Nursing care of patients with acute glomerulonephritis

2021-07-09 10:50 AM

Acute malignant glomerulonephritis, formerly known as rapidly progressive glomerulonephritis, is a name characterized by rapid disease progression and early death.


Acute glomerulonephritis is the clinical manifestation of an acute inflammatory lesion of the glomeruli, characterized by the sudden appearance of erythrocytosis, proteinuria, edema, and hypertension. Acute glomerulonephritis is very rare before the age of two years, is more common in children between the ages of 3 and 8, and is more common in boys than in girls. The male/female ratio is about 2/1. Acute glomerulonephritis is not just a disease, but a syndrome called an acute glomerular syndrome. The reason is that the clinical picture is often the same, but the histopathological lesions are diverse, the disease arises not only after streptococcal infection but also after infection with staphylococci, pneumococcal, virus or due to allergies to certain substances. . Acute glomerulonephritis syndrome is also secondary to diseases such as systemic lupus erythematosus, rheumatoid arthritis, and periarteritis.

Acute glomerulonephritis was formerly known as rapidly progressive glomerulonephritis. This name is characterized by a rapid progression of the disease, early death due to kidney failure, and rarely a cure within 6 months.

Post-streptococcal glomerulonephritis is considered a model of acute glomerulonephritis syndrome. The disease usually appears after an episode of bacterial infection in the throat, or skin, complicated immune mechanism. The causative organism is group A beta-hemolytic streptococcus, strain (type) 12. Other strains (1, 2, 4, 18, 25, 49, 55, 57, 60) can also cause disease, but more rarely. . Usually strains 4, 12, 24 if the infection is in the throat. Strains 14, 19, 50, 55, 57 if it is a skin infection (different from acute rheumatism, any streptococcal strain can cause disease). The antigen is the M protein of the streptococcal cell membrane. To explain this difference, many authors believe that only some strains of streptococci are antigens that are nephrophilic or that patients have specific sensitivities.

Acute glomerulonephritis after streptococcal infection is not known in absolute terms because many cases are kept on frontline treatment. The frequency of the disease is decreasing in modern industrialized countries but is still common in tropical countries (Africa, Caraibes, South America). The disease appears in sporadic form, or in outbreaks, especially in areas where sanitation is poor.

Etiology and pathogenesis

Group A beta-hemolytic streptococcal infection, usually after a streptococcal infection of the skin and throat.

Some other bacteria can also cause disease such as staphylococcus, pneumococcus.

Some viruses.

Due to allergies to drugs, foods.

Clinical and subclinical manifestations

The disease is common in children and appears after an episode of bacterial infection in the throat or skin from 7 to 15 days. Skin infections often have a longer incubation period.

Dental infections can also lead to acute glomerulonephritis. Acute glomerulonephritis can also occur in viral, staphylococcal, or other diseases.

Onset is usually sudden, there may be warning signs such as fatigue, loss of appetite, feeling of pain in the hips on both sides. There are also patients who come with symptoms of fever, sore throat, and skin inflammation.

The full-blown stage is clinically manifested by the following symptoms:

Edema: At first, it usually appears on the face as heavy eyelids, can pass quickly but can also spread to the limbs and then the whole body. The edema is soft, white, indented, leaving finger marks. Edema around the ankle, anterior tibia, instep. There may be generalized swelling in the abdomen, back, and genitals. More severe can be ascites, pleural effusion, acute pulmonary edema, cerebral edema. Swelling more or less depends on the diet.

Oliguria or anuria: occurs early, patients usually only urinate 500-600 ml/24 hours.

Hematuria: often occurs early along with edema. Gross hematuria, red or dark urine when urinary red blood cells are above 300,000/min. Or microscopic hematuria, with red blood cells in the urine but not much. Red blood cells are often distorted, broken into pieces, and hypochromic. RBC casts are a characteristic sign that red blood cells are descended from the kidneys. Gross hematuria usually resolves early, but microscopic hematuria is often prolonged. Urinary erythrocytosis may take up to 3 months to clear. Therefore, long-term monitoring is required, and the urine must be retested once every 3 months.

High blood pressure: over 60% of patients have hypertension. Increase in both systolic and diastolic blood pressure. Acute pulmonary edema is a common complication of hypertension.

Heart failure can occur, but if present, the prognosis is poor, possibly left heart failure due to hypertension, or total heart failure due to salt and water retention.

Blood tests:

There is usually mild anemia, hypochromic or hypochromic.

Elevated erythrocyte sedimentation rate.

Increased antibodies:

Streptolysin O (ASLO) Resistance.

Streptokinase resistant (ASK).

Resistance to Nicotinyladenin Dinucleotidase (ANADAZA).

Anti-Hyaluronidase (AH).

Elevated ASLO is very specific for streptococcal pharyngeal infections but less specific for skin infections. ASLO is often elevated before other enzymes, so multiple tests and repeats are needed to confirm the diagnosis.

The breakdown product of fibrin increases. Presence in urine and elevation in plasma is an important marker for diagnosis, treatment, and prognosis. Need to test early and often. Is a manifestation of blood coagulation in the vessels of the glomerulus. This is an indicator to indicate treatment with heparin. When the breakdown product of fibrin decreases, the inflammatory process in the glomerulus has been restored.

Urea, blood creatinine increased, clinical signs of hyperuricemia syndrome.

Proteinuria is always present in the urine, on average 2 - 3 grams/24 hours. There are isolated cases of proteinuria increased over 3.5 grams/24 hours. Very rare nephrotic syndrome in acute glomerulonephritis.

Progression and prognosis

Post-streptococcal glomerulonephritis is common in children and has a better prognosis than in adults.

Complete cure 80% in children and 60% in adults.

After only a few days to a week, the patient urinated more and more, edema decreased, urine increased gradually, blood pressure returned to normal. However, erythrocytosis, proteinuria can take 6 months to 1 year to clear.

About 10-20% turn into chronic glomerulonephritis after many years, the kidneys gradually atrophy. Long or short time depending on the case and depending on the cause of the disease, it can take 10-20 years to have chronic kidney failure.

A very small number (1-2%) may die during acute exacerbations due to acute pulmonary edema, acute heart failure, acute renal failure, infection.


Implementing the quadrants

History of bacterial infections in the throat, skin.

Edema, oligouria, hematuria, high blood pressure.

Proteinuria (+), erythrocytosis (+).

Decreased blood complement.

Serum ASLO is increased.

Diffuse capillary cell proliferation.

Differential diagnosis

Exacerbation of chronic glomerulonephritis is based on:

History and medical history.

Retroperitoneal inflation, UIV, ultrasound, two kidneys are smaller than normal.

Post-streptococcal glomerulonephritis with acute non-streptococcal glomerulonephritis:

Based on medical history.

Bacterial culture of nasopharyngeal fluid.

ASLO and other anti-streptococcal antibodies.


Eat lightly and rest during illness.

Use systemic antibiotics when there are signs of infection.

Daily dental hygiene.

Use corticosteroids on a case-by-case basis.


Take good care of infections in the skin and throat.

Keep warm in the cold season and treat acute glomerulonephritis well.

Care of patients with acute glomerulonephritis

Assess the situation

When the patient enters the ward for treatment, the nurse must observe and assess the patient's condition in a timely manner and have a good attitude to interact with the patient.

Assess by asking questions:

Did you have an infection, cough or fever before getting sick?

Do you have a digestive disorder?

Do you have a sore throat or skin inflammation?

Normal or little urine, yellow or red urine?

Have a headache?

Have you used any drugs?

Has anyone in the family had this?

First time or how many times?

Have high blood pressure?


Patient's mental status, the patient's walking problem.

Skin and mucosal conditions.

Facial or body edema.

Observe the amount and color of urine.

Sore throat, cough.

Skin signs such as boils or old scars may be observed.

Examination by examination:

Check vital signs.

Measure urine quantity, color.

Measure weight.

Assess edema.

Perform the necessary tests.

Examine the patient's abdomen, respiratory and cardiovascular systems.

Collect other information:

Information is obtained through the patient's records and through the patient's family.

Collected through previous tests and treatments.

Nursing diagnosis

Some diagnoses that may be encountered in patients with acute glomerulonephritis:

Low urine output due to decreased glomerular filtration rate.

Increased fluid volume due to fluid and salt retention.

Risk of left heart failure due to hypertension.

Risk of acute pulmonary edema due to heart failure.

Care planning

Exploiting the above signs helps nurses to get a care diagnosis. Nurses need to analyze, synthesize and summarize data to determine the needs of the patient, thereby making diagnoses and planning care. Care planning must consider the patient's overall health, recommending priorities, and deciding which issues to do first and which to do later.

Basic care:

Allow the patient to rest appropriately.

Eat enough energy, limit salt and water as indicated.

Daily cleaning of the skin and ears, nose, and throat, paying attention to the infected skin area.

Execute the commands:

Administer medication to the patient and administer medication as directed.

Do tests as required.

Follow up:

Pulse, temperature, blood pressure, breathing rate, and weight.

Monitor urine output and color.

Monitor some tests such as proteinuria, erythrocytes, electrocardiogram, ultrasound, urea, and blood creatinine, if there is any abnormality, notify the doctor immediately.

Health education:

Patients and families need to know about the cause, how to detect the disease and how to treat and care for acute glomerulonephritis.

Know the progression and complications of acute glomerulonephritis, as well as how to prevent acute glomerulonephritis.

Implement a care plan

Perform basic care:

Place the patient at rest with the head elevated.

Rest in bed, limit movement. The patient's personal belongings must be placed in a convenient place for the patient to easily use, and limited travel. Rest depends on the patient's condition, especially on the amount of urine:

Under 300 ml/24 hours, make the patient absolutely bed rest and elevate the head.

From 300 - 500 ml/24 hours, the patient can walk as needed.

Above 500 ml/24 hours, the patient can walk and do light tasks.

Always keep the patient's body warm, do not use cold water to bathe or wash hands and feet because the patient can easily get cold glomerulonephritis when the patient is infected with streptococcus.

Diet and water:

Drinking water: should be based on edema condition, if little edema appears only in the ankles or eyelids, the amount of water including food and drink during the day is about 500 ml and added to the amount of urine in 24 hours. If the patient has a lot of edema, the amount of water included in eating and drinking is about 300 ml plus the amount of urine during the day.

Protein amount: based on the blood urea status in the patient, if:

Blood urea less than 0.5g/l can give patients more vegetable protein, less animal protein. The amount of protein taken in a day is about 0.25g/kg of body weight.

Blood urea from 0.5 to 1g/l, should use vegetable protein, not animal protein and the amount of protein taken in the day is less than 0.25g/kg body weight.

Blood urea on 1g/l diet is mainly glucid and some essential amino acids.

Salt: Limit salt intake to less than 1g/day. Attention should be paid to cases of edema and hypertension in patients. Limit substances with the most potassium, especially bananas and oranges, when the patient has hyperkalemia or a small amount of urine during the day or the patient have kidney failure.

Daily hygiene for patients: daily cleaning of teeth and skin to avoid foci of infection, early detection of infection foci to guide patient treatment. Clothes, pants, linens, and other items must always be kept clean. If there is an ulcer on the skin, it must be washed with hydrogen peroxide or methylene blue.

Execute the commands:

Fully comply with medical orders when using drugs: injections, oral or topical drugs. In the process of taking the drug, if there is any abnormality, you must notify the doctor.

Perform tests:

Blood tests such as: urea, creatinine, electrolytes, ASLO.

Electrocardiogram tests, abdominal ultrasound...

Urine tests: daily urine volume and color should be carefully monitored. Collecting urine for testing must ensure the correct procedure. The tests to do are protein, urea, creatinine, germ cells...

Follow up:

Vital signs: daily must closely monitor the patient's pulse, temperature, blood pressure, breathing rate. Pay attention to your blood pressure.

Watch for other symptoms:

Urine: track on quantity, color.

Weight to assess edema.

Electrocardiogram, renal function, proteinuria...

Monitor complications of acute glomerulonephritis.

Health education:

Let the patient and family know about the illness.

Complications can occur with acute glomerulonephritis.

Let the patient know about rest and activity regimes.

It is necessary to have a proper diet and drink.

There is a suitable mode of rest and work.

Avoid cold.

Clean personal hygiene pays attention to teeth, mouth, skin and ears, nose, and throat.

Thoroughly treat the foci of infection.

Register for monitoring and periodic re-examination.


Assess the patient's condition after taking the order and implementing the care plan compared to the beginning, see what problems are good, what problems still exist, or what new problems arise for the patient to evaluate and add to the plan of care, specifically:

Is the edema assessment improving?

Assess the amount and color of urine compared to baseline.

Are vital signs (especially hypertension) abnormal or better?

Complications of the disease.

How about health education?

Assess whether basic nursing care has been performed and is responsive to the patient's needs.

Errors or omissions need to be added to the care plan for implementation.