3/11/2020

GLOMERULAR DISEASES IN CHILDREN

-NURSING CARE PLAN-
PEDIATRIC NURSING DEPARTMENT
FACULTY OF NURSING UNPAD

Dept. Keperawatan Anak FKep Unpad - 2020

GLOMERULAR DISEASE IN CHILDREN

Acute glomerulonephritis

Chronic glomerulonephritis

Nephrotic syndrome

Dept. Keperawatan Anak FKep Unpad - 2020

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ACUTE GLOMERULONEPHRITIS

Dept. Keperawatan Anak FKep Unpad - 2020

DEFINITION

• 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 (Belleza, 2018).
• The sudden onset of hematuria, proteinuria, and
red blood cell (RBC) casts in the urine.
• It may be a primary events or manifestation of a
systemic disorder (Hockenberry & Wilson, 2015).

Dept. Keperawatan Anak FKep Unpad - 2020

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ETIOLOGY

• Acute GN is a condition that appears to be an

allergic reaction to a specific infection, most often
group A β -hemolytic streptococcal infection.

• Other bacteria or viruses  uncommon

Dept. Keperawatan Anak FKep Unpad - 2020

INCIDENCE

• Highest in children between 2-6 yo

• More common in boys

Dept. Keperawatan Anak FKep

Unpad - 2020

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PATHOPHYSIOLOGY

(Ball, Bindler., and Cowen, 2012)

Dept. Keperawatan Anak FKep Unpad - 2020

CLINICAL MANIFESTASIONS

• Asymptomatic
• Flank or abdominal pain
• Irritability
• Malaise
• Fever
• Hematuria (microscopic  2/3 cases & gross hematuria  tea-
coloured urine)
• proteinuria, azotemia (accumulation of nitrogenous wastes in
blood)
• Hypertension (varying degrees)  acute HT may cause
encephalophaty (headache, nausea, vomitting. Irritability,
lethargy and seizures
• Mild periorbital edema
• Edema on feet and ankles
• Oliguria (may or may not be present)
(Ball, Bindler., and Cowen, 2012)
Dept. Keperawatan Anak FKep Unpad - 2020

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COMPLICATIONS

• Hypertensive encephalophaty
• Acute cardiac decopensation
• Acute renal failure

Dept. Keperawatan Anak FKep Unpad - 2020

DIAGNOSTIC EVALUATION

• Urinalysis  hematuria proteinuria, increased

specific gravity
• Blood examination azotemia
• Cultures of pharynx  streptococci
• Serologic test

Dept. Keperawatan Anak FKep Unpad - 2020

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CHRONIC
GLOMERULONEPHRITIS

Dept. Keperawatan Anak FKep Unpad - 2020

DEFINITION

• In CGN tissue damage and progression to fibrosis

are related to the immune response that brings
about inflammation, failure to activate glomerular
repaire, and excessive fibrogenic activity (Niaudet
in Hockenberry & Wilson, 2015)
• The disease is more common in adolescents than
younger children

Dept. Keperawatan Anak FKep Unpad - 2020

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ETIOLOGY

• Continued GNA, often without a history of infection

(group A Streptococcus beta hemolithicus).
• Poisoning.
• Diabetes mellitus
• Renal vein thrombosis.
• Chronic hypertension
• Collagen disease
• Another unknown cause is found at an advanced
stage.

Dept. Keperawatan Anak FKep Unpad - 2020

PATHOPHYSIOLOGY

Accumulation of
immune
Direct attack on complexes from
the kidney previously
damaged
glomeruli

Initiate
chronic
changes in
glomerular
structures
Hockenberry & Wilson, 2015).

Dept. Keperawatan Anak FKep

Unpad - 2020

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CLINICAL MANIFESTASIONS

• Early onset: proteinuria, microscopic hematuria

• Decreased renal function
• Nephrotic range proteinuria may be present
• Symptoms based on the cause
• Hypertension
• Edema
• Intermittent gross hematuria

Dept. Keperawatan Anak FKep Unpad - 2020

COMPLICATION

• Renal insufficiency may extend from 5-15 years or

rapid deterioration may progress to end-stage renal
disease (ESRD)

Dept. Keperawatan Anak FKep Unpad - 2020

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DIAGNOSTIC EVALUATION

• Urinalysis: henaturia, proteinuria

• Blood examination: elevated BUN, creatinine and
uric acid, electrolyte alterations (metabolic
acidosis, elevated pottasium, elevated phosphorus,
decreased calcium level)

Dept. Keperawatan Anak FKep Unpad - 2020

NEPHROTIC SYNDROME

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DEFINITION

• Massive proteinuria, hypoalbuminemia,

hyperlipidemia, and edema, but the disorder ia a
clinical manifestation of a large number of distinct
glomerular isorders in which increased glomerular
permeability to plasma protein results in massive
urinary protein loss (Gipson et al. in Hockenberry &
Wilson, 2015)
• A clinical state characterized by edema, massive
proteinuria, hypoalbuminemia, hypoproteinemia,
hyperlipidemia, and altered immunity (Ball, Bindler.,
and Cowen, 2012)

Dept. Keperawatan Anak FKep Unpad - 2020

TYPES OF NEPHROTIC SYNDROM &

ETIOLOGY

Minimal change nephrotic syndrome

Secondary nephrotic syndrome

Congenital nephrotic syndrome

Dept. Keperawatan Anak FKep

Unpad - 2020

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PATHOPHYSIOLOGY

(Ball, Bindler., and Cowen, 2012)

Dept. Keperawatan Anak FKep Unpad - 2020

CLINICAL MANIFESTASIONS
• Weight gain which progresses over a period of days or weeks
• Puffiness of the face, especially around the eyes (arising in the morning,
but subsides during the day)
• Swelling of the abdomen, genitalia and lower extremities (more
prominent)
• Anasarca (develop gradually or rapidly)
• Diarhea  poor intestinal absorption
• Loss appetite
• Decreased urine volume  appears darkly opalescent and frothy
• Extreme skin pallor
• Skin breakdown
• Irritable, fatigue, lethargic
• Changes in the nails appears as white (Muehrcke) lines parallel to the
lunula cause byy hypoalbuminemia
• Blood pressure usually normal or slightly decreased
• Child is more susceptible to onfection (cellulitis, pneumonia, peritonitis, or
sepsis)

Dept. Keperawatan Anak FKep Unpad - 2020

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Dept. Keperawatan Anak FKep

Unpad - 2020

DIAGNOSTIC EVALUATION

• Urinalysis  proteinuria, hematuria

• Blood examination  serum albumin, sodium, BUN,
cholesterol, electrolytes
• Renal ultrasound  detect structural kidney
problems

Hypoalbuminemia  serum albumin level < 2.5g/dL

Dept. Keperawatan Anak FKep Unpad - 2020

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TREATMENT
• Diet (Child may need to limit):
• Protein. Protein is vital for proper growth and nutrition. But the kidneys may
not be able to get rid of the waste products that come from eating too
much protein.
• Potassium. Potassium is an important nutrient. But when the kidneys don’t
work well, too much potassium can build up in the blood. Potassium comes
from certain foods. Child may need to limit or not eat foods with a lot of
potassium.
• Phosphorus. The kidneys help remove excess phosphorus from the body. If
the kidneys are not working well, too much phosphorus builds up in the
blood and can cause calcium to leave the bones. This can make child's
bones weak and easy to break.
• Sodium. A low-sodium diet can help prevent or reduce fluid retention in
child's body..
• Medicine
• Increase urination (diuretic)
• Reduce blood pressure
• Lower the amount of the mineral phosphorus in the blood (phosphate
binders)
• Lessen the body’s immune system response (immunosuppressive medicine)

Dept. Keperawatan Anak FKep

Unpad - 2020

NURSING CARE FOR CHILDREN

WITH GLOMERULAR ALTERATIONS

Dept. Keperawatan Anak FKep

Unpad - 2020

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NURSING ASSESSMENT

• Vital signs
• Fluid-electrolytes balance
• Signs of central nervous system problems
• Monior urine
• Assess edema
• Assess for pulmonary effusion

Dept. Keperawatan Anak FKep Unpad - 2020

NURSING DIAGNOSIS AND

INTERVENTION

• Excess fluid volume related to decreased

glomerular filtration
• Monitor vital signs
• Monitor fluid and electrolytes status
• Monitor intake output
• Monitor degree of ascites and edema
• Make sure parents and visitors understand the
need to limit fluids to prevent excessive intake

Dept. Keperawatan Anak FKep Unpad - 2020

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NURSING DIAGNOSIS AND

INTERVENTION

• Risk for infection related to renal impairment

and corticosteroid therapy
• Monitor signs of infection (fever, malaise,
elevated white blood cells)
• Instruct family to perform good hand hygiene
• Limit visitors
• Screen family members for the presence of
streptococcal infection and refer to the
treatment

Dept. Keperawatan Anak FKep Unpad - 2020

NURSING DIAGNOSIS AND

INTERVENTION

• Risk for impaired skin integrity related

to tissue edema
• Bed rest
• Turn the child frequently
• Make sure the child’s bed is free of crumbs
or sharp toys
• Keep sheets thight and free of wrinkles

Dept. Keperawatan Anak FKep Unpad - 2020

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NURSING DIAGNOSIS AND

INTERVENTION

• Imbalanced nutrition: Less than body

requirements related to loss appetite and
proteinuria
• Colaborate with dietitian  “no added salt” and
low protein diet
• Encourage parents to give favourite food
• Serve foods in age-appropriate quantities
• Allow child to eat with other children or with
family members

Dept. Keperawatan Anak FKep Unpad - 2020

NURSING DIAGNOSIS AND

INTERVENTION
• Effective therapeutic regimen management
related to child’s medication schedule and
treatment after discharge
• Teach parents about the child’s medication regimen,
potential side effects of medication, dietary restriction, and
signs and symptomps of complications
• Emphasize that it is important to avoid exposing the child to
people wit acute respiratory tract infection
• Advise parents to allow the child to gradually return to his or
her activities after discharge, with periods allowed for resr.

Dept. Keperawatan Anak FKep Unpad - 2020

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REFERENCES

• Ball, J., Bindler., and Cowen. (2012). Principles of

Pediatric Nursing: Caring for Children. Upper Saddle
River: Pearson Education, Inc
• Belleza, M. (2018). Acute Glomerulonephritis.
https://nurseslabs.com/acute-glomerulonephritis/
• Hockenberry, M. J., and Wilson, D. (2015). Wong’s
Nursing Care of Infants and Children, 10th ed.
Missouri: Elsevier Mosby
• Wenderfer, S. E., and Gaut, J. P. (2017). Glomerular
Diseases in Children. Adv Chronic Kidney Dis.
24(6):364-371. doi: 10.1053/j.ackd.2017.09.005.
Dept. Keperawatan Anak FKep
Unpad - 2020

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