CHRONIC
GLOMERULONEPHRITIS
Chronic
glomerulonephritis may be due to repeated episodes of acute glomerulonephritis,
hypertensive nephrosclerosis, hyper-lipidemia, chronic tubulointerstitial
injury, or hemodynamically mediated glomerular sclerosis. The kidneys are
reduced to as lit-tle as one-fifth their normal size (consisting largely of
fibrous tis-sue). The cortex shrinks to a layer 1 to 2 mm thick or less. Bands
of scar tissue distort the remaining cortex, making the surface of the kidney
rough and irregular. Numerous glomeruli and their tubules become scarred, and
the branches of the renal artery are thickened. The result is severe glomerular
damage that results in ESRD.
The
symptoms of chronic glomerulonephritis vary. Some pa-tients with severe disease
have no symptoms at all for many years. Their condition may be discovered when
hypertension or ele-vated BUN and serum creatinine levels are detected. The
diag-nosis may be suggested during a routine eye examination when vascular
changes or retinal hemorrhages are found. The first in-dication of disease may
be a sudden, severe nosebleed, a stroke, or a seizure. Many patients report
that their feet are slightly swollen at night. Most patients also have general
symptoms, such as loss of weight and strength, increasing irritability, and an
in-creased need to urinate at night (nocturia). Headaches, dizziness, and
digestive disturbances are common.
As
chronic glomerulonephritis progresses, signs and symp-toms of renal
insufficiency and chronic renal failure may develop. The patient appears poorly
nourished, with a yellow-gray pig-mentation of the skin and periorbital and
peripheral (dependent) edema. Blood pressure may be normal or severely
elevated. Reti-nal findings include hemorrhage, exudate, narrowed tortuous
ar-terioles, and papilledema. Mucous membranes are pale because of anemia.
Cardiomegaly, a gallop rhythm, distended neck veins, and other signs and
symptoms of heart failure may be present. Crackles can be heard in the lungs.
Peripheral
neuropathy with diminished deep tendon reflexes and neurosensory changes occurs
late in the disease. The patient becomes confused and demonstrates a limited
attention span. An additional late finding includes evidence of pericarditis
with a peri-cardial friction rub and pulsus paradoxus (difference in blood
pres-sure during inspiration and expiration of greater than 10 mm Hg).
A
number of laboratory abnormalities occur. Urinalysis reveals a fixed specific
gravity of about 1.010, variable proteinuria, and uri-nary casts (protein plugs secreted by damaged kidney tubules).
Asrenal failure progresses and the GFR falls below 50 mL/min, the following
changes occur:
· Hyperkalemia due to
decreased potassium excretion, acido-sis, catabolism, and excessive potassium
intake from food and medications
· Metabolic acidosis from
decreased acid secretion by the kid-ney and inability to regenerate bicarbonate
· Anemia secondary to
decreased erythropoiesis (production of RBCs)
· Hypoalbuminemia with
edema secondary to protein loss through the damaged glomerular membrane
· Increased serum
phosphorus level due to decreased renal excretion of phosphorus
· Decreased serum calcium
level (calcium binds to phospho-rus to compensate for elevated serum phosphorus
levels)
· Hypermagnesemia from
decreased excretion and inadver-tent ingestion of antacids containing magnesium
· Impaired nerve
conduction due to electrolyte abnormalities and uremia
Chest
x-rays may show cardiac enlargement and pulmonary edema. The electrocardiogram
may be normal or may indicate left ventricular hypertrophy associated with
hypertension and signs of electrolyte disturbances, such as tall, tented (or
peaked) T waves associated with hyperkalemia. Serum markers, including vascular
endothelial growth factor and thrombospondin-1, are being evaluated for their
reliability in assessing renal disease (Kang et al., 2001).
Symptoms
guide the course of treatment for the patient with chronic glomerulonephritis.
If the patient has hypertension, the blood pressure is reduced with sodium and
water restriction, anti-hypertensive agents, or both. Weight is monitored
daily, and di-uretic medications are prescribed to treat fluid overload.
Proteins of high biologic value (dairy products, eggs, meats) are provided to
promote good nutritional status. Adequate calories are also im-portant to spare
protein for tissue growth and repair. UTIs must be treated promptly to prevent
further renal damage.
Initiation
of dialysis is considered early in the course of the dis-ease to keep the
patient in optimal physical condition, prevent fluid and electrolyte
imbalances, and minimize the risk of compli-cations of renal failure. The
course of dialysis is smoother if treat-ment begins before the patient develops
significant complications.
If the
patient is hospitalized or seen by the nurse in the home, the nurse observes
the patient for changes in fluid and electrolyte status and for signs and
symptoms of deterioration of renal function. Changes in fluid and electrolyte
status and in cardiac and neurologic status are reported promptly to the
physician. Anxiety levels are often extremely high for both the patient and
family. Throughout the course of the disease and treatment, the nurse gives
emotional support by providing opportunities for the patient and family to
verbalize their concerns, have their ques-tions answered, and explore their
options.
The nurse
has a major role inteaching the patient and family about the prescribed
treatment plan and the risks associated with noncompliance. Instructions to the
patient include explanations and scheduling for follow-up evaluations: blood
pressure, urinalysis for protein and casts, and blood studies of BUN and
creatinine levels. If long-term dialysis is needed, the patient and family are
taught about the procedure, how to care for the access site, dietary
restrictions, and other nec-essary lifestyle modifications.
Periodic
hospitalization, visits to the outpatient clinic or of-fice, and home care
referrals provide the nurse in each setting with the opportunity for careful
assessment of the patient’s progress and continued education about changes to
report to the primary health care provider (worsening signs and symptoms of
renal failure, such as nausea, vomiting, and diminished urine output). Specific
teaching may include explanations about recommended diet and fluid
modifications and medications (purpose, desired effects, adverse effects,
dosage, and administration schedule).
Periodic
evaluation of creatinine clearance andserum BUN and creatinine levels is
carried out to assess residual renal function and the need for dialysis or
transplantation. If dial-ysis is initiated, the patient and family will require
considerable assistance and support in dealing with therapy and its long-term
implications. The patient and family are reminded of the importance of
participation in health promotion activities, including health screening. The
patient is instructed to inform all health care providers about the diagnosis
of glomerulonephritis so that all medical management, including pharmacologic
therapy, is based on altered renal function.
Related Topics
Privacy Policy, Terms and Conditions, DMCA Policy and Compliant
Copyright © 2018-2024 BrainKart.com; All Rights Reserved. Developed by Therithal info, Chennai.