Imagine this:
A 7 year old boy comes into your clinic complaining of a headache and is having trouble breathing. His mother tells you that he hasn’t been going to the bathroom very much, and when he does his urine is darker than normal.
Of course, your mind immediately goes to glomerulonephritis because that’s what this weeks post is all about! (You are so on top of things!)
Now, what are you going to do about it?
Tricky, I know.
So let’s find out together, shall we?
Here’s your acute glomerulonephritis study guide. We’ll walk through it step-by-step.
Pathophysiology
Glomerulonephritis simply means an infection of the glomerulus within the kidneys.
The glomerulus is responsible for filtering the blood, which is the first step for making urine. So, obviously, healthy glomeruli are super important because otherwise you would basically be peeing blood. And none of us want that, right?
Glomerulonephritis is most often caused by an infection somewhere else in the body, and your body makes antibodies that go and stick to those infectious pathogens. This creates large complexes with all of the pathogens and antibodies stuck together. And as these large complexes move through the blood, they get stuck in the glomeruli and cause inflammation. This inflammation damages the glomeruli, reducing it’s ability to function.
Possible Causes
Strep throat is one of the top causes of glomerulonephritis. But it can also be caused by a viral infection, bacterial infection, skin infection or Goodpasture Syndrome.
Nursing Assessment
Patient’s with infection, and especially patients with kidney damage who aren’t able to offload fluid properly, are at a high risk for fluid overload. And we know that fluid overload comes packed with a lot of problems like: edema, pulmonary congestion, and heart failure.
So check for edema, shortness of breath, crackles in the lungs, hypertension and an additional heart sound called the S3 heart sound.
Your patient may or may not have signs of infection. Check their skin for any cuts or scrapes and ask them if they were stuck with anything or had any illness over the past month or so.
Assess their urine color, odor, and amount. Most often in glomerulonephritis, there will be blood in the urine, so it will be darker than normal, brown, or look like coca cola. Also, ask them if they have been urinating less frequently lately. Since the glomeruli are responsible for making urine, there will be less urine production when they are damaged.
Lab Values
Now that we’ve covered the nursing physical assessment piece, let’s chat a bit about what lab values you will want to look at.
The first, of course, is a urinalysis. You will most likely see hematuria, meaning blood in the urine, and red blood cell casts, which indicate bleeding from the kidney. You may also see proteinuria, meaning the urine is positive for protein and decreased albumin levels in the blood. Proteins are larger molecules and don’t pass through healthy kidneys. But when your kidneys become damaged, they get holes poked through them, and protein molecules can fit inside those holes, which indicate renal damage.
The glomerular filtration rate (GFR) will probably be decreased because of the glomerular damage. Normally, your glomerulus can filter 60-120mL of blood per minute. Anything less than that is abnormal and may indicate kidney damage.
The blood urea nitrogen level (BUN) will probably be elevated. Your kidneys are responsible for filtering urea from your body. But when your kidneys are damaged, they can’t filter as effectively and urea backs up. So the blood urea nitrogen level will be increased.
And last but definitely not least, check their potassium level. When the kidneys are damaged, they will retain potassium. And if potassium levels rise, it affects the hearts electrical system and can cause life threatening cardiac arrhythmias. Meaning, death. So you should always check their potassium level.
Nursing Interventions
The priority nursing interventions are to reduce fluid overload, help blood circulate through the kidneys and keep potassium levels within normal range.
Remember that fluid overload can cause pulmonary edema and heart failure and high potassium levels can cause cardiac arrythmias, three things that can be life threatening.
Make sure to weigh them every 24 hours to get an accurate assessment of fluid volume changes. Weight them at the same time of day, in the same clothes, and with the same scale.
To reduce their fluid overload, the patient may need diuretic therapy (Furosemide), a low sodium diet and fluid restriction. To reduce their blood pressure due to fluid overload, antihypertensives may also be prescribed. The most common antihypertensives are angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs).
To prevent hyperkalemia and reduce blood urea nitrogen, the patient may be on a low potassium and low protein diet in addition to reduced salt and fluid restriction.
You will also need to reduce the infection that is present, most likely by administering antibiotics. If the original infection was caused by a strep infection, the most common antibiotics that you will give are penicillin, erythromycin, and azithromycin.
And there you have it! That is just about everything you will need to know for glomerulonephritis in nursing school!
