128 mmol/L 137-145 mmol/L137-145 mmol/L NormalNormal

PotassiumPotassium 2.9 mmol/L2.9 mmol/L 3.6-5.0 mmol/L3.6-5.0 mmol/L NormalNormal

Table 2. Taken on (02-02-08)

CHEMISTRYCHEMISTRY RESULTSRESULTS NORMAL NORMAL VALUESVALUES

INTERPRETATINTERPRETATIONION

HemoglobinHemoglobin 9.8 gms%9.8 gms% 12-17 gms%12-17 gms% Decreased; Decreased; due to loss of protein, there is also loss of transferrin that causes decreased hemoglobin level

Erythrocytes, Erythrocytes, Volume Volume

Fraction (Hct)Fraction (Hct)

27.0 vol%27.0 vol% 40-45 vol%40-45 vol% Decreased;Decreased; contain pigment

hemoglobin, when there is a decrease in hemoglobin, there is also decrease in erythrocyte

Leukocytes, Leukocytes, number on number on

concentrationconcentration

3,700/mm33,700/mm3 5,000-5,000-10,000/mm310,000/mm3

Indicates decrease immunity

Table 3.Taken on (02-04-08)Table 3.Taken on (02-04-08)URINE

Physical

ColorColor Yellow Yellow NormalNormal

TransparencyTransparency Clear Clear NormalNormal

PHPH 5.0 5.0 NormalNormal

Specific GravitySpecific Gravity 1.021 1.021 NormalNormal

Yeast cellsYeast cells ManyMany Represents Represents an infection an infection

Pus CellsPus Cells 3-5/hpf 3-5/hpf NormalNormal

RBCRBC 0-2/hpf 0-2/hpf NormalNormal

Epithelial cellsEpithelial cells Few Few NormalNormal

Chemical

AlbuminAlbumin ++++ ++++ Proteinuria (7gm/24 hours or greater); changes to capillary endothelial cells, the glomerular basement membrane or podocytes which normally filter serum protein

SugarSugar ++ Glycosuria; Diabetes Mellitus

Repeat TestTable 4. Taken on (02-03-08)

CHEMISTRYCHEMISTRY RESULTSRESULTS NORMAL VALUESNORMAL VALUES INTERPRETATIONINTERPRETATION

PotassiumPotassium 3.0 mmol/L3.0 mmol/L 3.6-5.0 mmol/L3.6-5.0 mmol/L Hypokalemia; abnormally high aldosterone levels can cause excessive urinary losses of potassium

DRUG STUDYDRUG STUDY

Drug NameDrug Name: : FelodipineFelodipine

Dosage: 5 mg OD5 mg OD

Specific Action: Specific Action: Anti-hypertensive, Calcium Anti-hypertensive, Calcium Channel BlockerChannel Blocker

Contraindications: In patients with allergy Contraindications: In patients with allergy to felodipine and other calcium channel to felodipine and other calcium channel blocker (heart block)blocker (heart block)

Drug Name: CiprofloxacinDrug Name: Ciprofloxacin

Dosage: 250 mg ODDosage: 250 mg OD

Specific Action: AntibacterialSpecific Action: Antibacterial

Containdications:In patients with Containdications:In patients with allergy to drugallergy to drug

Drug Name: Drug Name: ROWATINEXROWATINEX

Dosage: Dosage: 50 mg50 mg BIDBID

Action: Inhibits prostaglandin synthesis and Action: Inhibits prostaglandin synthesis and peripherally mediated analgesiaperipherally mediated analgesia

Contraindications: Hypersensitivity to drugContraindications: Hypersensitivity to drug

Brand Name: Brand Name: FUROSEMIDEFUROSEMIDE

Dosage: Adult 20-80mg single dose daily preferably in the morning

Action: Inhibits sodium and chloride absorption at the proximal tubules and ascending loop of Henle leading to excretions of water together with sodium chloride and potassium diuretics, anti hypertensive

Contraindications: Anuria, Hypersensitivity to sulfonylureas

Brand Name: Brand Name: OMEPRAZOLEOMEPRAZOLE

Dosage: Adult 10-20mg/day for 2-4 weeksDosage: Adult 10-20mg/day for 2-4 weeks

Action: Suppresses gastric secretion by Action: Suppresses gastric secretion by inhibiting hydrogen/ potassium ATAnd now the inhibiting hydrogen/ potassium ATAnd now the pase enzyme system in the gastric cell: pase enzyme system in the gastric cell: Characterized as a gastric acid pump inhibitor, Characterized as a gastric acid pump inhibitor, since it blocks the final step of acid productionsince it blocks the final step of acid production

Contraindications: Not given to patients with Contraindications: Not given to patients with hepatic impairment, hypersensitivity, hepatic impairment, hypersensitivity, combination therapy with clarithromycin combination therapy with clarithromycin should not be used in the patient’s with should not be used in the patient’s with hepatic impairmenthepatic impairment

VIII. Problem List (based on Maslow’s Hierarchy of Needs)Decreased cardiac output related to increased blood pressure

Risk for Impaired skin integrity related to decreased skin elasticity secondary to shifting of fluid from intravascular to interstitial

Impaired physical mobility related to pedal edema on both lower extremities secondary to nephrotic syndrome

Irregular Bowel Movement related to decrease peristaltic movement secondary to decreased body mobility

hopelessness related to situation development

NCP

X. Health TeachingX. Health Teaching

General Objectives: To promote a General Objectives: To promote a good quality of life and wellness to good quality of life and wellness to the patient.the patient.

Specific Objectives of treatment Specific Objectives of treatment includes:includes:

Control of InfectionControl of Infection

Control of Edema and promotion Control of Edema and promotion of good nutritionof good nutrition

General Objectives(supportive)

Monitoring and maintaining euvolemia (the correct amount of fluid in the body)

-monitoring urine output, BP regularly - Fluid restrict to 1L - diuretics (IV furosemide) Monitoring kidney

function -maintain blood glucose

Specific treatment of underlying causean ACE inhibitor Fluid retention is managed by diuretics. Nothing: some cases of the nephrotic

syndrome will improve with time and require no special treatment. Others are known to respond very poorly to any known treatment.

Steroids tablets (eg. Prednisolone)Immunosuppression:

Dietary recommendations

Limit high protein animal foods to 1oz per meal ( preferably to lean cuts of meat, fish and poultry)

Limit high phosphorus foods such as cheese, tofu, and yogurt, including cokes and colas.

Limit high potassium vegetables and fruits such as avocado, okra, potatoes, pumpkin, sweet potatoes, tomatoes, tomato juice, bananas, honeydew, and oranges.

Avoid saturated fats and eat unsaturated fats in moderation.

Eat low-fat desserts only.Monitor fluid intake, which includes

all fluids and foods that are liquid at room temperature.

D.) Discharge advice (Health Teaching) Explain about the need of treatment and

advice to continue it at home Avoid cold and draughts Avoid contact with people suffering from

upper respiratory tract infection Advice to maintain the personal hygiene Emphasis on the high protein diet Explain the administration of the medicine

and its continuation To come for the frequent medical checkup. Weight control, exercise program

XI. ConclusionXI. Conclusion

General Objectives:Towards the end of the case study

or learning, the level 3 nursing students were able to rectify, expound, and relate all ideas or perception to the nursing approach by exhibiting a valid and outmost care with the patient that has been diagnosed with Nephrotic syndrome.

Specific Objectives:Specific Objectives:the level 3 student nurses will be the level 3 student nurses will be

able to accomplished:able to accomplished:

1. Proposed the over all assessment 1. Proposed the over all assessment findings with the patient experiencing a findings with the patient experiencing a

Nephrotic syndrome. Nephrotic syndrome. 2. Expounded thoroughly and 2. Expounded thoroughly and articulately the anatomy and articulately the anatomy and

physiology of the systems involved in physiology of the systems involved in Nephrotic syndrome.Nephrotic syndrome.

3. An intricate illustration and 3. An intricate illustration and explanation of the pathophysiology of explanation of the pathophysiology of the Nephrotic syndrome with regards the Nephrotic syndrome with regards

to the patient.to the patient.

4. Devised a well planned, with the 4. Devised a well planned, with the principle of SMART a comprehensive principle of SMART a comprehensive

nursing care plan that is applicable to the nursing care plan that is applicable to the patient with Nephrotic syndrome.patient with Nephrotic syndrome.

5. Inculcated health teachings for the 5. Inculcated health teachings for the patient to follow and be in great help for patient to follow and be in great help for

his condition.his condition.6. Elucidated and discuss the rationale of 6. Elucidated and discuss the rationale of the different nursing interventions to the the different nursing interventions to the

patient and to the family as well.patient and to the family as well.7. Evaluated the effectiveness and 7. Evaluated the effectiveness and

accuracy of the outcome of the nursing accuracy of the outcome of the nursing interventions.interventions.

8. Provided the needed information or 8. Provided the needed information or knowledge to attain a healthy living.knowledge to attain a healthy living.