Nursing Care Plan (NCP) for Nephrotic Syndrome

Understand the Pathophysiology of Nephrotic Syndrome:
- Identify the underlying renal and vascular changes associated with nephrotic syndrome.
- Recognize the impact of proteinuria on the body’s fluid balance and oncotic pressure.
Assessment and Diagnosis:
- Learn the clinical manifestations of nephrotic syndrome, including edema, proteinuria, hypoalbuminemia, and hyperlipidemia.
- Understand the diagnostic criteria and laboratory tests used to confirm and monitor nephrotic syndrome.
Pharmacological Interventions:
- Explore the pharmacological treatments commonly used in managing nephrotic syndrome, such as corticosteroids and immunosuppressive agents.
- Understand the rationale behind medication choices and potential side effects.
Fluid and Electrolyte Balance:
- Comprehend the importance of monitoring and maintaining fluid balance in patients with nephrotic syndrome.
- Learn strategies to address electrolyte imbalances, particularly related to hypoalbuminemia.
Patient Education and Lifestyle Modification:
- Develop effective patient education strategies regarding medication adherence, dietary modifications, and fluid restriction.
- Emphasize the importance of regular follow-up appointments and ongoing monitoring for disease management.

Pathophysiology of Nephrotic Syndrome

Altered Blood Lipid Levels:
- Nephrotic Syndrome disrupts the normal filtration function of the glomeruli, leading to increased permeability. This allows the loss of large molecules, including proteins, into the urine. The decrease in serum albumin triggers compensatory mechanisms in the liver, resulting in increased synthesis of lipoproteins and cholesterol. Elevated blood lipid levels are common in nephrotic patients, contributing to the development of atherosclerosis and increasing the risk of cardiovascular complications.
Edema Formation:
- The loss of proteins, particularly albumin, through the urine reduces the oncotic pressure in the blood vessels. This results in a shift of fluid from the intravascular space into the interstitial spaces, leading to generalized edema. Edema formation is a hallmark manifestation of nephrotic syndrome, affecting areas such as the face, abdomen, and extremities.
Hypercoagulability:
- The urinary loss of anticoagulant proteins, such as antithrombin III, along with alterations in blood flow dynamics due to edema, contributes to a hypercoagulable state in individuals with nephrotic syndrome. This increases the risk of thromboembolic events, including deep vein thrombosis (DVT) and pulmonary embolism, posing additional complications for these patients.
Glomerular Damage:
- The glomeruli of the kidneys are damaged, leading to increased permeability.
Proteinuria:
- Increased permeability allows proteins, particularly albumin, to leak into the urine.
Hypoalbuminemia:
- Loss of albumin in the urine results in decreased blood albumin levels.
Edema Formation:
- Decreased oncotic pressure leads to fluid accumulation in interstitial spaces, causing edema.
Hyperlipidemia:
- The liver compensates for protein loss by producing more lipoproteins, leading to elevated blood lipid levels.

Etiology of Nephrotic Syndrome

Primary Glomerular Diseases:
- Conditions such as minimal change disease, focal segmental glomerulosclerosis (FSGS), or membranous nephropathy.
Secondary Causes:
- Underlying conditions like diabetes, lupus, infections, or certain medications.
Genetic Predisposition:
- Some individuals may have a genetic susceptibility to nephrotic syndrome.
Renal Vein Thrombosis:
- Blood clots in the renal veins can contribute to nephrotic syndrome.
Idiopathic:
- In some cases, the exact cause remains unknown.

Desired Outcome of Nursing Care Plan (NCP) for Nephrotic Syndrome

Fluid Balance: Achieve and maintain euvolemia by managing edema.
Protein Balance: Preserve or restore normal protein levels in the blood.
Minimization of Edema: Reduce and prevent the development of edema.
Prevention of Complications: Identify and address potential complications, such as infection or thrombosis.
Patient Education: Enhance patient and caregiver understanding of the condition, treatment plan, and self-management.

Nephrotic Syndrome Nursing Care Plan

Subjective Data:

Weight gain
Fatigue
Loss of appetite

Objective Data:

Foamy urine
Anemia
Vitamin D deficiency
Malnutrition
Ascites
Hypertension
Dependent edema

Nursing Assessment of Nursing Care Plan (NCP) for Nephrotic Syndrome

Fluid Status Assessment:
- Monitor daily weights to assess fluid balance.
- Assess for edema, noting location, severity, and pitting characteristics.
Nutritional Assessment:
- Evaluate dietary intake, paying attention to protein and sodium restrictions.
- Monitor serum albumin levels and nutritional status.
Cardiovascular Assessment:
- Monitor blood pressure for hypertension, a common complication.
- Assess for signs of hypovolemia or fluid overload.
Renal Function Assessment:
- Monitor urine output and characteristics.
- Check laboratory values, including serum creatinine and blood urea nitrogen (BUN).
Skin Assessment:
- Inspect the skin for signs of edema, changes in texture, or breakdown.
- Assess for any signs of infection, especially in areas prone to edema.
Respiratory Assessment:
- Evaluate respiratory status, especially in cases of severe edema affecting the thorax.
- Monitor for signs of respiratory distress.
Risk of Thrombosis:
- Assess for risk factors contributing to thrombosis, such as immobility.
- Monitor for signs of deep vein thrombosis (DVT).
Psychosocial Assessment:
- Evaluate the patient’s and family’s understanding of the condition and emotional response.
- Identify support systems and coping mechanisms.

Implementation of Nursing Care Plan (NCP) for Nephrotic Syndrome

Fluid Management:
- Administer diuretics as prescribed to manage edema.
- Monitor fluid intake and output closely.
Protein Replacement:
- Administer albumin or other protein supplements as prescribed.
- Encourage a diet rich in high-quality protein.
Nutritional Support:
- Collaborate with a dietitian to develop a nutrition plan.
- Educate the patient on dietary restrictions and the importance of compliance.
Infection Prevention:
- Implement strict aseptic techniques during procedures.
- Monitor for signs of infection and initiate prompt treatment.
Thrombosis Prevention:
- Encourage mobility and ambulation.
- Administer anticoagulant medications if prescribed.

Nursing Interventions and Rationales of Nursing Care Plan (NCP) for Nephrotic Syndrome

Monitor vitals

Temperature- monitor for signs of infection, especially with immunosuppressant therapy Blood pressure- hypotension may indicate hypovolemia Heart rate- tachycardia may be a sign of infection or hypovolemia

Monitor fluid balance

Measure for decreased output <400 mL/24 hr period may be evident by dependent edema
Daily weights at the same time on the same scale each day, >0.5kg/day is indicative of fluid retention
Note changes in characteristics of urine: dark, frothy or opalescent appearance, hematuria

Insert indwelling catheter unless contraindicated for infection

The indwelling catheter will provide a more accurate measurement of urine output

Monitor diagnostic studies
- Lab
- Ultrasound
- Kidney biopsy (as indicated)

Urine test

24-hour urine or single urine specimen/urinalysis
>30mg albumin / 1g creatinine
Increased protein, decreased creatinine clearance
Microhematuria
Proteinuria that does not contain albumin is indicative of multiple myeloma

Serum test

Serum albumin will be lower than 3.5 – 4.5 (normal range)
Tests for hepatitis B, hepatitis C, HIV, syphilis, and lupus may help determine etiology

Ultrasound

Can help determine the severity and cause of the nephrotic syndrome

Kidney biopsy

Typically, not needed, but maybe indicated in diabetic patients

Assess for skin integrity

Lack of protein in the blood reduces the integrity of the skin and increases the risk of breakdown and ulceration.

Assess dependent and periorbital edema

Evaluate and report the degree of edema (+1 – +4) There may be a gain of up to 10lbs of fluid before pitting is noticed

Administer medications and evaluate the response

ACE Inhibitors or ARBs: (benazepril, losartan) reduce the amount of protein released in urine
Diuretics: (furosemide, spironolactone) Increase fluid output
Hypolipidemics: (atorvastatin, simvastatin) reduce cholesterol in the blood
Anticoagulants: (warfarin, apixaban) prevent blood clots
Immunosuppressants: (prednisone) corticosteroids decrease inflammation from underlying conditions such as lupus and amyloidosis
IV Albumin infusion: as ordered, to reduce ascites; draws the fluid from the body to the bloodstream to treat hypovolemia and replace low serum protein

Monitor for volume depletion with use of diuretics

Diuretics help to flush out fluid from the tissues to decrease edema. Excess urination may result in volume depletion and lead to dehydration or hypovolemia Assess symptoms

Daily weights
Pulse
Blood pressure

Monitor for corticosteroid toxicity for ongoing use

Long term use of corticosteroids can have severe side effects. Monitor for:

GI bleeding- higher risk of bleeding and perforation; use antacids to prevent GI symptoms
Blood sugar levels may be elevated.
Supplement with calcium and vitamin D to prevent bone loss
Encourage yearly eye exam to assess for cataracts and glaucoma as corticosteroids may increase intraocular pressure and cause clumping together of proteins that result in cataracts
Avoid exposure to communicable diseases with immunosuppressant therapy to prevent infections and disease complications.

Assist with Rest / Ambulation

Initially, bed rest is encouraged to help mobilize edema. After the first few days of treatment, encourage ambulation and elevation for venous return and prevent thromboses

Provide nutrition education

Malnutrition may occur due to excretion of protein, but may not be evident in weights due to edema
Diet high in lean protein (1g/kg/day) and low sodium to reduce swelling
Limit foods that increase blood sugar such as simple carbohydrates, refined sugars, and processed foods
Refer to a dietitian as needed

Evaluation of Nursing Care Plan (NCP) for Nephrotic Syndrome

Fluid Balance:
- Evaluate the effectiveness of diuretic therapy in managing edema.
- Monitor daily weights and assess for signs of fluid imbalance.
Protein Status:
- Monitor serum albumin levels and assess for improvements in protein balance.
- Evaluate the patient’s response to protein replacement therapy.
Edema Management:
- Assess for a reduction in edema and improvement in skin integrity.
- Evaluate the success of nutritional interventions in minimizing fluid retention.
Complication Prevention:
- Monitor for and address any complications promptly.
- Assess for the prevention of infection and thrombosis.
Patient Understanding:
- Evaluate the patient’s and family’s comprehension of the condition and treatment plan.
- Ensure that the patient is actively involved in self-management and adhering to dietary restrictions.

References

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Transcript

This is the care plan for nephrotic syndrome. So pathophysiology. Nephrotic syndrome is a collection of symptoms that indicate some type of kidney damage. The symptoms of nephrotic syndrome include albuminuria, hyperlipidemia, and hypoalbuminemia, and that’s just pretty much low albumin circulating in the blood. And dependent edema. What happens is the glomerular in the kidneys are damaged and then allows proteins, most likely albumin to leak into the urine. As the albumin leaks into the urine, the blood can no longer absorb the fluid and it results in edema, at least the third spacing in ascites. So some nursing considerations that we want to think about when we’re taking care of these patients with nephrotic syndrome, we want to assess the fluid balance. These patients can become dehydrated and lose fluid really quickly. We want to monitor their vital signs. We want to administer any medications that’s ordered, and we want to assess their skin integrity. The desired outcome for these patients is to maintain adequate fluid balance and nutrition.

So a patient comes in and they are presenting with nephrotic syndrome. So what are some things that you think that this patient is going to say or going to feel? Well, I can tell you this, that these patients are oftentimes very fatigued. They’re tired when they come in. You’ve got to think they’re losing a lot of their nutrition so they’re going to be tired. Their body is working a little extra hard to keep them going. They’re going to have a loss of appetite. That also ties into fatigue. So they’re going to have a decreased appetite. They’re not going to eat as much. Okay? When we assess these patients, there are some things that are hallmark to nephrotic syndrome. Some of the things are they’re going to have foamy urine. So the urine is going to be foamy.

And that’s just because there’s going to be a buildup of protein in the urine. They’re also going to be anemic. So you’re going to see a decrease in their hemoglobin lab values. A lot of the values are going to be down with their vitamins, such as a vitamin D deficiency, and this is going to come from malnutrition. That’s also one of the signs. They’re going to have some ascites, which is third spacing, generally around the abdomen of fluid. They’re going to have some hypotension, low BP. Let’s write that down. They’re going to have some low BP and that’s going to be, because again, while they have all this third spacing, like the dependent edema, they’re going have the dependent edema. While they have all this buildup of fluid on them, it’s not in the right place. It’s not in the vascular system.

So their BP is going to be low. Okay? Some things that we can do as nurses, when we’re taking care of these patients, we can monitor their vital signs. Let’s see what type of vitals they’re going to have their temperature. They may have a fever. So they’re going to have increased temp. That could be because of the infection process that’s going on, especially for those patients that are on some type of immunosuppressants. We are going to look at their blood pressure. Like I said, they’re going to have low BP. They’re going to be hypotensive. That’s going to be because they’re hypovolemic, they’re not going to have enough volume inside of their vascular system. Their heart rate, because of the hypovolemia, they are going to be tachycardic. So they’re going to have an increased heart rate.

The next thing we want to be mindful of, we’re going to monitor their fluid balance. We’re going to look for decreased urine output. Decreased urine output is going to be anything less than a, so decreased urine output, anything less than 400 MLs in the 24 hour period. That’s going to definitely be evident by any dependent edema. We want to insert a Foley catheter. We want to make sure that we get accurate I&Os, and we want to make sure we know any changes or characteristics of the urine such as if it’s dark or is it the foamy color. Okay? We are also going to administer any medications that are ordered, and we’re going to evaluate the response. Medications such as ACE inhibitors, ACE inhibitors, or ARBs. And that’s angiotensin receptor blockers, diuretics, hyperlipidemia, anti-coagulants, IV albumin infusion. All of these types of medications are going to work on being therapeutic for the patient with nephrotic syndrome.

And then we are also going to assess the skin integrity. Remember, these patients are holding onto fluids, third spacing. So the lack of protein in their blood dramatically reduces. So decreased protein and dramatically reduces the integrity of the skin. It increases the risk of skin breakdown and ulceration. Okay? So let’s take a look at these key points. These are some really good key points. This is what you need to focus on with nephrotic syndrome. Remember that it’s just a collection of symptoms that indicates kidney damage. Some subjective things that the patient is going to complain about though. They may have some weight gain, even though they have the loss of appetite. They’re going to be fatigued. What we’re going to notice from this patient is we’re going to notice that they are hypotensive, low BP. That we’re going to notice some ascites. We may see on the lab values that their hemoglobin is low or anemia. Frothy, concentrated, urine.

Their urine is going to be concentrated, because they’re not producing much because of the kidney damage. Our goals for these patients is fluid management. We want to make sure that these patients are adequately hydrated in their vascular space. So we’re going to insert a catheter for accurate I&Os. We may need to give some IV albumin to pull that fluid back until their vascular system. Remember, we want to report to the physician that any of your output is less than 400 MLs for the 24 hour period. We want to make sure we report that. And finally, medication management. ACE inhibitors, ARBs. Remember those things reduce the amount of protein released. Diuretics, hypolipidemic. So we want to lower that fluid volume. We want to give some anticoagulants and some IV albumin infusion, as they are ordered. We want to reduce ascites.

This was a big topic, but you all did great. We love you guys. Go out and be your best self today. And always remember, happy nursing.