Nurse’s Knowledge regarding Nursing Care of

Nurse’s Knowledge regarding Nursing Care of

Children with Nephrotic Syndrome at wad Medani

Pediatric Teaching Hospital, Gezira State, Sudan

(2020)

Omnia Babiker Mohammed Ahmed

B.Sc. in Nursing Science

Gezira University (2015)

A dissertation

Submitted in Partial Fulfillment for the Requirements

for the of the Degree of Master of Science

in

Pediatric Nursing

Department of nursing

Faculty of Applied Medical Sciences

i


Children with Nephrotic Syndrome at Wad Medani


(2020)


Supervision Committee

Name Poisson Signature

Dr. AmnaEltom Ibrahim Hassan MainSupervisor ...…………….

Dr. Sonia AbdulgaderAhamed Co-supervisor ………………

Date: 21/11/2020

ii


Children with Nephrotic Syndrome at Wad Medani


(2020)


Examination Committee

Name Poisson Signature

Dr. AmnaEltom Ibrahim Hassan Chair Person ...…………….

Dr.Hanadi Mohammed Elhassen External Examiner ...…………….

Dr.Ekhlas Mohammed Ali Internal Examiner ...…………….

Date of Examination: 21/11/2020

iii

Dedication

I dedicate this work to my:

Parent

Husband

Brothers and Sister

Children Friends

iv

Acknowledgment

I would like to thanks the greatest Allah for giving me the

strength to complete this research .

I wish to express particular thanks to my main supervisor Dr.

AmnaEltom Ibrahim Hassan and co-supervisor Dr. Sonia

AbdalgaderAhmed for their help and advice they offered me great full

acknowledge and deep thanks to the University of Gezira Faculty of

Applied Medical Sciences and all nurses participant of the study and all

hospital staaf for giving me this chance to complete my post graduate

studies .

Also my warm thanks to my husband Alsharawy Mohammed

and my son Mohammed and my mother Hafssa Abbas I would like to

thank all my family and every one how are support me to complete this

work.

v

Nurse’s Knowledge regarding Nursing Care of Children

with Nephrotic Syndrome at Wad Medani Pediatric

Teaching Hospital, Gezira State, Sudan (2020)


Abstract

Nephrotic syndrome is the most common acquired kidney disease

in children. Affected children have recurrent episodes (or relapses) of

proteinuria that may lead to life-threatening complications including

sepsis, peritonitis and thromboembolism.This study aim to assess nurse’s

knowledge regarding nursing care of children with nephrotic Syndrome

This study is a descriptive hospital based study was conducted at Wad

Medani Pediatric Teaching Hospital in Gezira state. The sample size of

this study was involved all nurses working at nephrology department and

their number was (47). The data was collected through a questionnaire

was analyzed using Statistical Package for Social Sciences (SPSS)

descriptive analytic method. The study showed that (46.8%) of the study

participants had a poor knowledge regarding signs and symptoms of

nephrotic syndrome (42.6%) of the study participants had a poor

knowledge regarding complications of nephrotic syndrome and primary

glomerulonephrosis. More than half (83.5%) of the study participants had

a good knowledge regarding treatments of nephrotic syndrome. More

than half(63.8%) of the study participants had a moderate knowledge

regarding nursing role for nephrotic syndrome and signs of excess fluid

volume less than half(23.8%) of the study participants had a poor

knowledge regarding nursing role for excess fluid volume. Less than half

(42.6%) of the study participants had a poor knowledge regarding

nursing role for fatigue . less than half (40.4)of the study participant shad

a poor knowledge regarding nursing role for deficient knowledge. more

than half (59.6%) of the study participants had a moderate knowledge

regarding nursing role for risk for infection.The study recommended that:

suggested training programs for nurses about nursing role of children

with nephrotic syndrome at Wad Medani Pediatrics teaching hospital.

vi

الرعاية التمريضية للأطفال المصابين بمتلازمة ين حولمعرفة الممرض، ولاية الجزيرة ، مستشفى ود مدني التعليمي للأطفالأمراض الكلى في

(0202السودان )

أحمد محمد بابكر أمنية

ملخص الدراسة

المتلازمة الكلوٌة هً أكثر أمراض الكلى المكتسبة شٌوعًا عند الأطفال. ٌعانً الأطفال المصابون من نوبات متكررة )أو انتكاسات( من البٌلة البروتٌنٌة التً قد تؤدي إلى

هدفت الصفاق والانصمام الخثاري ، هابمضاعفات تهدد الحٌاة بما فً ذلك الإنتان والتتقٌٌم معرفة الممرضات فٌما ٌتعلق بالرعاٌة التمرٌضٌة للأطفال الى هذه الدراسة

المصابٌن بالمتلازمة الكلوٌة. بمستشفى ود مدنً التعلٌمً للأطفال بولاٌة الجزٌرة. اشتمل الكلى وعددهم حجم عٌنة هذه الدراسة على جمٌع الممرضات العاملات فً قسم أمراض

(. تم جمع البٌانات من خلال استبٌان تم تحلٌله باستخدام الطرٌقة التحلٌلٌة الوصفٌة :7)٪( من ;.79( وأظهرت الدراسة أن )SPSSللحزمة الإحصائٌة للعلوم الاجتماعٌة )

المشاركٌن فً الدراسة لدٌهم معرفة ضعٌفة بعلامات وأعراض المتلازمة الكلوٌة المعرفة بشأن مضاعفات المتلازمة كٌن فً الدراسة ٌعانون من فقرشار٪( من الم9..7)

٪( المشاركٌن فً الدراسة 8..;الكلوٌة والتهاب كبٌبات الكلى الأولً. أكثر من نصف )المشاركٌن فً ٪( ;..9الكلوٌة. أكثر من نصف ) لدٌهم معرفة جٌدة بعلاجات المتلازمة

ور التمرٌض للمتلازمة الكلوٌة وعلامات حجم الدراسة لدٌهم معرفة معتدلة فٌما ٌتعلق بد٪( المشاركٌن فً الدراسة لدٌهم معرفة ;...السائل الزائد ، وكان أقل من نصف )

٪( 9..7ضعٌفة فٌما ٌتعلق بدور التمرٌض لحجم السوائل الزائد. أقل من نصف )ل من المشاركٌن فً الدراسة لدٌهم معرفة ضعٌفة فٌما ٌتعلق بدور التمرٌض للتعب. أق

( المشاركٌن فً الدراسة لدٌهم معرفة ضعٌفة فٌما ٌتعلق بدور التمرٌض 7..7نصف )٪( المشاركٌن فً الدراسة لدٌهم معرفة معتدلة 9.>8للمعرفة الناقصة. أكثر من نصف )

فٌما ٌتعلق بدور التمرٌض لخطر الإصابة. أوصت الدراسة بما ٌلً= برامج تدرٌبٌة التمرٌضً للأطفال المصابٌن بالمتلازمة الكلوٌة بمستشفى مقترحة للممرضات حول الدور ود مدنً التعلٌمً لطب الأطفال.

vii

List of Contents

Topic Page

Dedication Iii

Acknowledgement Iv

English Abstract V

Arabic Abstract Vi

List of Contents Vii

List of Tables Ix

List of Figures X

List of Abbreviations Xi

Chapter One Introduction

1.1 Background 1

1.2 Problem Statement 2

1.3 Justification 4

1.4 Objectives. 1.4. 1 General objective, 1.4.2 Specific objectives 5

Chapter Two Literature Review

2.1 Definition of Nephrotic syndrome: 6

2.2 Path physiology 6

2.3 Causes 7

2.4 signs and symptoms 10

2.5 Complication 11

2.6 Diagnosis: 14

2.7 Treatment 15

2.8 Prognosis 20

2.9 Epidemiology 20

2.10 Nursing Care Plans 21

viii

Chapter Three Materials and Methods

3.1. Study Design: 25

3.2. Study area: 25

3.3. Study Setting: 25

3.4. Study Participants: 25

3.5. Sample size: 25

3.6. Data collection tools: 26

2.7. Data analysis: 26

Chapter Four Results and Discussion

4.1 Results: 28

4.1 Discussion: 46

Chapter Five Conclusion and Recommendations

5.1 Conclusion 50

5.2 Recommendations 51

References 52

Appendix 55

ix

List of Tables

Table Title Page

Table (4.1) Distribution of the study participants according to their age groups and gender 28

Table (4.2) Distribution of the study participants according to their level of education and

years of experiences 29

Table (4.3) Distribution of the study participants according to their knowledge regarding

definition and signs and symptoms of nephrotic syndrome 32


complications of nephrotic syndrome and primary glomerulonephrosis 33


secondary glomerulonephrosis and histologic pattern Membranous nephropathy 34


pathophysiology and diagnosis of nephrotic syndrome (NS) 35


treatments and symptomatic treatment of nephrotic syndrome 36

Table (4.8)

Distribution of the study participants according to their knowledge regarding how

to manage the edema and the procedure of the strong diuretic action of

intravenous treatment

37


hypoalbuminemia and hyperlipidaemia 38


thrombophilia and infectious complications 39

Table (4.11)

Distribution of the study participants according to their knowledge regarding

treatment of kidney damage (corticosteroids) and prognosis for nephrotic

syndrome under treatment

40

Table (4.12)


nursing care plan for nephrotic syndrome and excess fluid volume (possibly

evidenced by)

41

Table (4.13)


nursing interventions for excess fluid volume and desired outcomes for excess

fluid volume

42

x


fatigue (Possibly evidenced by) and nursing interventions for fatigue 43

Table (4.15)


deficient knowledge (possibly evidenced by) and nursing interventions for

deficient knowledge

44


nursing interventions for risk for infection 45

Table (4.17) Total summary of Nurse’s Knowledge Regarding Nephrotic Syndrome 46

Table (4.18) Total summary of nursing care plans for children with nephrotic syndrome (NS ) 46

xi

List of Figures

Figure Title Page

Figure (4.1)

Distribution of the study participants according to their source of

knowledge regarding nursing care of pediatrics patients with

Nephrotic syndrome

30

Figure (4.2)

Distribution of the study participants according to receive training

programs regarding nursing care of pediatrics patients with Nephrotic

syndrome

31

xii

List of Abbreviations

NS Nephrotic Syndrome

MCNS Minimal Change Nephrotic Syndrome

ESRD End-Stage Renal Disease

MPGN Membranoproliferative GN

SLE Systemic Lupus Erythematosus

ENaC Epithelial Sodium Channel

MCD Minimal Change Disease

FSGS Focal Segmental Glomerulosclerosis

MGN Membranous glomerulonephritis

GFR Glomerular Filtration Rate

RPGN Rapidly Progressive Glomerulonephritis

MPGN Membranoproliferative Glomerulonephritis

SLE Systemic Lupus Erythematosus

FSGS Focal Segmental Glomerulosclerosis

CMP Comprehensive Metabolic Panel

LMWH Low Molecular Weight Heparin

OAC Oral Anticoagulants

CNS Congenital Nephrotic Syndrome

CCPD Continuous Cycling Peritoneal Dialysis

NCP Nursing Care Plans

NDs Nursing Diagnosis

SPSS Statistical Package for Social Sciences

WHO World Health Organization

1

1. Introduction

1.1 Background:

Nephrotic Syndrome (NS) is a clinical state that includes massive

proteinuria , hypoalbuminemia, hyperlipidemia, and edema. The disorder can

occur as first, primary disease known as idiopathic nephrosis, childhood

nephrosis or minimal change nephrotic syndrome (MCNS), second ,a secondary

disorder that occurs as clinical manifestation after or in association with

glomerular damage (Zolotas E. and Krishnan R.G. 2011).Nephrotic syndrome is

the most common acquired kidney disease in children. Affected children have

recurrent episodes (or relapses) of proteinuria that may lead to life-threatening

complications including sepsis, peritonitis and thromboembolism. The goals of

treatment are to induce remission of proteinuria, reduce the number of relapses,

minimize toxicity of treatments and delay kidney damage (Alharthi A.A.;

2011).Children will normally spend several days in hospital following a first

presentation with nephrotic syndrome. Even if there is not significant oedema, a

short admission will be necessary to teach children and their parents about

nephrotic syndrome. For many children with their initial presentation, there is

significant oedema and discharge date will be determined according to when the

child is judged to be cardiovascularly stable. Each day during their in-patient

stay, children should have a thorough assessment of their fluid status including

accurately completed fluid balance charts, regularly blood pressure monitoring

and a daily weight. They should be examined daily for extent of oedema and

signs of hypovolaemia (Alharthi A.A.; 2011).Nurses play an important role in

nursing care of children with nephrotic syndrome. The pediatric nurse should

advise or supervise or teach as well as to give expert nursing care. She should be

able to give the most care for children during the period of hospitalization. The

important nursing role of the child with nephrotic syndrome includes observation

of the child and his family during hospitalization, monitoring of vital signs,

giving medications, making balance sheet between fluid intake and fluid output,

urine analysis daily and observe urine (colour , amount) teaching of child and

2

hisfamily treatment program and support to the children and their parent (Amro

A.H., Hagras A.M, et al; 2012).

1.2 Problem statement:

In Worldwide:

Where there are large diaspora participantss, such as the United

Kingdom, South Asians are reported to have a higher incidence of nephrotic

syndrome ranging from 7.4 to 16.9 per 100,000 persons compared to Europeans

(14, 24, 25). Studies from the US report a higher estimated incidence among

children of African compared to European descent.

In Developed countries:

Over 10 years, the overall incidence increased from 1.99/100,000 to

4.71/100,000 among children ages 1–18 years old. In 2011, South Asians had a

higher incidence rate ratio of 6.61 (95% confidence interval, 3.16 to 15.1)

compared with Europeans. East/Southeast Asians had a similar incidence rate

ratio (0.76; 95% confidence interval, 0.13 to 2.94) to Europeans.

In Developing countries:

In Nigeria the describe the current spectrum of pediatric nephrology

disease in a tertiary hospital in Sub-Saharan Africa and highlight the challenges

encountered in their care.. Results were compared with nationwide data. Kidney

diseases accounted for 8.9% of pediatric admissions Nephrotic syndrome, acute

kidney injury and nephroblastoma accounted for almost 70% of admissions.

(Taiwo A Ladapo, et al, 2014).

In Sudan:

Retrospectively reviewed the clinical records of 321 children seen with

nephritis/nephrosis at the Pediatric Nephrology Unit, Soba University Hospital

and Dr. Salma Dialysis and Kidney Transplantation Centre, Khartoum, Sudan

during the period from 2002 to 2007. Biopsies were studied with light

microscopy and immuno-histochemistry with electron microscopy performed

abroad in selected patients (predominantly Alport's). The mean age of the 321

study children was 8.71 years (range 2 months-16 yrs) of whom, 188 were males

3

(60.2%). The most common presentation was with the nephrotic syndrome, seen

in 202 patients (62.9%) the most common glomerular disease encountered was

minimal change disease, seen in 96 children (29.9%), focal and segmental

glomerulosclerosis, seen in 44 patients (13.7%). Membranoproliferative GN was

seen in 43 patients (13.4%) while mesangioproliferative GN was seen in 24

(7.5%). Systemic lupus erythematosus (SLE) was the most common secondary

glomerular disease accounting for 16 patients (4.9%), HBsAg was positive in 10

patients and the most common associated lesion was MPGN (60%).

(Abdelraheem MB, Ali el-TM, Mohamed RM, et al, 2010).

4

1.3 Justification :

Nurses play an important role in nursing care of children with nephritic

syndrome. The nurse should advise and supervise and teach as well as to give

expert nursing care. She should be able to give the most care for children during

the period of hospitalization. The important nursing role includes observation of

the child and his family during hospitalization , monitoring of vital signs, giving

medications, making fluid balance sheet ,urine analysis daily and observe urine

(colour ,amount) teaching of child and his family treatment program and support

to the children and their parent .There is a lack knowledge of nursing assessment

regarding nephrotic syndrome such as hypovolumia and edema and protinuria

and that is lead to recurrent admission with long hospitalization.

5

1.4.Objectives:

4.1 General objective:

• To study nurse’s knowledge regarding nursing care of children with

nephritic syndrome at Pediatrics Teaching Hospital, Gezira State, Sudan

during the period of the study (May-August-2020)

1.4.2 Specific objectives:

• To identify the nurses knowledge regarding definition, causes, treatment,

and complication of disease and treatment during the period of the study.

• To assess the nurses knowledge regarding nursing role of nephritic

syndrome during the period of the study.

6

2. Literature Review

2.1 Definition of Nephrotic syndrome:

Nephrotic syndrome is a collection of symptoms due to kidney damage.

This includes protein in the urine, low blood albumin levels, high blood lipids,

and significant swelling. Other symptoms include the following weight gain,

feeling tired, and foamy urine. Complications include the following blood clots,

infections, and high blood pressure.Causes include a number of kidney diseases

such as focal segmental glomerulosclerosis, membranous nephropathy, and

minimal change disease (Kher, Kanwal; Schnaper, H. et al, 2016). It may also

occur as a complication of diabetes or lupus. The underlying mechanism

typically involves damage to the glomeruli of the kidney. Diagnosis is typically

based on urine testing and sometimes a kidney biopsy. It differs from nephritic

syndrome in that there are no red blood cells in the urine (Ferri, Fred F. 2017).

2.2 Pathophysiology:

The kidney glomerulus filters the blood that arrives at the kidney. It is formed of

capillaries with small pores that allow small molecules to pass through that have

a molecular weight of less than 40,000 Daltons, but not larger macromolecules

such as proteins.In nephrotic syndrome the glomeruli are affected by an

inflammation or a hyalinization (the formation of a homogenous crystalline

material within cells) that allows proteins such as albumin, antithrombin or the

immunoglobulins to pass through the cell membrane and appear in

urine.Albumin is the main protein in the blood that is able to maintain an oncotic

pressure, which prevents the leakage of fluid into the extracellular medium and

the subsequent formation of edemas.(Curtis, Michael J.; Page, Clive P.;et al.;

2015).As a response to hypoproteinemia the liver commences a compensatory

mechanism involving the synthesis of proteins, such as alpha-2 macroglobulin

and lipoproteins. An increase in the latter can cause the hyperlipidemia

associated with this syndrome (Ferri, Fred F. 2017)

7

2.3 Causes:

Nephrotic syndrome has many causes and may either be the result of a

glomerular disease that can be either limited to the kidney, called primary

nephrotic syndrome (primary glomerulonephrosis), or a condition that affects the

kidney and other parts of the body, called secondary nephrotic syndrome. (Kher,

Kanwal; Schnaper, H. et al, 2016).

Primary glomerulonephrosis

Primary causes of nephrotic syndrome are usually described by their histology:

Minimal change disease (MCD): is the most common cause of nephrotic

syndrome in children. It owes its name to the fact that the nephrons

appear normal when viewed with an optical microscope as the lesions are

only visible using an electron microscope.

Focal segmental glomerulosclerosis (FSGS): It is characterized by the

appearance of tissue scarring in the glomeruli. The term focal is used as

some of the glomeruli have scars, while others appear intact; the term

segmental refers to the fact that only part of the glomerulus suffers the

damage.

Membranous glomerulonephritis (MGN):The inflammation of the

glomerular membrane causes increased leaking in the kidney

Membranoproliferative glomerulonephritis (MPGN): is the inflammation

of the glomeruli along with the deposit of antibodies in their membranes

which makes filtration difficult.

Rapidly progressive glomerulonephritis (RPGN): (Usually presents as a

nephritic syndrome) It is characterized clinically by a rapid decrease in

the glomerular filtration rate (GFR) by at least 50% over a short period,

usually from a few days to 3 months.(Kher, Kanwal; Schnaper, H. et al,

2016). they are diagnosed only after secondary causes have been

excluded.(Curtis, Michael J.; Page, Clive P.;et al.; 2015).

8

Secondary glomerulonephrosis:

Secondary causes of nephrotic syndrome have the same histologic patterns as

the primary causes, though they may exhibit some difference suggesting a

secondary cause, such as inclusion bodies. They are usually described by the

underlying cause.

Diabetic nephropathy: is a complication that occurs in some diabetics.

Excess blood sugar accumulates in the kidney causing them to become

inflamed and unable to carry out their normal function. This leads to the

leakage of proteins into the urine.

Systemic lupus erythematosus: this autoimmune disease can affect a

number of organs, among them the kidney, due to the deposit of

immunocomplexes that are typical to this disease. The disease can also

cause lupus nephritis.

Sarcoidosis: This disease does not usually affect the kidney but, on

occasions, the accumulation of inflammatory granulomas (collection of

immune cells) in the glomeruli can lead to nephrotic syndrome.

Syphilis: kidney damage can occur during the secondary stage of this

disease (between 2 and 8 weeks from onset).

Hepatitis B: certain antigens present during hepatitis can accumulate in

the kidneys and damage them.

Sjögren's syndrome: same mechanism as occurs in systemic lupus

erythematosus.

HIV: the virus's antigens provoke an obstruction in the glomerular

capillary's lumen that alters normal kidney function.

Amyloidosis: the deposit of amyloid substances (proteins with anomalous

structures) in the glomeruli modifying their shape and function.

Multiple myeloma: kidney impairment is caused by the accumulation and

precipitation of light chains, which form casts in the distal tubules,

resulting in kidney obstruction. In addition, myeloma light chains are also

directly toxic on proximal kidney tubules, further adding to kidney

dysfunction.

9

Vasculitis: inflammation of the blood vessels at a glomerular level

impedes the normal blood flow and damages the kidney.

Cancer: as happens in myeloma, the invasion of the glomeruli by

cancerous cells disturbs their normal functioning.(Fogo AB, Bruijn JA.;

et al.; 2016).

Drugs ( e.g. gold salts, penicillin, captopril): gold salts can cause a more

or less important loss of proteins in urine as a consequence of metal

accumulation. Penicillin is nephrotoxic in people with kidney failure and

captopril can aggravate proteinuria. (Behrman, Richard E.; 2015).

By histologic pattern

Membranous nephropathy (MN)

Sjögren's syndrome

Systemic lupus erythematosus (SLE)

Diabetes mellitus

Sarcoidosis

Drugs (such as corticosteroids, gold, intravenous heroin)

Malignancy (cancer)

Bacterial infections, e.g. leprosy & syphilis

Protozoal infections, e.g. malaria (Goldman, Lee; Braunwald, Eet al.;

2015).

2.4 Signs and symptoms:

Nephrotic syndrome is characterized by large amounts of proteinuria

(>3.5 g per 1.73 m2 body surface area per day, or > 40 mg per square meter body

surface area per hour in children), hypoalbuminemia (<2.5 g/dl),

hyperlipidaemia, and edema that begins in the face. Lipiduria (lipids in urine) can

also occur, but is not essential for the diagnosis of nephrotic syndrome.

Hyponatremia also occurs with a low fractional sodium excretion (Fogo AB,

Bruijn JA.; et al.; 2016).

11

2.4.1 Hyperlipidaemia is caused by two factors:

Hypoproteinemia stimulates protein synthesis in the liver, resulting in the

overproduction of lipoproteins.

Lipid catabolism is decreased due to lower levels of lipoprotein lipase,

the main enzyme involved in lipoprotein breakdown. Cofactors, such as

apolipoprotein C2 may also be lost by increased filtration of

proteins(Fogo AB, Bruijn JA.; et al.; 2016).

Edema (Lower serum oncotic pressure causes fluid to accumulate in the

interstitial tissues) Sodium and water retention aggravates the edema.

This may take several forms:

o Puffiness around the eyes, characteristically in the morning.

o Pitting edema over the legs.

o Fluid in the pleural cavity causing pleural effusion. More

commonly associated with excess fluid is pulmonary edema.

o Fluid in the peritoneal cavity causing ascites.

o Generalized edema throughout the body known as anasarca.

Hypertension may also occur.

Anaemia (iron resistant microcytic hypochromic type) maybe present due

to transferrin loss.

Dyspnea may be present due to pleural effusion or due to diaphragmatic

compression with ascites.

Erythrocyte sedimentation rate is increased due to increased fibrinogen &

other plasma contents.

foamy or frothy urine, due to a lowering of the surface tension by the

severe proteinuria.

May have features of the underlying cause, such as the rash associated

with systemic lupus erythematosus, or the neuropathy associated with

diabetes(Fogo AB, Bruijn JA.; et al.; 2016).

Examination should also exclude other causes of gross edema—

especially the cardiovascular and liver system.

Muehrcke's nails; white lines (leukonychia) that extend all the way across

the nail and lie parallel to the lunula. (Fogo AB, Bruijn JA.; et al.; 2016).

11

A proteinuria of greater than 3.5 g /24 h /1.73 m2 (between 3 and 3.5 g/24

h /1.73 m2 is considered to be proteinuria in the nephrotic range) or

greater than 40 mg/h/m2 in children. The ratio between urinary

concentrations of albumin and creatinin can be used in the absence of a

24-hour urine test for total protein. This coefficient will be greater than

200–400 mg/mmol in nephrotic syndrome. Under normal conditions a 24-

hour urine sample should not exceed 80 milligrams or 10 milligrams per

deciliter (SazPeiro, Pablo. 2019).

A hypoalbuminemia of less than 2.5 g/dL, that exceeds the liver clearance

level, that is protein synthesis in the liver is insufficient to increase the

low blood protein levels.

Hyperlipidaemia is caused by an increase in the synthesis of low and very

low-density lipoproteins in the liver that are responsible for the transport

of cholesterol and triglycerides. There is also an increase in the liver

synthesis of cholesterol. (Ferri, Fred F. 2017).

Thrombophilia, or hypercoagulability, is a greater predisposition for the

formation of blood clots that is caused by a decrease in the levels of

antithrombin III in the blood due to its loss in urine.

Lipiduria or loss of lipids in the urine is indicative of glomerular

pathology due to an increase in the filtration of lipoproteins (Ferri, Fred

F. 2017).

2.5 Complications

Nephrotic syndrome can be associated with a series of complications that can

affect an individual's health and quality of life:

Thromboembolic disorders: particularly those caused by a decrease in

blood antithrombin III levels due to leakage (Curtis, Michael J.; Page,

Clive P.;et al.; 2015).

Infections: The increased susceptibility of people with nephortic

Syndrome to infections can be a result of the leakage of immunoglobulins

from the blood. The most common infection is peritonitis, followed by

lung, skin and urinary infections, meningoencephalitis and in the most

12

serious cases septicaemia. The most notable of the causative organisms

are Streptococcus pneumoniae and Haemophilusinfluenzae.

Spontaneous bacterial peritonitis can develop where there is ascites

present. (Kher, Kanwal; Schnaper, H. et al, 2016).

Acute kidney failure due to hypovolemia: the loss of vascular fluid into

the tissues (edema) produces a decreased blood supply to the kidneys that

causes a loss of kidney function.

Pulmonary edema: the loss of proteins from blood plasma and the

consequent fall in oncotic pressure causes an abnormal accumulation of

liquid in the lungs causing hypoxia and dyspnea.

Hypothyroidism: deficiency of the thyroglobulin transport protein

thyroxin (a glycoprotein that is rich in iodine and is found in the thyroid

gland) due to decreased thyroid binding globulin.

Vitamin D deficiency can occur Vitamin D binding protein is lost.

Hypocalcaemia: lack of 25-hydroxycholecalciferol (the way that vitamin

D is stored in the body). As vitamin D regulates the amount of calcium

present in the blood, a decrease in its concentration will lead to a decrease

in blood calcium levels

Microcytic hypochromic anaemia: iron deficiency caused by the loss of

ferritin (compound used to store iron in the body).

Protein malnutrition: this occurs when the amount of protein that is lost in

the urine is greater than that ingested, this leads to a negative nitrogen

balance.

Growth retardation: can occur in cases of relapse or resistance to therapy.

Causes of growth retardation are protein deficiency from the loss in urine

Cushing's syndrome. (Ferri, Fred F. 2017).

2.6 Diagnosis:

A long with obtaining a complete medical history.

A series of biochemical tests are required in order to arrive at an accurate

diagnosis that verifies the presence of the illness

Imaging of the kidneys (for structure and presence of two kidneys) is

sometimes carried out, and/or a biopsy of the kidneys.

13

Urinalysis test for high levels of proteins, the test will involve a 24-hour

bedside urinary total protein estimation.

Blood screen, comprehensive metabolic panel (CMP) will look for

hypoalbuminemia: albumin levels of ≤2.5 g/dL (normal=3.5-5 g/dL).

Creatinine Clearance CCr test will evaluate kidney function particularly the

glomerular filtration capacity.

Electrolytes and urea levels may also be analysed at the same time as

creatinine (EUC test) in order to evaluate kidney function.

A lipid profile will also be carried out as high levels of cholesterol

(hypercholesterolemia), LDL,VLDL, is indicative of nephrotic syndrome

(Behrman, Richard E.; 2015).

A kidney biopsy may also be used as a more specific and invasive test

method.

2.6.1 Differential diagnosis

Some symptoms that are present in nephrotic syndrome, such as edema

and proteinuria, also appear in other illnesses. Therefore, other pathologies need

to be excluded in order to arrive at a definitive diagnosis.(Curtis, Michael J.;

Page, Clive P.;et al.; 2015).

Edema: in addition to nephrotic syndrome there are two other disorders

that often present with edema; these are heart failure and liver failure. Congestive

heart failure can cause liquid retention in tissues as a consequence of the

decrease in the strength of ventricular contractions. Liver failure caused by

cirrhosis, hepatitis and other conditions such as alcoholism, IV drug use or some

hereditary diseases can lead to swelling in the lower extremities and the

abdominal cavity.. Less frequently symptoms associated with the administration

of certain pharmaceutical drugs have to be discounted. These drugs promote the

retention of liquid in the extremities such as occurs with NSAIs, some

antihypertensive drugs, the adrenal corticosteroids and sex hormones. (Ferri,

Fred F. 2017).

Proteinuria: the loss of proteins from the urine is caused by many pathological

agents and infection by these agents has to be ruled out before it can be certain

14

that a person has nephrotic syndrome. Multiple myeloma can cause a proteinuria

that is not accompanied by hypoalbuminemia.In diabetes mellitus there is an

association between increases in glycated hemoglobin levels and the appearance

of proteinuria. Other causes are amyloidosis and certain other allergic and

infectious diseases. (Goldman, Lee; Braunwald, Eet al.; 2015).

2.7 Treatment

The treatment of nephrotic syndrome can be symptomatic or can directly

address the injuries caused to the kidney. (Voguel S, Andrea; Azócar P,; et al,

2018).

2.7.1 Symptomatic:

The objective of this treatment is to treat edema, hypoalbuminemia,hyperlipemia,

hypercoagulability and infectious complications.

Edema:

Rest: depending on the seriousness of the edema and taking into account

the risk of thrombosis caused by prolonged bed rest.

Medical nutrition therapy: based on a diet with the correct energy intake

and balance of proteins that will be used in synthesis processes and not as

a source of calories. A total of 35 kcal/kg body weight/day is normally

recommended. This diet should also comply with two more requirements:

the first is to not consume more than 1 g of protein/kg body weight/ day,

as a greater amount could increase the degree of proteinuria and cause a

negative nitrogen balance. People are usually recommended lean cuts of

meat, fish, and poultry. The second guideline requires that the amount of

water ingested is not greater than the level of diuresis. In order to

facilitate this the consumption of salt must also be controlled, as this

contributes to water retention. It is advisable to restrict the ingestion of

sodium to 1 or 2 g/day, which means that salt cannot be used in cooking

and salty foods should also be avoided. Foods high in sodium include

seasoning blends (garlic salt, Adobo, season salt, etc.) canned soups,

canned vegetables containing salt, luncheon meats including turkey, ham,

15

bologna, and salami, prepared foods, fast foods, soy sauce, ketchup, and

salad dressings.

Medication: The pharmacological treatment of edema is based on diuretic

medications (especially loop diuretics, such as furosemide). In severe

cases of edema (or in cases with physiological repercussions, such as

scrotal, preputial or urethral edema) or in peoeple with one of a number

of severe infections (such as sepsis or pleural effusion), the diuretics can

be administered intravenously. This occurs where the risk from plasmatic

expansion is considered greater than the risk of severe hypovolemia,

which can be caused by the strong diuretic action of intravenous

treatment. : (Voguel S, Andrea; Azócar P,; et al, 2018).

The procedure is the following :

o Analysehaemoglobin and haematocrit levels.

o A solution of 25% albumin is used that is administered for only

4 hours in order to avoid pulmonary edema.

o Haemoglobin and haematocrit levels are analysed again: if the

haematocrit value is less than the initial value (a sign of correct

expansion) the diuretics are administered for at least 30

minutes. If the haematocrit level is greater than the initial one

this is a contraindication for the use of diuretics as they would

increase said value.(Goldman, Lee; Braunwald, Eet al.; 2015).

It may be necessary to give a person potassium or require a change in

dietary habits if the diuretic drug causes hypokalaemia as a side effect. (Curtis,

Michael J.; Page, Clive P.;et al.; 2015).

Hypoalbuminemia: is treated using the medical nutrition therapy described as a

treatment for edema. It includes a moderate intake of foods rich in animal

proteins.

Hyperlipidaemia: depending of the seriousness of the condition it can be treated

with medical nutrition therapy as the only treatment or combined with drug

therapy. The ingestion of cholesterol should be less than 300 mg/day, which will

require a switch to foods that are low in saturated fats. Avoid saturated fats such

16

as butter, cheese, fried foods, egg yolks, and poultry skin. Increase unsaturated

fat intake, including olive oil, canola oil, peanut butter, avocadoes, fish and nuts.

In cases of severe hyperlipidaemia that are unresponsive to nutrition therapy the

use of hypolipidemic drugs, may be necessary (these include statins, fibrates and

resinous sequesters of bile acids) (Curtis, Michael J.; Page, Clive P.;et al.; 2015).

Thrombophilia: low molecular weight heparin (LMWH) may be appropriate for

use as a prophylactic in some circumstances, such as in asymptomatic people that

have no history of suffering from thromboembolism. When the thrombophilia is

leads to the formation of blood clots, heparin is given for at least 5 days along

with oral anticoagulants (OAC). During this time and if the prothrombin time is

within its therapeutic range (between 2 and 3), it may be possible to suspend the

LMWH while maintaining the OACs for at least 6 months.(Behrman, Richard E.;

2015).

Infectious complications: an appropriate course of antibacterial drugs can be

taken according to the infectious agent.

In addition to these key imbalances, vitamin D and calcium are also taken

orally in case the alteration of vitamin D causes a severe hypocalcaemia, this

treatment has the goal of restoring physiological levels of calcium in the person.

Achieving better blood glucose level control if the person is diabetic. Blood

pressure control. ACE inhibitors are the drug of choice. Independent of their

blood pressure lowering effect, they have been shown to decrease protein loss.


Kidney damage

The treatment of kidney damage may reverse or delay the progression of

the disease. Kidney damage is treated by prescribing drugs:

Corticosteroids: the result is a decrease in the proteinuria and the risk of

infection as well as a resolution of the edema. Prednisone is usually prescribed at

a dose of 60 mg/m2 of body surface area/day in a first treatment for 4–8 weeks.

After this period the dose is reduced to 40 mg/m2 for a further 4 weeks. People

suffering a relapse or children are treated with prednisolone 2 mg/kg/day till

urine becomes negative for protein. Then, 1.5 mg/kg/day for 4 weeks. Frequent

17

relapses treated by: cyclophosphamide or nitrogen mustard or ciclosporin or

levamisole. People can respond to prednisone in a number of different ways:

People with Corticosteroid sensitive or early steroid-responder: the subject

responds to the corticosteroids in the first 8 weeks of treatment. This is

demonstrated by a strong diuresis and the disappearance of edemas, and also by a

negative test for proteinuria in three urine samples taken during the night.

People with Corticosteroid resistant or late steroid-responder: the proteinuria

persists after the 8-week treatment. The lack of response is indicative of the

seriousness of the glomerular damage, which could develop into chronic kidney

failure.People with Corticosteroid intolerant: complications such as hypertension

appear, and they gain a lot of weight and can develop aseptic or avascular

necrosis of the hip or knee, cataracts and thrombotic phenomena and/or

embolisms. People with Corticosteroid dependent : proteinuria appears when the

dose of corticosteroid is decreased or there is a relapse in the first two weeks

after treatment is completed.The susceptibility testing in vitro to glucocorticoids

on the person's peripheral blood mononuclear cells is associated with the number

of new cases of not optimal clinical responses: the most sensitive people in vitro

have shown a higher number of cases of corticodependence, while the most

resistant people in vitro showed a higher number of cases of ineffective therapy.

(Behrman, Richard E.; 2015).Immunosupressors (cyclophosphamide): only

indicated in recurring nephrotic syndrome in corticosteroid dependent or

intolerant people. In the first two cases the proteinuria has to be negated before

treatment with the immunosuppressor can begin, which involves a prolonged

treatment with prednisone. The negation of the proteinuria indicates the exact

moment when treatment with cyclophosphamide can begin. The treatment is

continued for 8 weeks at a dose of 3 mg/kg/day, the immunosuppression is halted

after this period. In order to be able to start this treatment the person should not

be suffering from neutropenia nor anaemia, which would cause further

complications. A possible side effect of the cyclophosphamide is alopecia


18

2.8 Prognosis:

The prognosis for nephrotic syndrome under treatment is generally good

although this depends on the underlying cause, the age of the person and their

response to treatment. It is usually good in children, because minimal change

disease responds very well to steroids and does not cause chronic kidney failure.

Any relapses that occur become less frequent over time; the opposite occurs with

mesangiocapillary glomerulonephritis, in which the kidney fails within three

years of the disease developing, making dialysis necessary and subsequent

kidney transplant. In addition children under the age of 5 generally have a poorer

prognosis than prepubescents, as do adults older than 30 years of age as they

have a greater risk of kidney failure.Other causes such as focal segmental

glomerulosclerosis frequently lead to end stage kidney disease. Factors

associated with a poorer prognosis in these cases include level of proteinuria,

blood pressure control and kidney function (GFR).Without treatment nephrotic

syndrome has a very bad prognosis especially rapidly progressing

glomerulonephritis, which leads to acute kidney failure after a few months.(Kher,

Kanwal; Schnaper, H. et al, 2016).

2.9 Epidemiology

Nephrotic syndrome can affect any age, although it is mainly found in

adults with a ratio of adults to children of 26 to 1.The syndrome presents in

different ways in the two groups: the most frequent glomerulopathy in children is

minimal change disease (66% of cases), followed by focal segmental

glomerulosclerosis (8%) and mesangiocapillary glomerulonephritis (6%)(Voguel

S, Andrea; Azócar P,; et al, 2018).There are also differences in epidemiology

between the sexes, the disease is more common in men than in women by a ratio

of 2 to 1.The epidemiological data also reveals information regarding the most

common way that symptoms develop in people with nephritic syndrome:

spontaneous remission occurs in up to 20% or 30% of cases during the first year

of the illness. However, this improvement is not definitive as some 50% to 60%

of people with Nephrotic syndrome die and / or develop chronic kidney failure 6

to 14 years after this remission (Curtis, Michael J.; Page, Clive P.;et al.; 2015).

19

2.10 Nurses Role For Child with Nephritic Syndrom

Nursing role for a child with nephrotic syndrome include relief from

edema, enhance nutritional status, conserve energy, supply sufficient information

about the disease, importance of strict compliance with the medication and

nutritional therapy, and absence of infection or prevention of a relapse.

Nursing diagnosis (NDs) for Nephritic Syndrome:

• Excess Fluid Volume

• Imbalanced Nutrition: Less Than Body Requirements

• Fatigue

• Deficient Knowledge

• Risk For Infection

Excess Fluid Volume: Increased isotonic fluid retention may be related to

decreased kidney function and fluid accumulation possibly evidenced

by(Pitting edema, periorbital and facial puffiness in morning, abdominal

ascites, Scrotal or labial edema,Edema of mucous membranes of

intestines, Anasarca, Slow weight gain,Decreased urine output

Desired Outcomes:Child’s edema will be decreased and achieve ideal body

weight without excess fluids.

Nursing interventions for excess fluid volume includes:

Weigh child daily utilize same weighing scale every day.

Strictly monitor and record intake and output.

Advised to limit fluid intake as order.

Instruct parents to provide frequent oral hygiene.

Administer medication as order.

Teach parents how to dipstick urine testing and urine collection

Imbalanced Nutrition: Less Than Body Requirements: Intake of nutrients

insufficient to meet metabolic needs may be related to inability to ingest

and digest foods and absorb nutrients sign of it includes,Anorexia,Weight

https://nurseslabs.com/imbalanced-nutrition-less-body-requirements/

21

loss,Edema of intestinal tract affecting absorption,Rejection of low salt

diet,Loss of protein [negative nitrogen balance]

Nursing interventions for imbalance nutrition less than body

requement.

Monitor child’s weight daily (using the same scale with the child

in the same clothing at the same time)

Assess child’s nutritional daily patterns including food preference,

caloric intake , and diet history.

Encourage high potassium ,low sodium diet with moderate

amount of protein.

Provide comfortable and delightful environment during meal

times

Refer to dietitian for a comprehensive nutrition assessment and

method for nutritional support.

Consider six small nutrient dense meals to reduce feeling of

fullness.

Fatigue :An overwhelming, sustained sense of exhaustion and decreased

capacity for physical and mental work at usual level may be related to

discomfort signs of it include, Easily fatigued with any activity,Extreme

edema,Lethargy

Desired Outcomes:Child will alternate activity with rest periods.

Nursing Interventions for fatigue include:

Assess extent of fatigue ,weakness,degree of edema and difficult

movement or activity in bed.

Plan activities with consideration and observe for changes in behavior

following in activity

Reinforce bed rest during the most acute stage

Provide chosen play activities as tolerated and modify the schedule to

allow for rest periods and after activity

21

Deficient Knowledge:Absence or deficiency of cognitive information related to

specific topic may be related to Lack of exposure to information about the

disease possibly evidenced by expressed need for information about the disease,

drug administration, follow-up care and procedures, Anxiety associated with

relapse of disease

Desired Outcomes:Parents verbalize understanding of cause and treatment for

illness.

Nursing intervention for deficient knowledge includes:

Assess knowledge of disease, signs and symptoms, dietary and

activity aspects of care, medication, monitor urine and vital signs.

Assess anxiety level and need for assistance in the care for ailing

child.

Educate child and parent and who are care him possibility of

relapse to prevent infection.

Notify parent that immunization may be delayed.

Encourage parents for questions and allow time for discussion

Educate parents about administration of medication and side

effect of steroid and immunosuppressive.

Offer parents and child with praise and encouragement as they

acquire skills.

Reinforce physician instructions about sodium restriction , activity

progression and pacing.

Educate child and parents to observe vital signs and monitor urine

for colour and amount.

https://nurseslabs.com/10-rs-rights-of-drug-administration/

https://nurseslabs.com/anxiety/

22

Risk For Infection: At increased risk for being invaded by pathogenic

organisms may be related to Inadequate secondary defenses.

Nursing intervention for risk of infection:

Assess for an increase in temperature, respiratory , urinary, skin

changes.

Maintain and teach medical aseptic techniques and hand washing

when providing care.

Maintain warmth for child ,regulate room environment

temperature and humidity.

Administer antibiotic therapy as ordered.

Advise parents to immediately notify the physician of signs or

symptom of infection (Source: Paul Martin, BSN, R.N., 2018 )

23

3. Materials and Methods

3.1. Study Design:

This study is a descriptive cross sectional hospital based study.

3.2. Study area:

Gezira state is one of the 18 states of Sudan. The state lies between

the Blue Nile and the White Nile in the east-central region of the country. It has

an area of 27,549 km2. The name comes from the Arabic word for island. Wad

Madani is the capital of the state. (Home review 2013)

3.3. Study Setting:

The study was conducted at Wad Medani Pediatric Teaching Hospital in

Gezira state. It provider care to large number of participants in and out state.

3.4. Study Participants:

The study was involved all nurses available at Wad Medani Pediatric Teaching

Hospital during the period of study.(from May-Auguest2020)

3.5. Sample size:

A convenient sample of 47 nurses who are working at pediatric teaching

hospital .

3.6. Data collection tool :

Self administered questionnaire include three following parts:

part one: demographic data of nurses such as (age group, gender, years of

experiences and educational level and etc.) part two: utilized nurses' knowledge

regarding NS such as (definition, signs and symptoms, complications and etc.)

part three: nurses' knowledge regarding nursing care of pediatrics patients with

NS).

https://en.wikipedia.org/wiki/States_of_Sudan

https://en.wikipedia.org/wiki/Sudan

https://en.wikipedia.org/wiki/Blue_Nile

https://en.wikipedia.org/wiki/White_Nile

https://en.wikipedia.org/wiki/Arabic_language

https://en.wikipedia.org/wiki/Wad_Madani

https://en.wikipedia.org/wiki/Wad_Madani

24

2.7. Data analysis:

The data was analyzed using Statistical Package for Social Sciences

(SPSS) descriptive statistics methodswas used.

Data presentation:

Knowledge were arbitrarily classified as given below based on percentage of

scores obtained

≤ 50% poor knowledge.

51 to 74% moderate knowledge.

≥75% very good knowledge. (Arthur J., et al, 2006).

2.8. Ethical considerations:

Each nurse was asked to give oral consent to participate in the study after full

explanation of the nature and main aim of the study. Each participant was free to

either participate or not in this study and had the right to withdraw from the study

at any time without any rational. .Official later was sent from the faculty of

applied medical science,university of gazira to the director of each study

sitting,to attain the permission to carry out the study.

25

4. Results and Discussion

4.1 Results

Demographic data:

Table {4.1}: Distribution of the study participants according to their age

groups and gender:

No= 47

Age groups No %

20 – 25 years 7 14.9%

26 – 30 years 10 21.2%

31 – 35 years 10 21.2%

36 – 40 years 11 23.6%

More than 40 years 9 19.1%

Total 47 100%

Gender No %

Male 2 4.3%

Female 45 95.7%

Total 47 100%

Table (4.1) shows that (23.6%) of the study participantstheir age were ranged

between 36 – 40 years.While (95.7%) were female.

26

Table {4.2}: Distribution of the study participants according to their

qualifications andyears of experiences:

No =47

Qualifications No %

Technical nursing certificate 10 21.3%

Diploma 12 25.5%

Bachelor 18 38.3%

Post graduate 7 14.9%

Total 47 100%

Years of experiences No %

1 to 4 years 15 31.9%

5 to 9 years 10 21.2%

10 to 14 years 9 19.1%

More than 15 years 13 27.7%

Total 47 100.0%

Table (4.2) revealed that(38.3%) of the participantshad bachelor degree.

Regarding years of experiencers also they found that (31.9%) of the

participantstheir experiences ranged between 1 to 4 years.

27

No =47

Figure (4.1) Distribution of the study participants according to their source

of knowledge regarding nursing care of pediatrics patients with Nephrotic

syndrome:

Figure (4.1) Illustrated that more than half 51.1% of the study participants their

source of knowledge regarding nursing care of pediatrics patients with Nephrotic

syndrome from colleagues.

UniversityMass-mediaTrainingPrograms

Books andReferences

Colleagues

21.20%

8.90% 14.90%

4.30%

51.10%

28

No = 47

Figure (4.2) Distribution of the study participants according to receive

training programs regarding nursing care of pediatrics patients with

Nephrotic syndrome:

Figure {4.2} illustrated that (17.1%) of the study participantshad received

training programs regarding nursing care of pediatrics patients with Nephrotic

syndrome.

No 82.9%

Yes 17.1%

29

4.1.2 Nurse’s Knowledge Regarding Nursing Role of Pediatric Patients with

Nephrotic Syndrome

Table (4.3): Distribution of the study participants according to their

knowledge regarding definition and signs and symptoms of nephrotic

syndrome

No =47

Nurses' knowledge

Adequate

knowledge

Moderately

adequate

knowledge

Inadequate

knowledge

Total

No % No % No % No %

Definition of Nephrotic syndrome 25 53.2% 13 27.7% 9 19.1% 47 100

Signs and symptoms 22 46.8% 15 31.9% 10 21.2% 47 100

Table (4.3) shows that (53.2% and 46.8%) of the study participants had Adequate

knowledge regarding definition of nephrotic syndrome and signs and

symptomsof nephrotic syndrome respectively.

31


knowledge regarding complications of nephrotic syndrome and primary

glomerulonephrosis

No =47

Nurses' knowledge

Adequate

knowledge

Moderately

Adequate

knowledge

Inadequate

knowledge

Total

No % No % NO % No %

complications of nephrotic syndrome 20 42.6% 18 38.3% 9 19.1% 47 100

primary glomerulonephrosis 18 38.3% 17 36.2% 12 25.5% 47 100

Table (4.4) revealed that (42.6% and 38.3%) of the study participants had

Adequate knowledge regarding complications of nephrotic syndrome and

primary glomerulonephrosis respectively.

31


knowledge regarding secondary glomerulonephrosis and histological pattern

Membranous nephropathy

No =47

Nurses' knowledge

Adequate

knowledge

Moderately

Adequate

knowledge

Inadequate

knowledge

Total

No % No % No % No %

secondary glomerulonephrosis 16 34.0% 22 46.8% 9 19.1% 47 100

histologic pattern Membranous

nephropathy

21 44.7% 17 36.2% 10 21.2% 47 100

Table (4.5) shows that (34.0% and 44.7%) of the study participants had Adequate

knowledge regarding secondary glomerulonephrosis and histologic pattern

Membranous nephropathy respectively.

32


knowledge regarding pathophysiology and diagnosis of nephrotic syndrome

(NS)

No =47

Nurses' knowledge

Adequate

knowledge

Moderately

adequate

knowledge

Inadequate

knowledge

Total

No % No % No % No %

pathophysiology of nephrotic

syndrome

20 42.6% 15 31.9% 12 25.5% 47 100

diagnosis of nephrotic syndrome 31 66.5% 15 21.3% 6 12.7% 47 100


Adequate knowledge regarding pathophysiology of nephrotic syndrome and

diagnosis of nephrotic syndrome respectively.

33


knowledge regarding general treatments and symptomatic treatment of

nephrotic syndrome

No =47

Nurses' knowledge

Adequate

knowledge

modertely

adequate

knowledge

Inadequate

knowledge

Total

No % No % No %

treatments of nephrotic syndrome 39 83.5% 7 14.9% 1 2.1% 47 100

symptomatic treatment of nephrotic

syndrome

33 70.2% 12 25.5% 2 4.3% 47 100


Adequate knowledge regarding general treatments of nephrotic syndrome and

symptomatic treatment of nephrotic syndrome respectively.

34


knowledge regarding management of edema and the procedure of the

strong diuretic action of intravenous treatment.

No =47

Nurses' knowledge

Adequate

knowledge

Moderately

adequate

knowledge

Inadequate

knowledge

Total

No % No % No % No %

Management of edema 35 74.5% 11 23.4% 1 2.1% 47 100

the procedure of the strong diuretic

action of intravenous treatment

17 36.2% 18 38.3% 12 25.5% 47 100

Table (4.8) showed that (74.5% and 36.2%) of the study participants had

Adequate knowledge regarding Management of edema and the procedure of the

strong diuretic action of intravenous treatment respectively.

35


knowledge regarding management hypoalbuminemia and hyperlipidaemia

No =47

Nurses' knowledge

Adequate

knowledge

Moderately

Adequate

knowledge

Inadequate

Knowledge

Total

No % No % No %

management hypoalbuminemia 21 44.6% 15 31.9% 12 25.5% 47 100

management hyperlipidaemia 18 38.3% 18 38.3% 11 23.4% 47 100


Adequate knowledge regarding management hypoalbuminemia and

hyperlipidaemia respectively.

36


knowledge regarding management of thrombophilia and infectious

complications

No =47

Nurses' knowledge

Adequate

knowledge

Moderately

Adequate

knowledge

Inadequate

Knowledge

Total

No % No % No % No %

management of thrombophilia 15 31.9% 20 42.6% 12 25.5% 47 100

management of infectious

complications

13 27.7% 21 44.7% 13 27.6% 47 100

Table (4.10) shows that (31.9% and 27.7%) of the study participants had

Adequate knowledge regarding management of thrombophilia and infectious

complications respectively.

37


knowledge regarding treatment of kidney damage (corticosteroids) and

prognosis for nephrotic syndrome under treatment

No =47

Nurses' knowledge

Adequate

knowledge

Moderately

Adequate

knowledge

Inadequate

Knowledge

Total

No % No % No % No %

treatment of kidney damage

(corticosteroids)

20 42.6% 19 40.4% 8 17.0% 47 100

prognosis for nephrotic syndrome

under treatment

35 63.8% 12 25.5% 5 10.6% 47 100


Adequate knowledge regarding treatment of kidney damage (corticosteroids) and

prognosis for nephrotic syndrome under treatment respectively.

38


knowledge regarding nursing care plan for nephrotic syndrome andsign of

excess fluid volume

No =47

Nurses' knowledge

Adequate

knowledge

Moderately

Adequate

knowledge

Inadequate

Knowledge

Total

No % No % No % No %

nursing care plan for nephrotic

syndrome

35 63.8% 12 25.5% 5 10.6% 47 100

sign of excess fluid volume 29 61.7% 11 23.4% 7 14.9% 47 100

Table (4.12) shows that more than half (63.8% and 61.7%) of the study

participantshad Adequate knowledge regarding nursing care plan for nephrotic

syndrome and sign of excess fluid volume respectively.

39


knowledge regarding nursing interventions for excess fluid volume and for

excess fluid volume

No =47

Nurses' knowledge

Adequate

knowledge

Moderately

Adequate

knowledge

Inadequate

Knowledge

Total

No % No % No %

nursing interventions for excess fluid

volume

30 23.8% 15 21.2% 7 14.9% 47 100

desired outcomes for excess fluid

volume

28 59.6% 13 27.6% 6 12.8% 47 100


Adequate knowledge regarding nursing interventions for excess fluid volume and

desired outcomes for excess fluid volume respectively.

41


knowledge regarding fatigue and nursing interventions for fatigue:

No =47

Nurses' knowledge

Adequate

knowledge

Moderately

Adequate

knowledge

Inadequate

Knowledge

Total

No % No % No % No %

fatigue 20 42.6% 18 38.3% 9 19.1% 47 100

nursing interventions for fatigue 20 42.6% 17 36.2% 10 21.2% 47 100

Table (4.14) shows that (42.6% and 42.6%) of the study participants had

Adequate knowledge regarding fatigue (Possibly evidenced by) and nursing

interventions for fatigue respectively.

41


knowledge regarding deficient knowledge, nursing interventions for

deficient knowledge and interventions for risk for infection:

No =47

Nurses' knowledge

Adequate

knowledge

Moderately

Adequate

knowledge

Inadequate

Knowledge

Total

No % No % No % No %

deficient knowledge (possibly

evidenced by)

19 40.4% 19 40.4% 9 19.1% 47 100

nursing interventions for deficient

knowledge

18 38.3% 19 40.4% 15 21.3% 47 100

interventions for risk for infection 28 59.6% 12 25.5% 7 41.9% 47 100

Table (4.15) revealed that (40.4%,38.3% and 59.6%) of the study participants

had Adequate knowledge regarding deficient knowledge, nursing interventions

for deficient knowledge and interventions for risk for infection.

42

Table (4.16) Total summary of Nurse’s Knowledge Regarding Nephrotic

Syndrome No =47

Nurses' knowledge

Adequate

knowledge

Moderately

Adequate

Knowledge

Inadequate

knowledge

No % No % No %

Definition of Nephrotic syndrome 25 53.2% 13 27.7% 9 19.1%

Signs and symptoms 22 46.8% 15 31.9% 10 21.2%

complications of nephrotic syndrome 20 42.6% 18 38.3% 9 19.1%

primary glomerulonephrosis 18 38.3% 17 36.2% 12 25.5%

secondary glomerulonephrosis 16 34.0% 22 46.8% 9 19.1%

histologic pattern Membranous nephropathy 21 44.7% 17 36.2% 10 21.2%

pathophysiology of nephrotic syndrome 20 42.6% 15 31.9% 12 25.5%

diagnosis of nephrotic syndrome 31 66.5% 15 21.3% 6 12.7%

treatments of nephrotic syndrome 39 83.5% 7 14.9% 1 2.1%

symptomatic treatment of nephrotic syndrome 33 70.2% 12 25.5% 2 4.3%

how to manage the edema 35 74.5% 11 23.4% 1 2.1%

the procedure of the strong diuretic action of

intravenous treatment

17 36.2% 18 38.3% 12 25.5%

Hypoalbuminemia 21 44.6% 15 31.9% 12 25.5%

Hyperlipidaemia 18 38.3% 18 38.3% 11 23.4%

Thrombophilia 15 31.9% 20 42.6% 12 25.5%

infectious complications 13 27.7% 21 44.7% 13 27.6%

treatment of kidney damage (corticosteroids) 20 42.6% 19 40.4% 8 17.0%

prognosis for nephrotic syndrome under treatment 35 63.8% 12 25.5% 5 10.6%

Mean total summary 23.3 49.0% 33.10% 15.8 18.2% 8.6%

43

Table (4.17): Total summary of nursing care plans for pediatric patients

with nephrotic syndrome (NS )

No =47

Nursing care

Adequate

knowledge

Moderately

Adequate

knowledge

Inadequate

knowledge

No % No % No %

nursing care plan for nephrotic

syndrome 35 63.8% 12 25.5% 5 10.6%

excess fluid volume 29 61.7% 11 23.4% 7 14.9%

nursing interventions for excess fluid

volume 30 23.8% 15 21.2% 7 14.9%

desired outcomes for excess fluid

volume 28 59.6% 13 27.6% 6 12.8%

fatigue 20 42.6% 18 38.3% 9 19.1%

nursing interventions for fatigue 20 42.6% 17 36.2% 10 21.2%

deficient knowledge 19 40.4% 19 40.4% 9 19.1%

nursing interventions for deficient

knowledge 18 38.3% 19 40.4% 15 21.3%

nursing interventions for risk for

infection 28 59.6% 12 25.5% 7 41.9%

Mean total summary 25.2 48.0% 15.1 30.9% 8.3 19.5%

44

4.2Discussion

This study is a descriptive hospital based study.The study was conducted

at Wad Medani Pediatric Teaching Hospital in Gezira state. It provider care to

large number of participants in and out state.The study was involved all nurses

available at study sitting during the period of study from may to august

(2020).This study aimed to evaluate nurses knowledge regarding nursing care of

children with nephritic syndrome

The study found that (19.1%) of the study sample at age more than 40

years, (23.6%) of the study participants at age ranged between 36 – 40 years,

while (21.2%) of them at age ranged between 26 to 35 years, while only (14.9%)

of them at age ranged between 20 to 25 years. Regarding gender it was found

that (95.7%) most of the study participants were female, while only (4.3%) of

them male. The study results found that, the majority of pediatric nurses age

were at more than 40 years old ,and majority of nurses in the current study are

female. Regarding educational level It revealed that (46.8%) of the study

participants had diploma, and (14.9%) had post graduate. This study found that

most of the nurses hold a diploma . This study illustrated that more than half

51.1% of the study participants their source of knowledge from colleagues and

this dose not respond complete knowledge about the disease .The study revealed

that (17.1%) of the study participants had received training programs regarding

nursing care of pediatrics patients with nephrotic syndrome this result found

there is a shortage of training program for the nurses in the hospital. This study

showed that (53.2% and 46.8%) of the study participants had Adequate

knowledge regarding definition of nephrotic syndrome and signs and symptoms

respectively. Nephrotic syndrome is a collection of symptoms due to kidney

damage. This includes protein in the urine, low blood albumin levels, high blood

lipids, and significant swelling. Other symptoms include the following weight

gain, feeling tired, and foamy urine. (Ferri, Fred F. 2017). This study revealed

that (42.6% and 38.3%) of the study participants had Adequate knowledge

regarding complications of nephrotic syndrome and primary glomerulonephrosis

respectively .Complications include the following blood clots, infections, and

high blood pressure (Kher, Knawel; Schnaper, H. et al, 2016).This study found

45

that (34.0% and 44.7%) of the study participants had Adequate knowledge

regarding secondary glomerulonephrosis and histological pattern Membranous

nephropathy respectively. This study found that (42.6% and 66.5%) of the study

participants had Adequate knowledge regarding path physiology of nephrotic

syndrome and diagnosis of nephrotic syndrome respectively. The kidney

glomerulus filters the blood that arrives at the kidney. It is formed of capillaries

with small pores that allow small molecules to pass through that have a

molecular weight of less than 40,000 Daltons, but not larger macromolecules

such as proteins (Curtis, Michael J.; Page, Clive P.; et al.; 2015). In contrast this

study revealed that more than half of the study participants had Adequate

knowledge regarding treatments of nephritic syndrome. The treatment of

nephrotic syndrome can be symptomatic or can directly address the injuries

caused to the kidney (Voguel S, Andrea; Azócar P,; et al, 2018). This study

showed that (74.5% and 36.2%) of the study participants had Adequate

knowledge regarding management of the edema and the procedure of the strong

diuretic action of intravenous treatment respectively. Medical nutrition therapy

based on a diet with the correct energy intake and balance of proteins that will be

used in synthesis processes and not as a source of calories. Analyze hemoglobin

and hematocrit levels .A solution of 25% albumin is used that is administered for

only 4 hours in order to avoid pulmonary edema. This procedure should be done

before administer strong diuretics (Goldman, Lee; Braunwald, Eet al.;

2015).This study revealed that (44.6% and 38.3%) of the study participants had

Adequate knowledge regarding hypo albuminemia and hyper lipidemia

respectively. Hypoalbuminemia is treated using the medical nutrition therapy

described as a treatment for edema. Hyperlipidaemia, depending of the

seriousness of the condition it can be treated with medical nutrition therapy as

the only treatment or combined with drug therapy. (Curtis, Michael J.; Page,

Clive P.; et al.; 2015).This study revealed that (31.9% and 27.7%) of the study

participants had Adequate knowledge regarding thrombophilia and infectious

complications respectively. When the thrombophilia is leads to the formation of

blood clots, heparin is given for at least 5 days along with oral anticoagulants

(OAC).This study revealed that (42.6% and 63.8%) of the study participants had

Adequate knowledge regarding treatment of kidney damage (corticosteroids) and

prognosis for nephrotic syndrome under treatmen trespectively. Kidney damage

46

is treated by prescribing drugs (Corticosteroids: the result is a decrease in the

proteinuria and the risk of infection as well as a resolution of the edema.

Prednisone is usually prescribed at a dose of 60 mg/m2 of body surface area/day

in a first treatment for 4–8 weeks. After this period the dose is reduced to 40

mg/m2 for a further 4 weeks (Behrman, Richard E.; 2015). The prognosis for

nephrotic syndrome under treatment is generally good although this depends on

the underlying cause, the age of the person and their response to treatment.This

study showed that more than half of the study participants e about nursing role of

nephrotic syndrome and excess fluid volume. Nursing role for a client with

nephrotic syndrome include relief from edema, enhance nutritional status,

conserve energy, supply sufficient information about the disease, importance of

strict compliance with the medication and nutritional therapy, and absence of

infection or prevention of a relapse.Nursing role and nursing diagnosis (NDs) for

Nephrotic Syndrome:Excess Fluid Volume, Imbalanced Nutrition: Less Than

Body Requirements, Fatigue, Deficient Knowledge and Risk For Infections.(Paul

Martin, BSN, R.N., 2018).This study It revealed that (23.8% and 59.6%) of the

study participants had Adequate knowledge regarding nursing interventions and

desired outcomes for excess fluid volume respectively. While (14.9% and

12.8%) had wrong answers respectively. This study showed that (42.6% and

42.6%) of the study participants had Adequate knowledge regarding signs and

nursing interventions for fatigue respectively.This study found that (40.4% and

38.3%) of the study participants had Adequate knowledge regarding deficient

knowledge and nursing interventions for deficient knowledge respectively.

Finally this study revealed that more than half of the study participants had

Adequate knowledge regarding nursing interventions for risk for infection. This

study found that most of the result from the nursing role are insufficient to care

for a child with nephritic syndrome

47

5. Conclusion and Recommendations

5.1 Conclusion

Based on the results the study, it concluded that:

Nurses' knowledge regarding nephritic syndrome at Wad Medani

Pediatrics teaching hospital, Gezira State, Sudan, was poor knowledge

with total mean of Adequate knowledge (49.0%).

Nurses' knowledge regarding nursing role of pediatrics patients with

Nephrotic syndrome at Wad Medani Pediatrics teaching hospital, Gezira

State, Sudan, was poor knowledge with total mean of Adequate

knowledge(48.0%).

48

5.2 Recommendations:

Based on the results of this study, the study recommended that:

Suggested training programs for nurses about nursing role of children

with nephrotic syndrome at Wad Medani Pediatrics teaching hospitalmust

be conduct.

Gide line for nursing role about nephrotic syndrome suggested design and

available in the hospital.

49

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52

Nurse’s Knowledge Regarding Nursing Care of children with

Nephrotic Syndrome at wad Medani Pediatric Teaching Hospital,

Sudan (2020)

Part One: Socio-demographic Data

1. Age group:

a. 20 – 25 years ( ) b. 25 – 30 years ( )

c. 31 – 35 years ( ) d. 35 – 40 years ( )

e. More than 40 years ( )

2. Gender:

a. Male ( ) b. Female ( )

3. Educational Level:

a. Diploma ( ) b. Bachelor ( )

d. Post graduate ( ) c. Teachnical nursing

certificate

4. Years of experience:

a. 1 – 4 years ( ) b. 4 to 9 years ( )

c. 9 - 14 years ( ) d. More than 15 years ( )

53

5. Source of Nurses' knowledge regarding nursing Care of

Pediatric Patients with Nephrotic Syndrome:

a. Colleagues ( ) b. Books and

references ( )

c. Training programs ( ) d. Mass-media

( )

e. University ( )

6. Did you receive training programs regarding nursing Care of

Pediatric Patients with Nephrotic Syndrome?

a. Yes ( ) b. No

( )

Part Two. Nurses' Knowledge regarding Nursing role of children

with Nephrotic Syndrome:

2.1 Definition of Nephrotic syndrome:

a. Nephrotic syndrome is a collection of symptoms due to kidney

damage. ( )

b. Nephrotic syndrome is a collection of symptoms due to protein in

the urine ( )

c. NS is a collection of symptoms due to low blood albumin levels

( )

d. Nephrotic syndrome is a collection of symptoms due to high blood

lipids ( )

e. Nephrotic syndrome is a collection of symptoms due tosignificant

swelling ( )

54

2.2 Signs and symptoms of NS include the following:

a. Nephrotic syndrome is characterized by large amounts of

proteinuria ( )

b. Hypoalbuminemia ( )

c. Hyperlipidaemia, and edema that begins in the face ( )

d. Lipiduria (lipids in urine) can also occur ( )

e. Hyponatremia also occurs with a low fractional sodium excretion

( )

2.3 Complications of NS include the following:

a. Thromboembolic disorders ( )

b. Infections ( )

c. Spontaneous bacterial peritonitis ( )

d. Acute kidney failure due to hypovolemia ( )

e. Pulmonary edema ( )

f. Hypothyroidism and Vitamin D deficiency can occur ( )

2.4 Primary glomerulonephrosis include the following

a. Minimal change disease (MCD) ( )

b. Focal segmental glomerulosclerosis (FSGS) ( )

c. Membranous glomerulonephritis (MGN) ( )

d. Membranoproliferative glomerulonephritis (MPGN) ( )

e. Rapidly progressive glomerulonephritis (RPGN) ( )

55

2.5 Secondary glomerulonephrosis

a. Diabetic nephropathy ( )

b. Systemic lupus erythematosus ( )

c. Sarcoidosis ( )

d. Syphilis ( )

e. Hepatitis B ( )

f. Sjögren's syndrome and HIV and Amyloidosis ( )

2.6 Histologic patternMembranous nephropathy (MN) include

the following

a. Sjögren's syndrome or Systemic lupus erythematosus (SLE)( )

b. Diabetes mellitus or Sarcoidosis ( )

c. Drugs or Malignancy (cancer) ( )

d. Bacterial infections or Protozoal infections ( )

e. Focal segmental glomerulosclerosis or Hypertensive

nephrosclerosis ( )

f. HIV or Obesity or Kidney loss ( )

2.7 Pathophysiology:

a. The kidney glomerulus filters the blood that arrives at the kidney

( )

b. In nephrotic syndrome ( )

c. The glomeruli are affected by an inflammation ( )

56

d. The glomeruli are affected bya hyalinization ( )

e. Allows proteins such as albumin, antithrombin or the

immunoglobulins to pass through the cell membrane and appear in

urine. ( )

2.8 Diagnosis of NS :

a. Along with obtaining a complete medical history ( )

b. A series of biochemical tests are required in order to arrive at an

accurate diagnosis that verifies the presence of the illness ( )

c. Imaging of the kidneys ( )

d. The urine sample is tested for proteinuria ( )

e. Measuring the concentration of organic compounds in both liquids

evaluates the capacity of the glomeruli to filter blood. ( )

f. Electrolytes and urea levels may also be analysed at same time as

creatinine (EUC test) in order to evaluate kidney function ( )

2.9 Treatment of NS include

The treatment of nephrotic syndrome can be symptomatic or

can directly address the injuries caused to the kidney.

2.9.1 Symptomatic treatment include the following

a. Edema ( )

b. Hypoalbuminemia ( )

c. Hyperlipemia ( )

d. Hypercoagulability ( )

57

e. Infectious complications. ( )

2.9.2 How to manage the edemainclude the following:

a. Rest: depending on the seriousness of the edema and taking into

account the risk of thrombosis caused by prolonged bed rest.

( )

b. Medical nutrition therapy: based on a diet with the correct energy

intake and balance of proteins that will be used in synthesis processes

and not as a source of calories ( )

c. Medication: The pharmacological treatment of edema is based on

diuretic medications. ( )

d. The diuretics can be administered intravenously. This occurs

where the risk from plasmatic expansion is considered greater than

the risk of severe hypovolemia ( )

2.9.2.1 The strong diuretic action of intravenous treatment. The

procedure is the following:

a. Analyse haemoglobin and haematocrit levels. ( )

b. A solution of 25% albumin is used that is administered for only 4

hours in order to avoid pulmonary edema. ( )

c. Haemoglobin and haematocrit levels are analysed again ( )

d. It may be necessary to give a person potassium if the diuretic drug

causes hypokalaemia as a side effect. ( )

2.9.3 Hypoalbuminemia:

a. Is treated using the medical nutrition therapy ( )

58

b. Using a moderate intake of foods rich in an animal protein ( )

c. Give vegetables meals ( )

2.9.4 Hyperlipidaemia:

a. Treated with medical nutrition therapy as the only treatment or

combined with drug therapy. ( )

b. The ingestion of cholesterol should be less than 300 mg/day

( )

c. Will require a switch to foods that are low in saturated fats .

Avoid saturated fats ( )

d. Increase unsaturated fat intake, including olive oil, canola oil,

peanut butter, avocadoes, fish and nuts. ( )

2.9.5 Thrombophilia:

a. Low molecular weight heparin (LMWH) may be appropriate for

use as a prophylactic in some circumstances ( )

b. Given for at least 5 days along with oral anticoagulants (OAC).

( )

c. The LMWH while maintaining the OACs for at least 6 months.

( )

2.9.6 Infectious complications:

59

a. An antibacterial drugs can be taken according to the infectious

agent ( )

B.vitamin D and calcium are also taken orally in case the alteration of

vitamin D causes a severe hypocalcaemia ( )

C. Achieving better blood glucose level control if the person is

diabetic . ( )

D. Blood pressure control. ACE inhibitors are the drug of choice( )

2.10 Treatment of Kidney damage include the following

2.10.1 Corticosteroids:

a. The result is a decrease in the proteinuria and the risk of infection

as well as a resolution of the edema. ( )

b. Prednisone is usually prescribed at a dose of 60 mg/m2 of body

surface area/day in a first treatment for 4–8 weeks. ( )

c. After this period the dose is reduced to 40 mg/m2 for a further 4

weeks. ( )

d. Children suffering a relapse are treated with prednisolone 2

mg/kg/day till urine becomes negative for protein then, 1.5

mg/kg/day for 4 weeks. ( )

e. Frequent relapses treated by: cyclophosphamide or nitrogen

mustard or ciclosporin or levamisole. ( )

2. 11Prognosisfor nephrotic syndrome under treatmentinclude

the following

a. The age of the person and their response to treatment. ( )

61

b. Focal segmental glomerulosclerosis frequently lead to end stage

kidney disease ( )

c. Factors associated with a poorer prognosis in these cases include

level of proteinuria, blood pressure control and kidney function

(GFR). ( )

d. Rapidly progressing glomerulonephritis ( )

2. 12Nursing Care Plans for NS include the following the

following

a. Excess Fluid Volume ( )

b. Imbalanced Nutrition: Less Than Body Requirements ( )

c. Fatigue ( )

d. Deficient Knowledge ( )

e. Risk For Infection ( )

2. 12.1Excess Fluid Volume (Possibly evidenced by) include the

following

a. Pitting edema ( )

b. Periorbital and facial puffiness in morning and dependent in the

evening ( )

c. Abdominal ascites,Scrotal or labial edema ( )

d. Edema of mucous membranes of intestines ( )

e. Anasarca, Slow weight gain and Decreased urine output ( )

61

2. 12.1.1Nursing Interventions for Excess Fluid Volume include

the following:

a. Weigh child daily; Utilize same weighing scale every day ( )

b. Strictly monitor and record intake and output ( )

c. Determine potential sources of excess fluid ( )

d. Advised to limit fluid intake as ordered ( )

e. Instruct parents to provide frequent oral hygiene ( )

2. 12.1.2Desired Outcomesfor Excess Fluid Volume include the

following:

a. Child’s edema will be decreased ( )

b. Child will achieve ideal body weight without excess fluids ( )

c. Child’s edema will be increased ( )

d. Child will achieve ideal body weight with excess fluids ( )

2. 12.2 Imbalanced Nutrition: Less Than Body Requirements

(Possibly evidenced by)

a. Anorexia ( )

b. Weight loss ( )

c. Edema of intestinal tract affecting absorption ( )

62

d. Rejection of low salt diet ( )

e. Loss of protein [negative nitrogen balance] ( )

2. 12.2.1Nursing intervention for Desired Outcomesfor

Imbalanced Nutrition include the following:

a. Monitor client’s weight daily ( )

b. Assess child’s nutritional daily ( )

c. Encourage high potassium, low-fat, low sodium diet with moderate

amounts of protein ( )

d. Provide comfortable and delightful environment during meal times

( )

e. Consider six small nutrient-dense meals instead of three larger

meals daily to reduce the feeling of fullne ( )

2.12.3 Fatigue (Possiblyevidencedby)

a. Easily fatigued with any active ( )

b. Extreme edema ( )

c. Lethargy ( )

d. Discomfort ( )

2.12.3.1Nursing Interventions for Fatigue include the following:

https://nurseslabs.com/fluid-electrolyte-imbalances-nursing-care-plans/

63

a. Assess extent of fatigue, weakness, degree of edema and difficult

movement or activity in bed ( )

b. Plan activities with consideration and observe for changes in

behavior following an activity ( )

c. Reinforce bed rest during the most acute stage ( )

d. Provide chosen play activities as tolerated and modify the

schedule to allow for rest periods and after activity ( )

e. Advise child to rest during times of exhaustion ( )

2.12.4DeficientKnowledge(Possibly evidenced by) include the

following

a. Expressed need for information about the disease ( )

b. Drug Administration ( )

c. Follow-up care and procedures ( )

d. Anxiety associated with relapse of disease ( )

2.12.4.1Nursing Interventions for DeficientKnowledgeinclude the

following:

a. Assess knowledge of disease, signs and symptoms of relapse( )

b. Assess dietary and activity aspects of care ( )

c. Assess medication administration and side effects ( )

https://nurseslabs.com/10-rs-rights-of-drug-administration/

https://nurseslabs.com/anxiety/

64

d. Monitoring urine and vital signs ( )

e. Assess anxiety level and need for assistance in the care of the

ailing child and possible rela ( )

2.12.5NursingInterventions for Risk For Infection include the

following:

a. Assess for an increase in temperature, respiratory changes( )

b. Maintain and teach medical aseptic techniques and handwashing

when providing care ( )

c. Maintain warmth for the child, regulateroom environmental

temperatureand humidity ( )

d. Provide private room or share room with children who are free

from infections ( )

e. Administer antibiotic therapy as ordered ( )

https://nurseslabs.com/hand-hygiene-handwashing/

https://nurseslabs.com/antibiotics/

Documents

Nurse’s Knowledge regarding Nursing Care of