Taking care of children with acute glomerulonephritis

2021-01-30 12:00 AM

Acute glomerulonephritis usually occurs several weeks or months after a child has strep throat, tonsillitis inflammation, early-stage, and skin sores. So, when examining patients with kidney oedema

General perception

Acute glomerulonephritis is diffuse glomerulonephritis, acute due to the deposition of circulating immune complexes in the glomeruli, which occurs after beta-hemolytic streptococcal infection of group A.

Spread: Over 80% of glomeruli are inflamed.

Acute: the disease lasts no more than 3 months.

Deposits of circulating immune complexes: Causes allergic inflammation, non-purulent inflammation in the glomeruli, edema and proliferation of glomerular endothelial cells (Endothelia) and cells between the capillaries (Mycangium).

The cause to the illness

Due to beta-hemolytic streptococci group A, type 12 (causing pharyngitis, tonsillitis inflammation) or type 49 (dermatitis, early stage). There are also motifs 2; 4; 14; 25; thirty first.

Beta-type A hemolytic coccidiosis does not reach the kidneys. They reside in the throat, skin and cause purulent lesions of the throat, tonsils, nose, sinuses, bronchi, or in the scalp, legs, forearms, etc. toxins (antigens). These antigens enter the bloodstream, stimulating the immune response system to produce antibodies. The KN-KT reaction with the involvement of complement C3 causes inflammatory lesions in the whole-body capillaries, but the damage is mainly in glomerular capillaries: Edema and proliferation of cells endothelia, mycangium leading to increased permeability and stenosis of glomerular capillaries. Increased permeability and stenosis of glomerular capillaries is the most basic step in the pathogenesis mechanism, leading to all clinical signs and clinical weight of glomerulonephritis.

Risk factor

Year old:

Children: 3 - 5 years old: Often have dermatitis, early.

Children: 7 - 15 years old: Usually sore throat, tonsillitis inflammation Localization: Allergy.

Weather: The sudden cold will reduce the resistance to infection.

Personal fertility: Poor oral and skin problems.

Clinical symptoms

Acute glomerulonephritis usually occurs several weeks or months after a child has strep throat, tonsillitis inflammation, early stage, and skin sores. Therefore, when examining patients with renal edema, it is necessary to observe carefully to determine whether there is a new healing scar or purulent inflammatory lesions in the skin, throat and tonsillitis

Whew

In acute glomerulonephritis, the symptom of edema has the nature:

Edema appears suddenly in the morning after waking up.

The edema begins to appear on the eyelids, on the face, and then on the legs, arms and elsewhere.

The level of edema: Usually mild edema, moderate edema, sometimes discreet edema, to be weighed for the patient daily to detect.

White edema.

Soft edema, concave.

Rapid progression of edema.

Appetite: decreased edema.

Mechanism of edema: The body retains salt and water due to decreased glomerular filtration rate.

Little pee

Based on the amount of urine, divided into 3 levels:

Anuria: When the amount of urine is less than 100 ml / m 2/24 hours (seen in acute glomerulonephritis anuria).

Primary urine: When the amount of urine is below 300 ml / m 2/24 hours.

Little urination: When the amount of urine is less than normal.

Urine color:

Dark yellow or red like meat wash (if it lasts more than 2 weeks, it is called acute hematuria).

Hypertension

Most patients with acute glomerulonephritis have hypertension with the following characteristics:

Blood pressure usually rises as early as the first week of illness.

Increases both maximum and minimum blood pressure.

Usually slightly increased (increase 10 - 20 mm Hg). Therefore, it must be measured accurately before it can be detected.

The increase is not frequent, so it must be measured many times a day to not miss.

For patients with high blood pressure glomerulonephritis: Blood pressure increases and increases frequently affecting the overall condition such as headache, dizziness, nausea, vomiting, chest pain, difficulty breathing, arrhythmia. ... This is one of the causes of death.

Test

Proteinuria

Proteinuria is always positive. Due to the concentration of urine, proteinuria can be from 0.5g / l to 3g / l, sometimes higher, but never exceeding 50mg / kg / 24 hours.

Urinary tract gap

The urinary tract is always more than the normal limit (microscopic hematuria) or microscopic thickening (gross hematuria) with small size and major deformation. Can see the bridge gaping.

CBC

Leukocytes increased; multiple neutrophils increased.

Increased blood sedimentation rate.

Blood chemistry

Normal or increased blood urea.

Normal or increased blood creatinine.

Normal or increased blood potassium.

Normal or decreased blood pH.

The level of glomerular filtration is reduced.

Evolution

Completely gone

Most children with acute glomerulonephritis completely recover.

Clinical symptoms disappear after 1-2 weeks.

The deficit and proteinuria usually go away more often. Particularly, a gap in the urine can persist for several months after the end of clinical symptoms.

Bad developments

Blood pressure is very high and prolonged, leading to acute heart failure, acute pulmonary edema, cerebral edema and death. This is the prominent symptom of high blood pressure acute glomerulonephritis.

Anuria lasts more than 5 days, without hemodialysis (dialysis), it is easy to die from acute kidney failure (acidosis, blood urea and K blood increase, glomerular filtration rate decreases ...). This is the prominent symptom of acute anuria.

The disease progresses to chronic: At the beginning, the clinical symptoms go away quickly, but the components in the urine are in lasting damage. After a while the disease manifests itself in the form of nephrotic syndrome or chronic glomerulonephritis.

Persistent red urination

Urticaria that lasts from 2 weeks to many months is the most prominent symptom in acute hematuria. This is the result of increased glomerular capillary permeability and scattered endothelial coagulation.

Take care of

Human determination

In order to give real nursing diagnoses to patients, nurses need to carefully exploit their history and medical history and must examine them comprehensively and accurately.

As for the history, it is necessary to exploit whether the pediatric blood pressure patient has itching (allergy), sore throat, dermatitis, the first time and how has been treated? Has been edema ever? Of course, acute glomerulonephritis is a disease that rarely recurs.

In terms of history, it is necessary to ask if the patient has hypertension, headache, sore throat, nausea, dizziness and low blood pressure, what color urine? Since when did the patient swelling, where did the edema appear first, determine a little edema?

As for the examination, it is necessary to determine:

Is there a focus of streptococcal infection? where? (sores on skin, scarring, red throat, red swollen tonsillitis and pus).

Is there any blood pressure? level of edema? edema? If in doubt, weigh the patient every day at fixed times.

The amount of urine? (for 8 hours, in 24 hours); urine color (dark yellow, gaping red, crimson, dark green). Accurate measurement of the amount of urine is extremely important in assessing the condition.

How much blood pressure? (measured several times a day); Mild increase in high blood pressure? Does it affect the whole situation yet? (Breathing rate, pulse, horse galloping, headache, vomiting, convulsions, enlarged liver, etc.).

Are there signs of heart failure? Are there signs of acute pulmonary edema yet? Are there signs of brain edema? Are there signs of acute renal failure?

In the case of pediatric patients with hypertension, oliguria or anuria, the nurse must monitor closely every hour to be able to make a nursing diagnosis, develop a care plan and implement timely and correct interventions. right.

Nursing diagnosis

After identifying a patient, the nurse must document the nursing diagnosis, then develop a care plan and implement the care plan. Some of the nursing diagnoses in commonly cited acute glomerulonephritis are:

Consistent - urinating less because the body hold salt and water retention, involving reduction m stasis c filter sloppy n:

This diagnosis is based on symptoms:

Edema (with the edematous nature of acute glomerulonephritis).

Little urination, dark yellow or bloody urine.

Decreased appetite decreased.

Proteinuria (+).

Glomerular (+).

Anuria (very low urination) 1, 2, 3, ... days due to impaired glomerular filtration ability associated with decreased renal tissue perfusion

This diagnosis is based on the following symptoms:

Little urination <100 ml / m2 / 24 hours during 1, 2, 3, ... day.

Edema (with the edematous nature of acute glomerulonephritis).

Proteinuria (+).

Glomerular (+).

Young tired, shortness of breath, deep breath because the accumulation of ph αΊ© m stand-related decline in function of glomerular filtration:

This diagnosis is based on the following symptoms:

Children are tired, headache, difficulty breathing ...

Edema (with the edematous nature of acute glomerulonephritis).

Dark yellow urine.

The breath smells like ripe apple (ketonic).

Laboratory tests: decreased blood pH, increased blood K, increased blood urea.

Little urination <100 ml / m2 / 24 hours.

The glomerular filtration rate is greatly reduced.

Babies vomiting, headache, and dizziness caused by hypertension associated with decreased renal perfusion:

This diagnosis is based on the following symptoms:

Children vomiting, headache, dizziness, dizziness ...

BP is> 10 mm Hg higher than normal.

Less edema, urinary retention, decreased glomerular filtration rate.

Skin integrity due to chronic inflammation:

This diagnosis is based on the following symptoms:

Skin sores in shins, forearms, early, new scarring.

Itching, pain, pus at the site of inflammation.

Fever.

Care plan

Based on nursing diagnosis, nurses will come up with an appropriate care plan.

Rest regime:

Resting regime is indicated for the case of suitable, low urination, especially in cases of anuria, hypertension.

With the lying position, more blood reaches the kidneys than usual. On the other hand, it is necessary to encourage the patient to be assured, not worry, and less volatile so that the blood does not have to focus on the brain and to the limbs more, creating conditions for more blood to the glomeruli. All of these factors will increase glomerular filtration rate, which means increased excretion of Na and other metabolic products. Therefore, nurses need to encourage and advise the patient to perform a good regimen of activities suitable to the progression of the disease:

Advise the patient to stay in bed during the period of swelling, low urination, increased blood pressure. With the supine position, the amount of blood to the kidneys will increase more than usual, the glomerular filtration rate will be increased, leading to increased excretion of salt, water and metabolic intermediates.

When the clinical manifestations are over, the pediatric patient can be advised to walk gently in the patient's room, in and out of the toilet, and in the bathroom; take care of yourself and, if possible, clean it up.

About eating:

Absolutely bland eating:

This is a completely salt-free diet and is indicated in case of compliance with low urination, especially in cases of oliguria, anuria, and hypertension. However, in food and cereals used in meals contains up to 2.5g of salt / day, accounting for about 50% of the body's need for Na. It is necessary to encourage and encourage children to eat completely bland during edema, low urination, oliguria, anuria, high blood pressure (average 2 - 4 weeks).

Relative binge eating:

When the swelling, urine volume and blood pressure are normal, the patient should be switched to a relatively bland diet. Here's a diet with increasing salt intake:

0.5 g / day for the first 1-2 weeks.

1 g / day for 1-2 weeks.

1.5 g / day for the next 1-2 weeks.

2 g / day for the last 1-2 weeks.

Thus, after 4-8 weeks of relatively light eating, the child can eat normally. However, it is necessary to advise children not to use too salty foods such as roasted meat, fish stock ...

The restriction on protein-rich foods is only put in place in cases of oliguria or anuria, high blood urea. The amount of Protein for these cases should not exceed the limit of 1 g / kg / day. The amount of protein in meat is 16% - 18%, in fish from 10 - 15% depending on the type of fish. Therefore, children should only eat foods rich in protein such as lean meat, beef, chicken ... no more than 6g / kg / day; fish no more than 8 - 10g / kg / day. During the recovery period, when the glomerular filtration rate has returned to normal, eating protein rich foods is necessary to increase the regeneration of organization, and to heal ulcers on the skin.

For children with acute anuria or oliguria, in addition to protein restriction, it is necessary to limit foods high in potassium such as soy, green beans, cabbage, amaranth, potatoes, water spinach, etc. pumpkin, rump, jute, beef, beef, pickled persimmon, copra, orange, lemon, jackfruit ...

Table: Potassium content in some foods

Potassium content (in 100g)

Vegetables, whole grains (in 100g)

Fruits (in 100g)

Meats and fish (in 100g)

From 250-299

Eggplant, red cabbage, chrysanthemum, lotus, watercress, celery

Na, guava, plum, apple

Eel, duck eggs, catfish, crab, pork ribs, pig kidney,

From 300-399g

Bamboo shoots, coconut trees, tomatoes, vegetables. taro, cassava tubers

 

pork, shrimp, pig liver, beef liver, rabbit meat, pigeon

From 400-499g

Pumpkin, water spinach, need me, jute, spinach, cheeks, taro.

Orange, Lemon, Jackfruit,

Beef, deer meat,

From 500-599

Sweet potato, potato, cabbage, red amaranth, banana flower, sage, sesame, rice

Pickled persimmon, old copra,

 

Over 600mg

Where is soy, where green, where chopsticks

 

Beef kidney, dried squid.

Amount of water taken into the body:

Nurses must strictly control the amount of water ingested and discharged by patients with acute glomerulonephritis. Water intake includes drinking water, meal broth (soup, vinegar, soup) and fluids. The effluent consists of urine and an invisible loss of water (loss through skin, breath, and feces).

The amount of water the patient consumes daily can be calculated using the following formula:

V = U + 200

Inside:

V is the volume of water (ml) given to the patient for 24 hours.

U is the amount of urine (ml) of the patient excreted in the previous day (24 hours).

200 ml is the invisible 24-hour loss of water.

For patients with severe anuria and life-threatening conditions, the calculation of the amount of water taken into the body must be considered in each work shift (every 8 hours):

V8h = U8h + 7 ml / kg

Inside:

V8h is the volume of water (ml) that will be given to the patient in the next 8 hours (next shift).

U8h is the amount of urine in the last 8 hours (last shift).

7 ml / kg is the volume of water lost in invisible 8 hours per body weight.

Thus, it is extremely important to monitor the patient's urine volume on a daily or work shift basis.

Nurses must perform or instruct patients to fully understand how to collect urine and how important it is so that they do not discard urine output during bowel movements.

Medications:

Penicillin antibiotic:

This is a bactericidal antibiotic so it should only be used 1 or 2 times a day. If used 2 times / day, it must be 12 hours apart.

If the physician gives the patient the use of Penicillin V (Phenoxy methyl - Penicillin), the nurse must give the patient a drink on an empty stomach 1 hour before meals.

Usually, Penicillin is indicated intramuscularly or oral at a dose of 50,000 VND / kg / day, but not more than 1,000,000 VND / day and lasts no less than 10 days. The duration of antibiotic use depends on inflammation in the skin, throat ...

Diuretic:

Diuretics are indicated for use in cases of compatibility, with minimal urination, especially in cases of anuria, high blood pressure.

Often use Furosemide or Hypothalamic. After each oral dose, diuretic effects last from 4-8 hours (Furosemide) to 10-12 hours (Hypothalamic). So should only use the drug 2 times in the morning and noon (not in the evening) to avoid causing insomnia for the patient. Lack of sleep and walking a lot will make blood flow to the body significantly reduced. The drug is indicated orally during or after meals with a dosage of 2-4 mg / kg / day and lasts for 3 - 5 - 7 days. In case it is necessary to use a longer period of time, the patient must stop taking the drug for 3-4 days, then continue taking the drug. For patients with severe, prolonged anuria can use Furosemide intravenously slow, or hemodialysis.

Lower blood pressure:

The drugs used in cases of hypertension are: Reserpine, Hydralazine, Diazoxide, Methyldopa... It is necessary to closely monitor blood pressure before and after taking the drug to evaluate the effectiveness of the drug, helping the physician to give. appropriate and timely treatment methods, to avoid unfortunate accidents and deaths. Among blood pressure drugs, Methyldopa is preferred because it has anti-Remine effects. Reserpine also works very slowly, causing stomach irritation, so it is rarely used. Methyldopa is administered in a dose of 10 mg / kg / day in 2 divided doses.

Nursing intervention

Edema caused by the body retaining salt and water retention, has been associated with decreased glomerular filtration rate.

Objective: Out of edema:

Nursing intervention:

Absolute resting regime to create conditions for more blood to the kidneys, to increase glomerular filtration rate.

Absolutely bland eating:

It is necessary to strictly follow the absolute bland diet: all children's dishes are completely free of salt. Need to encourage and supervise this diet. Because, in fact, many children eat salt clumsily, even because they love their children, parents stealthily feed their children salt. It is important to explain to the patient and family about the harms of eating salt while sick.

When the patient has no edema, then switch to a relatively bland diet.

Water restriction:

In addition to absolute bland eating, it is necessary to implement a diet to limit water intake. The amount of water taken into the body is calculated by the formula V = U + 200.

Taking a diuretic:

As we all know, eating bland absolutely only 50% limit sodium intake in the body. Thus, the absolute bland eating is not enough to reduce the amount of salt needed, when the filtering function of the glomeruli has been impaired. Therefore, we must give patients a diuretic, that is, drugs that inhibit renal tubular sodium reabsorption. The drug commonly prescribed by doctors is Furosemide or Hypothalamic. The drug is used at a dose of 2-4 mg / kg / day divided 2 times in the morning and at noon; Should drink when full, not drink in the afternoon, to avoid making the patient have to wake up to urinate at night. The drug is usually indicated for 3 - 5 consecutive days.

Anuria (very little) 1, 2, 3, ... days due to impaired glomerular filtration capacity associated with reduced renal tissue perfusion

Goal: Pee with a normal amount of urine:

Nursing intervention:

Absolutely resting: eat, rest at bed.

Warm compresses in the fovea are aimed at dilating blood vessels in the fovea, making more blood flow to the kidneys.

Absolute binge eating should be strictly adhered to.

Water restriction: To balance the amount of water in and out of water for the patient. The amount of water taken must be calculated for each shift (every 8 hours) by the formula: V8h = U8h. 7ml / kg.

Strong diuretics are often prescribed by doctors, such as slow intravenous Lasix.

Limit eating foods rich in Protide, but must ensure the body a necessary amount of Protide is lg / kg / day, ie 5-6g of meat kg / day or 8-10g fish / kg / day.

Limit foods rich in potassium such as soy beans, green beans, beef kidney, beef, banana pepper, plum, oranges ...

Carry out the instructions of infusion of alkaline solution when blood acidosis, hyperkalemia.

If anuria is more than 5 days, the glomerular filtration rate will be reduced to less than 30% compared to normal; Potassium in blood above 7.5 mEq / l; blood urea over 2g / l; blood pH below 7.2; BE below 8 mEq / l must prepare patients for hemodialysis.

Child discomfort due to vomiting, headache, dizziness ... due to increased blood congestion related to reduced renal perfusion

Objectives: All discomfort, vomiting, headache, dizziness free:

Nursing intervention:

Lie absolutely rest.

Apply hot compresses to the fovea.

Absolutely bland food.

Water restriction.

Diuretic.

Renin antihypertensive drugs:

Usually doctors appoint Aldomet 10 mg / kg / day, orally divided 2 times / day. Possible side effects such as nausea, vomiting, headache, and erythema should be monitored.

Children with shortness of breath, blush due to heart failure related to high blood pressure:

Goal: End difficulty breathing, stop cyanosis.

Nursing intervention:

Lie absolutely rest.

Apply hot compresses to the fovea.

Absolutely bland food.

Water restriction.

Anti-renin drugs, lowering blood pressure.

Diuretic.

Absorb phlegm, breathe oxygen.

Performing medical orders for pediatric patients using Digoxin heart-aid: Dosage: 0.04 - 0.05 mg / kg / 24 hours.

Slow intravenous injection 1/2 dose, then every 8 hours to inject 1/4 dose.

Must capture pulse before, during and after injecting Digoxin. While you are pumping the medicine but the pulse refills or clears up quickly, you must stop the pump because you may have overdosed or pumped too quickly. As such, it is not necessary to use up all the given dose.

When there is a risk of acute pulmonary edema:

Oxygen is administered through an alcohol solution with a concentration of 10-20%.

Children over 5 years old may have to use Morphine 0.25 - 0.5mg / year / time subcutaneous injection.

You may need to inject 100-200 ml / m2 of skin area.

If the child is accompanied by anemia, it is possible to use the genus root method instead of a blood injection: 1 root garland, then every 5 minutes to add another root. At 15 minutes, remove the garland from the first garland and place the fourth, in turn, so that there are always 3 limbs at all times, and one limb remains free and each limb is not more than 15 minutes.

Prepare equipment for intubation and mechanical ventilation as directed by your physician.

Skin integrity due to chronic inflammation

Objective: Skin free from ulcers, free from inflammatory lesions:

Nursing intervention:

Antibiotics to kill streptococcus: follow the exact same command using penicillin orally or inject for no less than 10 days.

Eat more protein-rich foods such as meat and fish to increase the proliferation of scar-forming cells. Attention should be paid to taking care of priority: Only give protein-boosted diets when the child is not in anuria.

Daily cleaning of skin is a must. It is necessary to avoid crushing purulent inflammatory nodules.

Evaluate

After implementing the care plan, the nurse must monitor the child regularly so that the results of treatment and care can be reported. In acute glomerulonephritis, issues to evaluate are:

Whew

To assess the extent and progression of edema it is necessary to:

Daily Exam: The Goder sign.

Weigh every day at fixed times with a single scale.

Subjective perception of the patient and the patient's family.

Little pee

Exploit the patient for the frequency of urination, the amount of urine during the day, at night, compared with the previous day.

Measure, determine the amount of urine every 8 hours or every 24 hours. Report daily to the doctor about the patient's urine output, especially when the child is anuria or oliguria.

Observe, determine urine color.

Blood pressure

Exploit the patient's subjective feelings such as headache, dizziness, dizziness, nausea, vomiting, shortness of breath, chest tightness and the progression of these signs before and after taking antihypertensive drugs.

Measure blood pressure daily or every 3-8 hours for the patient.

Pulse count, daily breathing.

Inflammation in the skin, throat

Daily body temperature measurement for patients.

Examination and evaluation of progression of skin lesions, pharyngitis.

Are regimes such as bed rest, bland food, drink less water, reduced protein intake, oral hygiene and skin care?

Health education

While located v A rea

Advise patients to practice oral hygiene, daily skin hygiene for good. Brushing your teeth every day after every meal or at night before bed is a good thing to do. Rinse mouth and drink water after each meal. However, it is important to pay attention to the amount of water taken into the body during the day for patients with advanced disease. Skin hygiene issues relate to clothes, blankets, mats and daily bathing. Avoid breaking, crushing purulent lesions on the skin, keeping the sores dry, preventing pus and fluid from draining onto the bed, mat and the skin healed. Avoid scratching, causing scratches, creating conditions for bacteria to easily enter the body.

Explaining the patient's understanding of a bland, water-restricted diet is extremely important. Due to not understanding the meaning of the bland diet, many children do not.

Recommend foods that should not be given to children because they are high in potassium.

Education is required so that the patient and the patient's family should not worry about the signs of edema, erythema, etc. affecting the child's health.

Explain that patients and families understand the role of bed rest, keeping warm to improve children's resistance.

It is important to use the medicine at the right dose, at the right time and at the right time. In fact, many patients automatically increase or decrease the dosage of drugs, affecting the outcome of treatment.

Before taking out

Need to educate patients and families.

Maintain a routine of oral and skin hygiene: brush your teeth at night or after each meal, rinse your mouth after eating, wash your hands often and take a shower.

Avoid strenuous activities such as labor, sports or exercise for 6 months from the date of recovery.

When you have dermatitis, sore throat must seek the advice of a physician. Intensive treatment in this case is necessary. It includes proper use and hygiene, skincare, and throat care. Doing this well will avoid acute glomerulonephritis.

Avoid getting cold when the weather changes. Chronic pharyngitis usually occurs in children with cold skin, especially the neck and 2 feet. Reducing the body's resistance to cold skin has been mentioned by many medical scientists.