Nephrotic syndrome is a kidney disorder characterized by heavy proteinuria, hypoalbuminemia, and edema. It is classified as congenital, primary, or secondary. Primary nephrotic syndrome includes minimal change disease, focal segmental glomerulosclerosis, and mesangial proliferative nephropathy. Nursing management focuses on reducing edema through diet, fluid restriction, and diuretics. Preventing infections through hygiene and immunizations is also important. Prognosis depends on the underlying cause and response to steroids or other immunosuppressive therapies.

1. NURSING MANAGEMENT
OF CHILDREN -
NEPHROTIC SYNDROME
N SHOBANA

2. “When bubbles settle on the
surface of the urine, it indicates
disease of the kidneys and that the
complaint will be protracted”
Hippocrates

3. NEPHROTIC SYNDROME
 Proteinuria
 > 40mg/m2/hour or
 > 50mg/kg/hour
 > 3 + / 4+ (by dipstick/sulfosalicylic acid)
 Hypoalbunemia
 S.albumin < 2.5 gm/dl
 Hyperlipidemia
 Cholesterol> 200mg/dl

4. INCIDENCE
 2-7 per 1,00,000
 Male> female
 2-5 years

5. CLASSIFICATION
 Congenital
 Primary
 Secondary

6. CONGENITAL(1%)
 Newborns& infants
 Finish type
 Autosomal recessive disorder
 Gene mutation in chromosome 9
 Infections
 TORCH

7. PRIMARY NEPHROTIC SYNDROME
Histopathological glomerular disease
Minimal change nephrotic syndrome (85%)
 Minimal thickening of mesangium & basement
membrane
Focal segmental sclerosis(10%)
 Focal areas of proliferation of mesangium &
sclerosis
Mesangial proliferative nephrotic syndrome
(5%)
 Severe proliferation of mesangium & areas of
sclerosis & infiltration of WBC

8. SECONDARY NS (10%)
 Varicella
 HIV
 Malaria
 SLE
 Rheumatoid arthritis
 Sickle cell disease
 Diabetes mellitus
 Leukemia
 Lymphoma

9. PATHOPHYSIOLOGY

10. CLINICAL FEATURES
 Edema & weight gain
 Puffiness of face
 Around the eyes
 Appears in the morning
 Ankle ,feet ,genitalia & hands
 Anasarca
 Acsitis & pleural effusion

11. CLINICAL FEATURES
 Irritability
 Fatigue
 Lethargic
 Raised Blood pressure
 Urinary
 Decreased urine output
 Frothy
 Haematuria

12. CLINICAL FEATURES
 Respiratory
 Breathing difficulty
 GI symptoms
 Anorexia
 Vomiting
 Abdominal pain
 Diarrhea
 Bloating

13. CLINICAL FEATURES
 Susceptibility to Infections
 URTI
 UTI
 Cellulitis
 Peritonitis

14. DIAGNOSIS-TO CONFIRM NS
 CBC- Anemia, leukocytosis
 S.Albumin- <2.5gm/dl
 S.Cholesterol- elevated
 RFT
 Electrolytes
 Urine analysis
 Proteinuria
 Haematuria
 Pyuria
 24 hour urinary protein
 Protein – creatinine ratio

15. DIAGNOSIS-TO CONFIRM NS
 USG abdomen
 Renal doppler
 Ascitic tap

16. INVESTIGATIONS
 Blood culture
 Mantoux test
 X ray chest
 Urine culture
 VDRL
 PS- malaria
 Kidney biopsy

17. MEDICAL MANAGEMENT

18. DIET
 High protein diet
 Salt restricted
 Fluid restricted

19. GENERAL MANGEMENT
 Edema
 Frusemide 1-2mg/kg/dose
 Spironolactone 2-3 mg/kg/day in 2 divided doses
 Human albumin infusion
 0.5-1gm/kg (over 1 hour)
 ACE inhibitors
 Enalapril 0.1-0.5 mg/kg/day

20. GENERAL MANGEMENT
 Antibiotics
 Vitamin supplements
 Calcium and vitamin D supplements
 Anticoagulants

21. DEFINITIONS
 Remission
 Neg or tr urine protein for 3 consecutive days
 Relapse
 2 + or > urine protein for 3 consecutive days
 Frequent relapser (FRNS)
 4 or more relapses in 1 year
 Steroid dependent (SDNS)
 In remission only when on steroids
 Primary non-responder

22. SPECIFIC MANAGEMENT
 Prednisolone
 2mg/kg/day (2-3 divided doses) for 04 weeks
 1.5mg/kg/day (alternative days) for next 04
weeks
 Relapse
 2mg/kg/day (2-3 divided doses) till urine protein
becomes negative for 03 consecutive days
 1.5mg/kg/day (alternative days ) for next 04
weeks

23. SPECIFIC MANAGEMENT
 For frequent relapses/ steroid resistant
 Immunosuppressive drugs
 Cyclophosphamide ( 2-3 mg/kg/day for 8-12
weeks)
 Levamisole (2mg/kg alternative days for 1-2
years)
 Cyclosporin ( 3-5 mg/kg/day for 1-2 years)
 Mycophenolate mofetil

24. COMPLICATIONS
 Infections
 Loss of immunoglobulins
 Altered T cell function
 Immunosuppressive therapy
 Presence of edema
 Thrombo embolic complications
 Increased risk for arterial & venous thrombosis
 Increased fibrinogen
 Volume depletion
 Infections
 Diuretic use
 Immobilisation

25. COMPLICATIONS
 Anaemia
 Hyponatremia
 Hpocalcemia
Urinary loss of vitamin D binding globulin & 25
hydroxy vitamin D3.
 Growth retardation
 Protein deficiency
 Anorexia
 Steroid therapy
 ARF

26. SIDE EFFECTS-STEROIDS
 Risk of ulcer
 Behavior/sleep changes
 Weight gain
 “Cushingoid facies”
 Growth arrest
 Osteoporosis
 Hyperglycemia
 Hypertension

27. NURSING MANGEMENT
 Goals of nsg management
 Reducing edema
 Nutrition
 Administering medications
 Skin care
 Infection prevention
 Promoting psychosocial growth
 Parental teaching

28. NURSING MANGEMENT
 Assessment
 Age, height and weight
 Vital signs
 Past hospital admissions
 Immunization status
 Edema
 Urinary output
 Presence of infections
 Dietary pattern
 Malnourishment

29. NURSING MANGEMENT
o Monitoring of
o Vital signs
o Intake output
o Urinary protein
o Diet
o Weight
o Abdominal girth

30. NURSING MANGEMENT
 Diet
 High protein diet 2-3 gm/kg/day
 Calories- 50- 70 kcal/kg/day
 No Added salt

31. NURSING MANGEMENT
 Protein rich food items
 Egg
 Milk
 Fish
 Chicken
 Paneer
 Spourts
 Pulses & legumes

32. NURSING MANGEMENT
 Breakfast 8:00am
Bread 02 slices with jam
milk.
2 egg whites/30gms paneer
 Midmorning 10:30am
1 Katori
sprouts(moong,chana)/
roasted chana.
 Lunch 1:00pm
1chappatis made from soya
flour.
½ katori rice
1 katori vegetable
1 katori dal
1 katori curds
 Teatime 4:30pm
1 cup milk
 Snacks 6:30pm
1 fruit
 Dinner 8:30pm
Same as lunch {Dal could
be substituted with fish
curry (1 small pc fish),
chicken(50gms), paneer
(40gms)}
 Bedtime 10:00pm
milk

33. FLUID MANAGEMENT
 Strict intake output monitoring
 Hypovolemic symptoms
 persistent tachycardia
 Hypotension
 abdominal pain
 Capillary refill >2sec
 urine Na <10mmol/l being
indicative of severe hypovolaemia
 Previous day output +
insensible water loss
 Urine output monitoring

34. NURSING MANGEMENT
 Administering medications
 Steroids
 After meal
 Along with antacids
 Assessment of complications
GI complications
Cushingoid face
Weakness of bone

35. NURSING MANGEMENT
 Prevention of infection
 Personal hygiene
 Hand washing
 Restricting visitors
 Asepsis
 Minimal invasive procedures

36. NURSING MANGEMENT
 Skin care
 Meticulous skin care
 Clean & dry
 Loose clothing
 Nails trimmed
 Change of position
 Active and passive exercise

37. NURSING MANGEMENT
 Parental teaching
 Importance of home care
 Administration of medications
 Observation of side effects
 Urine testing
 Prevention of infection
 Maintaining records
 Follow up

38. NURSING MANGAEMENT
 Promoting psychosocial growth
 Frequent hospitalizations- increase
dependency
 Disturbances in self concept.
 Low self image, fear of infection- social
isolation
 Encourage to express- fear, anger, anxiety
 Allowing play & self care

39. NURSING MANGAEMENT
 Immunization
 Live vaccines should not be given to
immunosuppressed children
 killed vaccines are safe to administer
 However live vaccine can be considered if the
child is not on steroids for minimum of
03months
 Recommended -varicella, pneumococcal
vaccines during remission.

40. PROGNOSIS
 Cause of disease and response to therapy
 Minimal change nephrotic syndrome- good
prognosis
 Glomeruloscelorsis and resistant to therapy
– CRF and uremia