Nephrotic Syndrome: A case report
Karthika1, Mahalakshmi2*
1Staff Nurse, Kauvery Hospital, Tennur
2Nursing Superintendent, Kauvery Hospital, Tennur
*Correspondence: M: +919361388804: Email: maha@kauveryhospital.com
Abstract
Nephrotic syndrome is a clinical syndrome defined by massive proteinuria (greater than 40 mg/m per hour), responsible for hypoalbuminemia less than 30g/l, with resulting hyperlipidemia, edema & various complications. It is caused by increased permeability through the damaged basement membrane in the renal glomerulus, especially infectious, immune- mediated or thrombo-embolic. This syndrome is apparent in any condition that seriously damage the glomerular capillary membrane and results in increased glomerular permeability to plasma proteins. Although the liver is capable of increasing the production of albumin, it cannot keep up with the daily loss of albumin through the kidneys. Thus, hypoalbuminemia results. This article explains the causes, symptoms, treatment and management of nephrotic syndrome.
Case presentation
A 24 years young girl came with the complaints of leg pain and swelling, body weakness. She had a known complaints of nephrotic syndrome for past 1 ½ months. She had no any other comorbidities. She had no complaints of fever, frequent micturition, hematuria and abdominal pain.
On Examination
Patient was conscious and oriented, afebrile, bilateral pedal edema (+). PR – 100/min, BP – 100/60 mm/hg, SPO2 – 99% in room air, RR – 22 berth/min, CVS – S1S2 (+), RS Bilateral AE (+), P/A soft and tenderness (+).
She was treated with antibiotics, anti-platelets and albumin for some days. Later she had a complaints of fever 102°f. To rule out the cause of fever we send some investigation such as blood culture and urine culture. In-between she had complaints of epistaxis and that is treated with inj. Tranexamic acid. The urine culture report showed that was sterile and blood culture had a growth of MDR Acinetobacter. Meanwhile patient had complaints of rashes and the dermatologist opinion was obtained and soframycin cream & liquid paraffin were advised. She had complaints of sleeping disturbance and worried about her health condition for that we obtained psychiatrist opinion and provided counseling session. On next day patient BP was 80/50 mm/hg and increased body temperature (101.2), tachycardia 116 b/ minutes, reverse Trendelenburg position was given and she was shifted to IMCU for nor ad infusion and further management.
Lab investigation
| Haemoglobin | 11.1 gm/dl |
| Total count | 13900 |
| Platelet | 3.65 lks |
| Urea | 77.7 |
| Creatinine | 4.94 |
| Sodium | 135 |
| Potassium | 5.1 |
| Albumin | 2 |
Management
We manage the patient with antibiotics, anti-platelet and provided a symptomatic treatment according to her condition and symptoms. She was treated with dytor infusion and albumin infusion continuously. Later she undergone dialysis. After completing dialysis her Creatinine value was 2.6. Our team provide a continuous care and psychological support to the patient and their family. Slowly She was improved and discharged after few days.
Health promotion
Prevention is better than cure. One can’t prevent NS but some factors that increase the risk of NS like DM, some non-steroidal anti-inflammatory drugs, infection like hepatitis, HIV. Proper care for diabetes and avoidance of over use of NSAID and regular health check to prevent NS help
Hemodynamic monitoring
Our nursing team aggressively managed this patient. We did 4th hourly re assessment done by using invasive technology that provide quantitative information about patient current vascular status, tissue perfusion.
We monitored the patient noninvasive BP, PR, Skin temperature and color, respiratory rate and rhythm capillary fill time.
Nursing management
- Edema: Observe for edema when performing physical examination of the patient with nephrotic syndrome.
- Weigh and measure: Weigh the patient 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
Edema management
- On Examination Patient had a pedal edema and facial puffiness.
- To provide foot end elevation with pillow supports to reduce swelling.
- To assess dorsalis pedis pulsation to re assure the vascular permeability.
- Daily monitor patient weight effetely at same time to rule out fluid retention.
- Abdominal girth monitoring was done.
- All the information was compared daily basis to provide effective nursing management.
Nutrition and Diet
- Maintaining a kidney health is a top priority for the individual with nephrotic syndrome. Diet may play a vital role in preventing and managing the condition effectively.
- We educated the patient to take a protein rich diet and advised to take 2 to 3 egg white per day.
- She had an anemic status so encouraged to take iron rich diet.
- Salt intake should be limited to 6 g per day to prevent edema and high blood pressure.
- Advised to stay hydrated within the fluid restriction.
- A balanced healthy diet is helpful to control the excessive accumulation of waste product and fluid in the blood, thus lessen the workload of kidneys.
- You can help reduce swelling by limiting amount of sodium in your diet.
- Reducing saturated fat and cholesterol in her diet. It can help manage hyperlipidemia. It’s a good idea to limit foods like full-fat dairy, red meat, processed meat, cheese, fried foods, baked goods and sweets.
Monitor the patient bleeding parameters
That reveals patient had increased blood pressure managed with anti-hypertensive drugs. Patient had an increased prothrombin time 3.13, it is managed with four units of fresh frozen plasma and five cryoprecipitate transfusion were done.
Educated the patient to restrict the activities that provoke bleeding and to monitor melena and gum bleeding.
Fluid management
- Strictly monitored the intake and output monitoring
- Hypovolemic symptoms
- Persistent tachycardia
- Hypotension
- Abdominal pain
- Capillary refill >2 sec
- Urine sodium <10 mmol / lit
- Previous day output and insensible water loss
- Urine output monitoring
Skin Care
- Checked the areas that are red, warm to touch, or bleeding. Informed her to avoid excessive bathing. Soap and water deplete the skin of the essential oils that hold in moisture.
- Advised to use a moisturizing lotion after bath or more frequently if skin tends to become dry easily. Avoid products that contain alcohol, because they can dry the skin.
- Avoid scratching skin or rubbing it vigorously with towels. If itching is a problem, see relief from itching.
- Avoid tight-fitting clothes and shoes. Wear natural-fiber clothes that allow moisture to evaporate from the skin. Avoid wearing wool and acrylic fabrics next to your skin.
Ambulation restriction
Patient had a pedal edema when ambulate the patient it is provoke the patient lower limb swelling.
Patient had a facial puffiness and fluid retention of body while ambulation or increased physical activity that increases the breathing difficulty and increased respiratory rate.
That education given to the patient and patient family members.
Nurse as a good counselor
Patient condition explained to her family members. Our nursing team gave emotional and psychological support give the patient and family members and provide the best communication and coordination with other team members. So the patient and family members were sustained the patient health improved and attained positive outcomes.
Psychological support
- Patient had a sleeping pattern disturbance psychiatrist opinion was obtained she reveals that she had a worrying about her health status (depression).
- Recreation therapies were explained like music hearing; communicate with family members, reading books. After that patient was psychologically improved
Conclusion
The nephrotic syndrome is a type of renal failure characterized by increased glomerular permeability and is manifested by massive proteinuria. Our patient had complaints of leg pain and swelling and diagnosed as nephrotic syndrome with the help of some investigations. Our team managed the patient with antibiotics, albumin infusion and dialysis. By providing continuous care, we recover the patient from the disease. we watched for the complications and prevent any worsening of the patient condition.
Ms. Karthika
Staff Nurse