GU
Acute Poststreptococcal Glomerulonephritis
1. Frequently in children at high risk for strep throat
2. May occur following a case of impetigo, scarlet fever, or others caused by S. pyogenes
3. Usually 1 – 2 weeks post step infection
4. Patho:
a. Inflammatory process from a toxin produced by strep bacteria. Affects the ability
of the glomerulus to filter blood.
b. Sodium & water are retained by body oliguria & edema
c. S/S:
i. Hematuria: urine turns dark brown (tea or coke color)
ii. Mild to moderate proteinuria
iii. Edema (especially on face subsides through day)
iv. Slight weight gain
v. HTN from sodium & water retention
vi. Elevated ASO (antibody antistreptolysin O) antibodies
5. Dx: history & picture
a. Hematuria w. mild to moderate proteinuria
b. Elevated ASO antibodies (infection as impetigo or other skin infections child may
not have produced ASO antibodies)
6. Tx:
a. Antibx
b. Palliative care (no cure)
i. Control HTN
1. Meds
2. No salt added diet
3. Fluid restriction
ii. Protect kidneys (no contact sports)
7. Nursing considerations:
a. Imbalanced fluid volume (interstitial excess and intravascular deficit)/ risk for
impaired gas exchange/risk for altered breathing pattern/risk for
injury/imbalanced nutrition: less than body requirements
i. I & O
1. Report output less than minimum
a. Infants & toddlers: 2 – 4 mL/kg/hr
b. Preschoolers & young school age: 1 – 2 mL/kg/hr
c. Older children: 0.5 – 1 mL/kg/hr
ii. Weight daily
iii. BP Q4H
iv. Auscultate lung & report adventitious sounds
1. Pulmonary edema can occur from fluid retention
v. Restrict fluids & salt intake (menu of low salt foods)
vi. AntiHTN meds
, b. Fatigue/activity intolerance:
i. Allow rest & sleep
ii. Give interesting, quiet activities (TV, video games, puzzles)
c. Risk for impaired skin integrity
i. Change positions frequently
ii. Lamb skin mattress
iii. Monitor dehydration (poor skin turgor & dry mucous membranes)
d. Anxiety/fear/risk for altered coping/deficient knowledge
i. Educate: fluid restriction, diet changes, BP management (antiHTN meds),
follow up (BP, urine, & serum assessments) at primary.
Nephrotic syndrome (nephrosis)
1. Patho:
a. Inflammatory disease
b. Glomerulus becomes enflamed & allows large molecules (protein albumin) to be
excreted into urine hyperproteinuria
c. As result; albumin is lost drop in circulating albumin (hypoproteinemia, low
level of protein circulating in blood)
i. Marked protein loss = marked drop in # of circulating antibodies
d. Hypoproteinemia = drop in colloidal pressure = fluid shifts in: anasarca
(generalized swelling), pulmonary edema, & hemoconcentration (increase in
concentration of cells & solids in blood caused by loss of IVF).
i. Hemoconcentration = high risk for thrombus formation in children
e. Kidney responds by increasing renin production = increases renin levels = renal
fluid retention = exacerbated edema
f. Increase in production of cholesterol & triglycerides = in hypercholesterolemia &
high concentrations of circulating triglycerides
2. Dx:
a. Clinical picture: edema develop insidiously, clothes become tight
b. S/S:
i. Massive hyperproteinuria: 3+ to 4+
ii. Thick, frothy urine bc of high concentration of protein
iii. Mild hematuria
iv. Elevated cholesterol, triglycerides, & hematocrit levels
v. No evidence of previous strep infection & normal BP
3. Tx:
a. High dose steroids (prenisone) to control inflammation
i. Continued few weeks after proteinuria subsides
b. Antineoplastic meds (cyclophosphamide) if child responds poorly to steroids
c. IV albumin to restore fluid balances
i. Lasix w. albumin to decrease risk of fluid volume overload
d. Salt & fluid restriction
e. Prophylactic antibx to protect from infection bc of loss of circulating antibodies
, f.Monitor for adverse effects resulting from hypercholesterolemia &
hemoconcentration (e.g. thrombi)
4. Nursing considerations:
a. Imbalanced fluid volume: interstitial excess & intravascular deficit
i. Weigh daily
ii. I & O
iii. Measure abdominal girth daily
iv. Auscultate lungs for adventitious sounds
v. Monitor: signs of dehydration, VS Q4H (esp. BP & pulse)
vi. IV fluids &/or meds (IV albumin, steroids, &/or diuretics)
vii. No added salt diet
b. Risk for infection:
i. Handwashing
ii. Screen visitors for infection
iii. Antibx
iv. Monitor signs of infection (temp elevation, elevated WBC count)
c. Risk for impaired skin integrity/activity intolerance
i. Change position Q2H
ii. Hygiene & skin care
iii. Age – appropriate activities that will not injure or excessively fatigue
iv. Place child on lamb skin blanket or alternating pressure mattress to
prevent decubiti
d. Anxiety/fear/risk for altered coping/deficient knowledge
i. Educate: fluid restriction, diet changes, skin care, activity restriction,
meds.
Wilms Tumor (nephrobastoma)
1. Patho:
a. Solid, cancerous tumor
b. One kidney (usually left) or both
c. Self – contained (encapsulated).
i. If ruptured will metastasize to lung
ii. Prognosis good if intact
d. Tumor staging:
i. Stage 1: 1 kidney, tumor removed intact
ii. Stage 2: 1 kidney, cancer spread locally, no lymph nodes affects, all cancer
removed
iii. Stage 3: 1 kidney, cancer spread to abdomen; unable to remove all cancer
iv. Stage 3: 1 kidney, cancer spread through body
v. Stage 4: both kidneys
e. S/S:
i. Abdominal mass on palpation & xray, MRI, or CT
1. Tumor should never be palpated again
, 2. To reduce the potential for injuring capsule, sign should be placed
at bedside to remind never to palpate abdomen
ii. Hematuria (mild)
iii. HTN
iv. Definitive dx: biopsy
2. Tx:
a. Surgery: remove kidney
b. Chemotherapy &/or radiation dependent on staging
c. Dialysis if both kidneys are affects & removed
i. Both kidneys = candidate for renal transplant
3. Nursing considerations:
a. Preop:
i. Risk for injury
1. Discourage activities
2. Sign: “ Do Not Palpate Abdomen”
ii. Anxiety/deficient knowledge:
1. Refrain from palpating abdomen
b. Postop:
i. Pain management, REEDA assessment, VS, monitor GI functioning, &
bleeding potential
ii. Risk for infection/impaired skin integrity
1. Handwashing
2. Aseptic technique
3. Monitor signs of infection at site & urinary & pulmonary infections
iii. Risk for imbalanced fluid volume
1. I & O
2. Weight daily
a. Increase in weight = fluid retention
Questions:
1. A 4-year-old girl with a urinary tract infection is scheduled to have a voiding
cystourethrogram. When preparing her for this procedure, the nurse would want to prepare her
to:
A) have a local anesthetic injected prior to the procedure.
B) drink three glasses of water during the procedure.
C) void during the procedure.
D) anticipate a headache afterward.
Ans: C
Feedback: A voiding cystourethrogram requires the child to void during the procedure so that
bladder emptying and urethra flow can be assessed.
Acute Poststreptococcal Glomerulonephritis
1. Frequently in children at high risk for strep throat
2. May occur following a case of impetigo, scarlet fever, or others caused by S. pyogenes
3. Usually 1 – 2 weeks post step infection
4. Patho:
a. Inflammatory process from a toxin produced by strep bacteria. Affects the ability
of the glomerulus to filter blood.
b. Sodium & water are retained by body oliguria & edema
c. S/S:
i. Hematuria: urine turns dark brown (tea or coke color)
ii. Mild to moderate proteinuria
iii. Edema (especially on face subsides through day)
iv. Slight weight gain
v. HTN from sodium & water retention
vi. Elevated ASO (antibody antistreptolysin O) antibodies
5. Dx: history & picture
a. Hematuria w. mild to moderate proteinuria
b. Elevated ASO antibodies (infection as impetigo or other skin infections child may
not have produced ASO antibodies)
6. Tx:
a. Antibx
b. Palliative care (no cure)
i. Control HTN
1. Meds
2. No salt added diet
3. Fluid restriction
ii. Protect kidneys (no contact sports)
7. Nursing considerations:
a. Imbalanced fluid volume (interstitial excess and intravascular deficit)/ risk for
impaired gas exchange/risk for altered breathing pattern/risk for
injury/imbalanced nutrition: less than body requirements
i. I & O
1. Report output less than minimum
a. Infants & toddlers: 2 – 4 mL/kg/hr
b. Preschoolers & young school age: 1 – 2 mL/kg/hr
c. Older children: 0.5 – 1 mL/kg/hr
ii. Weight daily
iii. BP Q4H
iv. Auscultate lung & report adventitious sounds
1. Pulmonary edema can occur from fluid retention
v. Restrict fluids & salt intake (menu of low salt foods)
vi. AntiHTN meds
, b. Fatigue/activity intolerance:
i. Allow rest & sleep
ii. Give interesting, quiet activities (TV, video games, puzzles)
c. Risk for impaired skin integrity
i. Change positions frequently
ii. Lamb skin mattress
iii. Monitor dehydration (poor skin turgor & dry mucous membranes)
d. Anxiety/fear/risk for altered coping/deficient knowledge
i. Educate: fluid restriction, diet changes, BP management (antiHTN meds),
follow up (BP, urine, & serum assessments) at primary.
Nephrotic syndrome (nephrosis)
1. Patho:
a. Inflammatory disease
b. Glomerulus becomes enflamed & allows large molecules (protein albumin) to be
excreted into urine hyperproteinuria
c. As result; albumin is lost drop in circulating albumin (hypoproteinemia, low
level of protein circulating in blood)
i. Marked protein loss = marked drop in # of circulating antibodies
d. Hypoproteinemia = drop in colloidal pressure = fluid shifts in: anasarca
(generalized swelling), pulmonary edema, & hemoconcentration (increase in
concentration of cells & solids in blood caused by loss of IVF).
i. Hemoconcentration = high risk for thrombus formation in children
e. Kidney responds by increasing renin production = increases renin levels = renal
fluid retention = exacerbated edema
f. Increase in production of cholesterol & triglycerides = in hypercholesterolemia &
high concentrations of circulating triglycerides
2. Dx:
a. Clinical picture: edema develop insidiously, clothes become tight
b. S/S:
i. Massive hyperproteinuria: 3+ to 4+
ii. Thick, frothy urine bc of high concentration of protein
iii. Mild hematuria
iv. Elevated cholesterol, triglycerides, & hematocrit levels
v. No evidence of previous strep infection & normal BP
3. Tx:
a. High dose steroids (prenisone) to control inflammation
i. Continued few weeks after proteinuria subsides
b. Antineoplastic meds (cyclophosphamide) if child responds poorly to steroids
c. IV albumin to restore fluid balances
i. Lasix w. albumin to decrease risk of fluid volume overload
d. Salt & fluid restriction
e. Prophylactic antibx to protect from infection bc of loss of circulating antibodies
, f.Monitor for adverse effects resulting from hypercholesterolemia &
hemoconcentration (e.g. thrombi)
4. Nursing considerations:
a. Imbalanced fluid volume: interstitial excess & intravascular deficit
i. Weigh daily
ii. I & O
iii. Measure abdominal girth daily
iv. Auscultate lungs for adventitious sounds
v. Monitor: signs of dehydration, VS Q4H (esp. BP & pulse)
vi. IV fluids &/or meds (IV albumin, steroids, &/or diuretics)
vii. No added salt diet
b. Risk for infection:
i. Handwashing
ii. Screen visitors for infection
iii. Antibx
iv. Monitor signs of infection (temp elevation, elevated WBC count)
c. Risk for impaired skin integrity/activity intolerance
i. Change position Q2H
ii. Hygiene & skin care
iii. Age – appropriate activities that will not injure or excessively fatigue
iv. Place child on lamb skin blanket or alternating pressure mattress to
prevent decubiti
d. Anxiety/fear/risk for altered coping/deficient knowledge
i. Educate: fluid restriction, diet changes, skin care, activity restriction,
meds.
Wilms Tumor (nephrobastoma)
1. Patho:
a. Solid, cancerous tumor
b. One kidney (usually left) or both
c. Self – contained (encapsulated).
i. If ruptured will metastasize to lung
ii. Prognosis good if intact
d. Tumor staging:
i. Stage 1: 1 kidney, tumor removed intact
ii. Stage 2: 1 kidney, cancer spread locally, no lymph nodes affects, all cancer
removed
iii. Stage 3: 1 kidney, cancer spread to abdomen; unable to remove all cancer
iv. Stage 3: 1 kidney, cancer spread through body
v. Stage 4: both kidneys
e. S/S:
i. Abdominal mass on palpation & xray, MRI, or CT
1. Tumor should never be palpated again
, 2. To reduce the potential for injuring capsule, sign should be placed
at bedside to remind never to palpate abdomen
ii. Hematuria (mild)
iii. HTN
iv. Definitive dx: biopsy
2. Tx:
a. Surgery: remove kidney
b. Chemotherapy &/or radiation dependent on staging
c. Dialysis if both kidneys are affects & removed
i. Both kidneys = candidate for renal transplant
3. Nursing considerations:
a. Preop:
i. Risk for injury
1. Discourage activities
2. Sign: “ Do Not Palpate Abdomen”
ii. Anxiety/deficient knowledge:
1. Refrain from palpating abdomen
b. Postop:
i. Pain management, REEDA assessment, VS, monitor GI functioning, &
bleeding potential
ii. Risk for infection/impaired skin integrity
1. Handwashing
2. Aseptic technique
3. Monitor signs of infection at site & urinary & pulmonary infections
iii. Risk for imbalanced fluid volume
1. I & O
2. Weight daily
a. Increase in weight = fluid retention
Questions:
1. A 4-year-old girl with a urinary tract infection is scheduled to have a voiding
cystourethrogram. When preparing her for this procedure, the nurse would want to prepare her
to:
A) have a local anesthetic injected prior to the procedure.
B) drink three glasses of water during the procedure.
C) void during the procedure.
D) anticipate a headache afterward.
Ans: C
Feedback: A voiding cystourethrogram requires the child to void during the procedure so that
bladder emptying and urethra flow can be assessed.
