[Music] hello everyone welcome back to our nclx arm review and for those who just join us today we are on the fifth day of the 90day free ankx review classes which we schedule daily 12 p.m. Eastern Standard Time and so we'll be covering all the nursing subjects and also rationalization of about 2,000 enlex style questions but for today I'll talk about the nursing care and management for an adult patient with nephrotic syndrome and we'll have some Q&A right after so to get started here we need to really identify what this disorder especially in the adult and so here we're talking about nephrotic syndrome in the medical surgical level and so this is a condition that is characterized by a significant increase in the urine protein and also a low blood alumin known as hypo aluminia and swelling or edema and also some elevation of the blood lipids and these are the symptoms that will arise due to the excessive plasma protein leakage into the urine and this can result from The increased permeability of the glome capillary membrane so these are the Hallmark signs of nephrotic syndrome and so first one is we have the protein nuura which is going to be about 3 gram per day that's a lot of protein leaking into the urine and then we're going to have the H hypo aluminia which is decreased serum level of the alumin and then we have EMA hyper lipidemia which is an elevation of the LDL and also the triglycerides we also have infections and possibly thrombosis so I really want you to focus on these manifestations because these are the often ask situations or assessment findings in the nephrotic syndrome now at this point we're going to talk about the picology and the different causes and also some conditions that can lead into the nephrotic syndrome so I really want you to pay attention and want you to follow all the way now we are going to talk about the different contributing factors such as the diabetes meletus which is the leading caus to nephrotic syndrome and of course this can result into what we call as Di diabetic nephropathy now let us refamiliarizing [Music] the kidneys including the glami which can increase the permeability and also protein loss now another condition that is associate with nephrotic syndrome is amiloidosis and this is a condition and there is an abnormal protein deposits called ameloid buildup in the organs and also the tissues including the kidneys now when this happens when there is ameloid deposits in the glome it will disrupt the normal function and also the integrity that's why it can also cause leaking of the protein into the urine now yesterday we talked about the SLE which is one of the um triggering factors in Glo nephritis well SLE is back to cause some problems especially in the Fric syndrome and we know that this is an autoimmune disease where it will attack its own tissues including the kidneys now there will be immune complexes that will be formed by the antibodies and also the antigens deposited in the glumi and so this will also cause the inflammation and damage that can result in and the nephrotic syndrome now we also have the viral infection such as the hepatitis A uh Hepatitis B rather and also hepatitis C and HIV so these viruses can directly infect the kidney cells or it might cause an immune response that can damage the glumi so for instance we have a hepatitis B and C they can lead to membrane nephropathy while HIV can cause HIV Associated nephropathy now we also have a medication here which is often quoted the non-steroidal anti-inflammatory drugs that can cause a direct toxicity to the kidney cells and can also lead to a condition called minimal change disease or membranous nephropathy and both of which can cause nephrotic syndrome now we also have some immune complexes deposition in the glamas which is basically the same mechanisms that we knew about yesterday with the glal nefritis so it's going to be uh the same pattern we're in the immune complexus from the various autoimmune diseases or let's say chronic type of infections can also Lodge into the glumi and it will also cause inflammation and damage now there's also the deposition of the imunoglobulin in the glus and again such as the deposition of the immunoglobulin a uh it can cause nephropathy also which can directly affect the glomular function and so the same pattern it can also trigger the inflammation of the glus and some subsequent uh damage to the Nephron now all these factors that I had mentioned can do the same end effect it will definitely damage the glome basement membrane again we're talking about the GBM that is the middle layer of the glus right and so when this is going to be compromised when it becomes more permeable it can now allow the proteins that should stay in the blood to pass into the urine now again this is going to cause the damage into the structure the GBM now this will also include the leaking of the critical proteins okay and so we know that the moderate and also the large size molecule of proteins will be leaking into the urine so remember those groups that I've mentioned I want you to recall because they're going to be the same kind of proteins that will be look uh that will be leaking into the urine and so let's talk about the first group of proteins that will be leaking and this is the um the antithrombin also the protein C and the protein s okay so these substances are actually innate and anticoagulants inside the body so they will kind of buffer into the procoagulants to prevent inadvertent coagulation throughout the body and so if the body will run out of these three substances then the person will be at higher risk to develop thrombosis okay and so again these are our natural anti-coagulants in the body and so when they are going to be depleted inside the body well what do you expect there will be thrombosis and it can affect several areas in the body and one of the primary site is the renal vein and it can cause problem it can lead into an impairment of blood supply to the kidney now it can also lead to pulmonary embolism because it can evolve all the blood vessels inside the body all the circulating blood it can have a tendency to clut and so the person here will be at higher risk to develop pulmonary embolism and it can also travel into the other systems of the body maybe the brain maybe a TIA can occur or maybe a stroke or in some cases with the sluggish circulation there will be now some form of hypertension that will develop because of of that hypercoagulable state and this is something that we need to pay attention because this person can really go into these complications really fast now another protein that we wasted into the urine is the um or another um complication here is the synthesis of the lipoproteins and this is because because of the rapid loss of the proteins in the urine then the body will try to pause this process that will lead into hyper lipidemia and so there will be now increasing circulating volume of triglycerides HDL or the LDL rather will be elevating and for those uh patients that have been uh having recurrence of the nephrotic syndrome then they're going to end up with some uh thos cerotic disease later on now another protein that we're going to be worried about is the albumin which is basically the major protein in the blood that is going to maintain the oncotic pressure now again oncotic pressure is exerted by the albumin right so I had um mentioned about that yesterday regarding its role to act like a sponge so it will prevent the vascular fluid to leak into the interstitial spaces and so it has that sponge effect however at this time because of the body running out of the alumin then what's going to happen here there will be a decrease in the oncotic pressure okay so it will lose its sponge effect and what's going to happen here there will be generalized edema the person will have what we call as anasara and and in turn this will activate the RAS system this is the renin enot tensin aldosterone okay so I want you to recall the lecture I gave you on the first day of the renal Concepts so again this will be activated because of the loss of fluid into the urine now when this is activated it can lead into sodium retention and so the person here will end up with hypernatremia of course and uh some other major problems later on which we will be talking later now please pay attention here because not just the alumin is affected and not just the protein C or the anti-thrombin but we also need to be worried about the immunoglobulin these are your moderate sized particles or molecules and they're also going to leak into the urine so these are your immunoglobulins IG G and the IG and we know that these are vital in the immune system right they are going to responsible to fight off infections and of course when there is a deficient uh presence of these imunoglobulin then the body's ability to defend against pathogen will be greatly diminished now what we're going to EXP fact here is that there will be uh some infections that can occur to our patient and most of these infections will be uh could be a gram NE or gram positive like your eoli or pseudomona perenosa or it could be the ner G or it could be the stafilic cus orus or MCA or strap tocus pyogenes or could be a strap tocus pneumonia and for some people they are going to be really prone to catch some chicken or virus type of infections now I really want to recap this so that you can retain this in your subconscious and so with the nephrotic syndrome this process will start with the different conditions that can cause damage into the glome basement membrane and so it will cause the basement membrane into more permeable okay and so it will allow the proteins to leak out and also the essential anti-coagulants like the protein c s and also the anti-thrombin and also the immunoglobulin and so these loss of the important proteins will really going to cause some major complications like the blood clots that I mentioned also the kidney damage and Pulmonary imis and stroke hypertension edema and also other risks of infections now I hope that you are able to capture that because the we're going to base our assessment findings and also our Laboratory Testing and also our nursing care and management with this diagram now we're going to talk about the different diagnostic tools or tests that will be ordered by our medical provider and so first things foremost the most popular sample that we will be expecting is the urine sample for year analysis now when the person has the uh nephrotic syndrome what you're going to expect here is that there will be protein murria that is the hmark of nephrotic syndrome there is massive leak of protein into the urine okay now this is going to be the first classic manifestation and so don't get confused we will make this much easier and so so another testing that you will be expecting or another significance significant finding that you will see with ve analysis is the presence of the blood especially the microscopic red blood cells right and so some of these red blood cells can actually leak into the urine and some casts or the urinary cast which are actually tube like particles they are like white blood cells red blood cells or kidney cells they're going to form in the kidney ules and their presence can indicate kidney disease so when you're going to look into the the laboratory data of your patient uh irregardless if they are with cardiac problems or maybe other urinary disorders you're going to get started to worry about the urine uh result if there is some urinary cast that's going to worth some form of kind of Investigation now another here is the foamy appearance I mentioned about this yesterday that foamy appearance in the urine actually will signify that there is a whole lot of protein in the urine it will appear like a beer it becomes bubbly and even though it's not really a definitive test it is going to give you a clue that something is very off with the kidney function so I want you to recall all these findings in the your analysis this will really guide you in the care of your patient now let's move on into another testing here which is the 24hour year in collection which is something that I've done way too many times um and even I've collected like the 48 hour year in collection um I get lucky sometimes that when I come back for the two days I still able to collect those urine specimen and send them to the laboratory but here we're only talking about the 24-hour urine collection and of course the same thing is going to happen here we will see increased protein there's protein UA again there is about 3.5 grams of proteins lost in the urine every day imagine that and with this it will actually um also reveal a potentially decreased creatinin clearance now this is actually actually going to help us tell that um the kidneys are not able to really filter the waste products and so the creatinine clearance that we will be expecting here will probably be decreased okay now another is the urine protein electroforesis so this is going to analyze the different proteins in the urine so this is going to separate the proteins in order to identify the types and it will also help pinpoint the specific proteins being lost and this can also uh give us some clues about the underlying cause of the nephrotic syndrome okay so here we will be able to tell if it's the moderate size or it could be the large size protein molecules all right now moving into another testing here which is the definitive diagnostic test the kidney biopsy and so this is going to be the procedure that will involve histological exam so this will um uh this involves the collection of a small tissue sample and this will confirm the diagnosis so um here the the test will actually will reveal the type and also the extent of the damage to the glamy and so this will help our medical provider to uh determine the specific cost and also the best treatment plan that they will incorporate in the patient care now another uh testing that we are going to expect are the blood tests and so here we are going to expect low total protein and I just give you here the the normal range which is actually six to 8.3 grams per deciliter so anything below six that's already considered as hypo um a low protein level all right because there's another testing for the the alumin now with the uh alumin anything that is below 3.5 grams per D liter is already considered hypo albuminemia okay and so if I'm talking about total protein it involves all the different kinds of proteins in the body that will be possibly leaked out into the urine right but we're going to focus also in the the aumen because this is the main protein that is responsible in the oncotic pressure it will hold the fluids inside the body supposedly now here at this point we are going to talk about the uh creatinine level which is going to be elevated as well and this is going to suggest that there is impaired kidney function and this is commonly going to be found in a more advanced stage of nephrotic syndrome okay again this is going to be much more elevated during the advanced stages of nephrotic syndrome now another test that we'll be expecting to see as being elevated is the triglyceride okay remember that because of the massive wasting of the protein the body will try to produce more of lipus and so this can also cause uh the problem this is going to elevate the triglycerides and also the cholesterol levels in the bloodstream and this will place the patient into uh different cardiovascular activation remember that there is reabsorption of the sodium ions by the kidneys it will allow those sodium ions back into the circulation now at this point we're going to talk about the possible complications of the nephrotic syndrome so one of those is the hypovolemia since we are going to lose the proteins also we are going to lose the circulating fluid inside the vascular compartment it will be depleted right and so the patient will be at risk to develop dehydration that is one okay and another is the thromboembolic events and this is going to affect the um the renal vein it can olude the renal vein and also can possibly cause pulmonary embolism and hypertension could be stroke all right so because again we are losing the natural anti-coagulant inside the body which are the protein C the protein s and the anti thumin now another thing that we're going to have to expect here since we are loosing a lot of the alumin okay and I've talked about the albumin's role especially with how it's going to deal with the different medications and so when we are going to take care of a patient and some of these patients are taking meds that are possibly highly protein bound and so that simpl means that it these medications are considered to be toxic when the person's body has a deficiency in the amount of the albumen so I'll to I'll explain this one much clear so you'll be able to capture this one so this is basic in Pharmacology wherein the medications being taken this is going to be available in the bloodstream right and for some medications let's say the moderately high or highly protein bound drugs let's say for example uh anti-convulsants let's say non-steroidal anti-inflammatory medications Warfarin or cadin these are known to be highly protein bound and so the the implication here is that they are supposed to attach into the albumen okay okay so it's not that when you have ingested a highly protein bound drug when you adest it when it's available to the bloodstream that it should readily go into the tissues no when we're talking about highly protein bound drug they're supposed to attach into those albumin and then one by one they're going to have to detach so the circles here okay um these are your um alumen molecules right so the medications those highly protein bound medications will attach into the albumin supposedly and once those uh particles of medications have already been used up when they have gone into the different body tissues then slowly some of those uh medication particles will detach from the albumin and they're going to go directly into the tissues so slowly they're going to detach up until the medications will be no longer available in the system so that's how what a protein a highly protein bound medication um behaves inside the bloodstream again if there is a low um albumin in the system so what do you think there will be no attachment for those free drug right so they're going to look everywhere there's no more albumin so what's going to happen the these medications will go directly into the body tissues those receptors causing rapid drug action and some of these medications are really not supposed to do that they're supposed to just slowly detach in a normal mechanism right but here it will directly cause that rapid effect and so this is going to cause some toxicity into the patient if they have hypo ALU memia okay so I hope that you're able to catch that so again if there is low albumin in the system it will cause an elevation of the free drugs especially the highly protein bound drugs free drugs it's not good all right now we're going to talk about some infections so what are these infections that can potentially happen well I've mentioned those the uh positive or gram negative or gram POS uh bacteria could be viruses or could be yes the chicken poox so those are potential infectious microorganisms can become opportunistic when the person has been depleted of the imunoglobulin uh G and a all right so here um I want you to recall really the importance of the imunoglobulin here so for the imunoglobulin G or actually a this is the predominant antibody that you can find or known to be found in the mucosal surfaces like the GI track or the gastrointestinal track or the urogenital track and so they're all going to be found in the saliva the tearce and also the breast milk and so the IGA can also play a crucial role in actually protecting the mucosal surfaces uh from any kind of infection because they are supposed to neutralize the pathogens and will prevent their attachment and also the invasion of these pathogenic microorganisms and so their role really is to bind to the pathogens and also the toxins and they're are going to neutralize them before they can enter the body tissues and we know that their pathogencity is actually going to be diminished because of the action of the IGA now for the IG the imunoglobulin G these are the most abundant imunoglobulin in the blood and also the extracellular fluid and so as we know like this is the only antibod that can also cross the placenta and this will provide some passive immunity into the fetus now Recall now that the IG GG the role for this type of imunoglobulin is actually to do the opposite ization I hope that you still remember that wherein the antibodies will coat the pathogens they're going to mark them for distraction by phagocytes and so they're going to Mark those microorganisms in order that the body those fyes can easily ingest them all right and so they are also responsible in neutralizing those toxins and also the pathogens they are going to attach to them they're going to block their ability to infect other cells and also uh interacting with host tissues now the role of the IGG is to also activate the compliment system wherein it will cost a series of the proteins that will assist in destroying the bacteria remember about the C3 that I mentioned yesterday with the glera nephritis the complement 3 is actually one of those important um aspects in the complement system and so here um the complement uh the IGG actually going to activate that as well in order to prevent the formation and also to actually uh activate that will lead the formation of a membrane attack complex and so with the absence or diminished amount of the imunoglobulin A and G so what expect well the person is really going to be prone to developing so many infections and especially if they're going to be in the hospital they can easily get those uh healthc care acquired infection okay or nosocomial infections because of their suppressed immune system now at this point we're going to talk about the different management of the nephrotic syndrome and here we're going to talk about different pharmacological um items so part of that would be the administration of the diuretic so um the diuretics that I am talking about here would be the loop diuretic which is the furosemide and this is going to be ordered to decrease or to actually allow excretion of the exess fluids as we know that the body has edema right from all these interstitial spaces then we're going to have to make sure these are going to be excreted okay and another medication that we're going to expect to be part of the treatment is the ACE inhibitors so this is the Angiotensin converting enzyme Inhibitors so I hope that you're still familiar with this medication classification and this is an anti-hypertensive drug and what it does actually is to prevent Vaso constriction that is one another is it will prevent the release of the aldosterone because there is no conversion from Angiotensin one to Angiotensin 2 so there is no triggering effect into the adrenal cortex to release the aldosterone it doesn't happen because there is no conversion at all and so what you're going to expect here is that there will be no no reabsorption of sodium ions in the kidney tubules there is also no reabsorption of the water in the kidney tubers so that's on top of its vasodilatory effect it will be beneficial for the patient to take this medication because the ace inhibitor can actually help widen the afferent arterials so remember this is one of those uh blood vessels that will actually lead the blood to go into the glus so the afferent arterial uh diameter will be widened and so when this happen when the diameter is bigger it will allow a very much slower or lower pressure okay so when there is a low pressure inside that blood vessel the hydrostatic pressure will also go down so simp L it will decrease the chances of allowing those proteins to leak out from the glus into the urine because of the lower pressure inside the glus or GLA I should say so that is the therapeutic effect of the ace inhibitor again it will widen the aerin arterials and also to decrease the hydrostatic pressure and thereby it will decrease the force leaking of the proteins into the urine all right now I also need you to get familiarized with other classification which is the corticosteroids they're actually uh considered as immunosuppressants as well and so this is what we referred way back in the past as the wonder drug in the treatment of nephrotic syndrome and this just started uh to be popularly used way back in the early '90s or 2,000 um and so we we really refer this medication as the wonder drug because it will decrease the inflammatory process especially with the blood vessel especially the blood vessel in the kidneys and so it will decrease the inflammation of the glus gleri and it will also decrease the incidence of protein muria okay now another medications that we have uh are the anti-coagulants why are we giving anti-coagulants to the patient with nephrotic syndrome well this is going to be based upon the uh lab work of the patient their coagulation studies if there is let's say um increasing clotting time then there is a high chance that the patient will have some coagulatory coagulopathy or let's say um they're going to be prone to developing blood clots easily all right and so the um the anti-coagulants that we're talking about here it could be in the form of an injectable heprin the infraction heprin that we can give as a subcutaneous um it could vary in different doses as well or it could be in a form of warrin or cumin or could be the novel anti-coagulant medications all right and so this medications will actually prevent the formation of the blood clots and to prevent those thrombotic complications because again we are talking about a possibility of PE a possibility of a stroke a deep vein thrombosis and also the renal vein thrombosis that's why we are going to anticipate um administering this medication and so if the patient probably would be complaining of let's say a flank pain well that is not a good assessment finding if the person will be complaining of the flank pain and they have an established diagnosis of nephrotic syndrome this is not going to be about pylon nephritis because Pyon nephritis is a totally different entity and so here with a patient that has nephrotic syndrome it's not about the infection but actually it's the thrombos is of the renal vein and so this is a medical emergency that needs to be dealt with okay now another uh medication that we'll uh be expecting or another treatment that we'll be expecting to uh to be implemented will be the edema management and we can do this by uh simple application of compression like TED hose or also leg elevation maybe sodium and fluid restriction so these are our preliminary um management for the edema um one is the infusion of albumin which is a blood product and this is going to be administered just similar to a blood transfusion but albumin is that yellowish clear yellow um fluid that we give to Patient especially um in renal disease for those who have aites um for those people that may have some hypotension issues um and so this is really going to help out in uh this patient with a nephrotic syndrome it will prevent the further leaking of the fluids into the interstitial spaces and also will decrease the incidence of Edema okay so remember alumin infusion okay so this is something that we're going to expect to administer okay so this is not really like a blood product um for say like similar to a platelet or let's say a red blood cell no it comes in a a bottle that we administer with a regular IV tubing and can be done through a regular um IV pump all right um but you really need to pay attention as well because some of these patients can develop some adverse reactions with the albumin infusion right now we're going to talk about some dietary uh protein protein supplements and this is very important that we're going to um involve the nutritionist or the dietician in the care of the patient because when they are losing a lot of those proteins the immunoglobulins the albumin those proteins that are involved with the coagulation when these are lost remember all these complications that we just talk about we need to replenish these okay and so we are going to involve The dietitian or the nutritionist in order to boost also the immune function remember about the IG IG and um we're going to have to reverse this effect by allowing a much more solid nutritional treatment to our patients so what we're going to promote here is to um allow them to take supplements containing the vitamins and also the minerals that will also improve their immune function could be in a form of a vitamin C vitamin D it could be zinc that will help reduce the risk of infections now also we're going to have to anticipate about some dietary adjustments so one of these would be to reduce the intake of saturated fats oh boy reduce the intake of saturated fat well because there is hyper lipidemia hyper triglyceride emia because of that liver causing the synthesis of more lipids because it's sensing that hey the body is getting malnourished right now because we are not getting the protein so it's forced to convert um causing this complication and so what we're going to do here we are going to control the hyperlipidemia or dyslipidemia by of course with a dietary modification but also have to anticipate the administration of the statins and these are the firstline medications that will help manage hyperlipidemia in nephrotic syndrome so what they're going to do is actually inhibit the enzyme that is involved in the cholesterol synthesis of the liver and they are going to lower the low density lipoproteins which are what we refer as a bad cholesterol level and so this will really reduce the risk of the cardiovascular events and uh I hope that you still remember the the medication names here we have the statins right so you have the atorvastatin sast Statin rusu vastatin pravastatin so there we go those are the generic names of the stattin now another is the acetam which is another medication that can be ordered or that can be part of the prescription in combination with the statins U to further lower that low density lipoproteins and this medication acts by blocking the absorption of the cholesterol from the intestine and this will lead into a decrease in the levels of the LDL in the blood so how fancy is that but I recall taking this medication way back about probably 10 years ago and so I actually took like five doses daily Doses and about a week later on I started to feel like having flu like manifestations my uh muscles were like kind of achy so I thought that I had some kind of uh influenza but when I review the adverse effect that's actually the adverse reaction so immediately the medication was discontinued um and that was replaced because this is one of the adverse reaction of the um the um uh like this kind of medication so another is the fibrates and so this is another class of medications that will uh Target the triglyceride in the blood but they can also Elevate the HDL right the good cholesterol and so they are going to be prescribed in combinations with the statins um especially for those patients that have persistent hyper triglyceridemia despite they've been on the Statin for so many uh months already and so the um the fibrates is uh represented by the gy fibril or known as the pheno fibrate now another group of medications that we'll be expecting here to administer will be the bile acid sequestrants and so these are uh this is a classification represented by the kelum which is going to be given orally and this is to bind the bile acids in the intestine and so it will prevent the absorption the reabsorption and so what is expected here is that there will be increased excretion of the bile acids and also the cholesterol so what is the expectation here there will be now an decrease in the LDL when you're going to look into the lapse it will surprise you now lastly we have the omega-3 fatty acids which is considered as a supplement and they're going to contain um the eoent noic acid um and they're really known to be V very beneficial especially on the lipid profile so they're going to really reduce the triglyceride levels and um yeah this is very beneficial you will see a whole lot of your patients taking the Omega GA 3 most of the adult uh patients that you'll be taking care of they're going to probably see this in their medication list now we're going to talk about the possible um actually we're going to talk about the nursing uh care at this point so what are those key nursing actions that we need to uh Implement into this patient well when we are taking care of a patient especially if this is the first time that you've met the patient you are the ones admitting the patient then definitely you need to get thorough symptom and history taking that is very important because if you're not going to be able to dig deeper into their medical history um and also if you're not obtaining the most uh important data especially the medications that they're taking the important past and present medical history you really going to miss those important um uh information that could delay the treatment and so what we're going to do here is to document the different symptoms uh maybe the onset of the symptoms if there's any urinary type of changes the onset of the swelling and so these are the key findings that we need to um find out okay now we're also going to do much thorough physical exam so again since we're going to expect this patient to have fluid shifting from the vascular compartment into the tissues well edema is very obvious right so you really need to pay attention into the the overall body parts here you got to check into the dependent areas of the body the legs and also ask the patient if they have noticed any form of swelling in the sacral area so you probably would really need to take a view of the private areas as well and also um well some of these body areas that are known to swell up easily of course the the hands um the uh tissue surrounding the eye or the sacral area or the legs or the feet they can easily be detected but I really want you to pay close attention to other areas of the body when there is a Dema now what we're going to do here is to properly do our assessment well of course vital science is very important we're going to have that basa information in order for us to compare future readings and also make sure that we are checking for the edema and their status such as hypovolemia they're running out of the fluids right and we got to check their weight Baseline information of their weight on admission and then we're going to have to daily monitor their weight as well now in take an output measurement is Biggie here anything that involves fluid and electrolyte imbalances weighing intake and output measurement edema checking vital science checking these are basic you should not forget these skills in your assessment now another thing that you need to do is to check on the laboratory studies compare it with the previous laboratory results the patient might have and so you really need to pay attention into the trend of the renal function studies uh the abuin level to see if these are significantly decreasing or maybe the creatin level is now skyrocketing that is not good sign because the patient now is probably going into renal failure now I'm another thing that we need to do here um especially the in the implementation phase we are going to have to monitor the daily weight strictly and intake and output measurement will be done strictly as well any significant variations need to be reported to the medical provider and make sure that we are checking the year in specific gravity to see if there is major changes and also the vile sign checking the creatinin the bun and also expect the administration of the medication that we tackled earlier so one of that would be the diuretics could be the alumen to uh prevent further uh wasting of the fluids and also we want to make sure that the edema is lessened now it's very important that we're going to prevent the infection since we are losing way too much of those imunoglobulin and we are going to check the patient for any manifestations of infection I know that you have mastered Des probably because we have repeated this so several times um signs of infection fever tachicardia could be change in the color of the drainage urine some sorts and so you really need to pay attention to those and checking onto the white blood cell account with a differential account look into the levels let's see if there's any right now when we are performing some kind of invasive procedures to the patient let's say there's an order for us to place a um continuous uh what do you call this a fully catheter that's very simple right you really need to do this strict uh surgical asepsis aseptic technique in order for us to prevent occurrence of urinat infection or let's say if you are putting in a new IV or let's say you're changing the Central Line dressing you need to observe a septic technique when you're removing the old dressing and also when you are applying the new dressing this is something that you need to do in order to prevent those opportunistic infections from coming in in their into their system now what we're going to do here is to really um encourage the patient to participate especially when we are um teaching them together with their family or their spouse it is very important that we are going to impart the necessary information in order that the patient will comply to the treatment regimen okay and so one of those teaching pieces uh would be the symptom awareness and this is about teaching the patient on the different syndromes or manifestations that they might experience at home and so this is what you need to do make sure that you're going to describe this to the patient and the family member these following um symptoms in order they can report all these findings to the medical uh medical provider now another is teaching them about the different medication side effects okay and so again if we are talking about the administration of the steel steroid glucocorticoid remember that it can cause hyperglycemia it can cause weight gain sodium retention and also the patient may be prone to developing more infection how sad is that the patient already has nephrotic syndrome and they're prone to getting opportunistic infection and they're going to be treated with corticosteroid which will further cause immune suppression so we're actually um yeah that's going to be a problem as well and so we want to make sure that we are teaching our patient to not um expose themselves into crowded areas um as much as possible and make sure that they know uh in practicing strict hand hygiene and if unavoidable if they really need to show up for the doctor's appointment they need to wear their mask um because they really going to be prone to catch those opportunistic infections now another is diet and fluid management and we talked about the different um dietary modifications and so again we are going to involve the nutritionist or The dietitian into planning their meals okay now there is also going to be a need for lifestyle changes and so we are going to incorporate uh maintenance of exercise reducing the cholesterol also the fat intake um especially everything is so much like we can patients can get their fast food so easily and so very uh easily to easy to access and so yeah there's going to be a need to modify their lifestyle and so a reduction in the intake of those cholesterol fat uh fatten food items and also and we need to address those other risk factors like smoking obesity and also to address stress in order to uh lower the risk of Thro and bowling events now another thing that we need to do is to prepare the patient for uh severe disease development and because if they're not going to respond to the therapy if they have been non-compliant to the treatment they're not taking their corticosteroids they're probably not taking any of the anti-hypertensive medications or the anti- lemic medications or the supplements then this will cause a much more worse of a problem here so they might go into a renal failure or it could be the endstage renal disease and some of these patients will really going to go into the estate renal disease if they are not compliant um they were not showing up into the appointments with the doctor and so when they come back their kidneys are already shut down so this is something that you really need to emphasize in educating your patient now we're going to have a quick break here and so again we are promoting our special offer to you especially for your friends that are not aware yet that we are conducting the free classes for the 9 days period so today this is the fifth day right and so I really want you to invite your friends to um see the videos that we had recorded for the live sessions I want you to encourage them to attend in the live sessions as well so they'll be able to get refreshed and we also want you to grab the opportunity especially with the offer um for our website at www sand coast and class coaching.com we do have the different offers here and I want you to check into the description below for more details now let's go into the different questions that we will be um answering here and so here's the first question for you so it says here the nerves will expect to educate a nephronic syndrome patient who experiences flank pain regarding treatment with again the nurse will expect to educate a nephrotic syndrome patient who experien pain or flank pain regarding treatment with a is it medications for bacterial infections or is it B medications for fungal infections or is it C blood thinners or is it D medications for high blood pressure I want you to take your pick right now is it a is it B C or D all right time is up I hope that you were able to um formulate your answer here and so the scenario is showing as a person or the nurse educating uh will expect to educate a nephronic syndrome patient who experiences flank pain so our scenario here will revolve into the manifestation of this patient with a flank pain okay and I just mentioned this just not too long ago about the flank pain in a patient with nephrotic syndrome so what do you think is the answer is it a medications for bacterial infection is it indicated for that patient well let's take a look well for this patient with a nephrotic syndrome and if they are having plank pain actually this is not going to be really the answer because um the antibiotics are only going to be indicated to those uh instances wherein there is a real infection in the case of Pyon nephritis right and so at this point the uh medications or let's say anti-infective antibiotics will not do any good to the patient because we are not thinking about the urinary tract infection not at all so we're going to eliminate that easy py what about letter B medications for fungal infections is a patient with a nephrotic syndrome um in this scenario with a fungal infection and we did not talk about fungal infections at all with the discussion of your of our um uh picology we did not mention about that and so this is something that can only occur in a patient with Pyon nephritis with the fungal type so we are going to eliminate this one and then what about letter C blood thinners we call them as blood thinners referring to the anti-coagulants like your oral uh warin or Kadin heprin or the Noak um this is going to be indicated for this patient especially that we are um thinking that the patient probably has already has renal veinous thrombosis right it is a medical emergency this is something that we need to treat right away in order to prevent the enlargement of the clut we need to do the anti-coagulation as early as possible for this patient and also to prevent other complications like PE right or renal failure now let's take a look into letter D which is medications for high blood pressure well the patient here with the nephrotic syndrome is actually going to be not going to need about the antihypertensive right there will be hypotension in this patient so we're going to eliminate this Choice as well so for the test taking skills that you need to do here what we're going to need is to Simply understand the medical condition being talked about in the question and so again we are revolving our scenario on the flank pain on the patient with the nephrotic syndrome and we need to analyze here the symptom Associated now remember we need to um match the symptoms according to the described um scenario and also look for that question stem and make sure that we are going to direct with the proper treatment option now another is we're going to have to also consider the prevalence we want to recognize the Rarity of the fungal Pyon nephritis compared to the other causes of flank pain and also to choose the treatment accordingly but like I've said again these manifestations do not reflect the assessment findings in nephrotic syndrome all right now we let's move on into the next question here it says a 48-year-old female patient is is hospitalized due to the sudden onset of nephrotic syndrome what clinical signs would the nurse anticipate assessing so we have an adult patient female patient with a sudden onset of nephrotic syndrome so what clinical signs would the nurse anticipate assessing is it a diminished skin elasticity or is it B recent increase in body weight or C presence of ketones in the urine or is it D reduction in the blood pressure I want you to take your pick right now all right let's move on now our scenario here is about again a patient with a new sudden onset of nephrotic syndrome so what are these clinical findings that you are going to expect well let's go through each option here is it a diminish skin elasticity remember guys that our patient has edema right there is uh presence of fluids into the interstitial spaces there will be puffiness of the skin and so the elasticity of the skin is not diminished at this point okay there is no loss of elasticity because of the edema easy py eliminate that one right away what about B recent increase in body weight well yeah nephronic syndrome remember there is increase in the body weight and because of the shifting of the fluids from the vascular compartment into the interstitial space right the body is not really enjoying the fluid because when I'm saying enjoying it should be circulating in the bloodstream right but what's happening here is that the fluids are in the interstitial spaces they're not usable they're just going to sit there nothing else and they can put the patient at risk to developing skin breakdowns right puffy skin tissue or puffy tissues is never good for a patient especially if they're debilitated um and so back to here recent increase in the body weight this is very significant and this is one of the key assessment findings that we will be noticing right away and so again the reason that there is a sudden weight gain it is because of the increased permeability of the glal filtration barrier which actually will cause the proteins to leak into the urine and this is going to cause the hypo Almia and then what's going to happen this will lead into the fluid retention into the interstitial spaces okay remember that we lost that sponge effect because we are running out of the albumin and so again those body fluids will leak into that inter spaces so that's not a very useable form of fluid now another here is so this is going to be a possible correct answer and then we're going to check on option letter C and this is presence of ketones in urine well I did not talk about ketones regarding U our case today which is nephrotic syndrome it's never you will never find keton in the urine if the patient doesn't have a dka and so um this is not a classic um or a hmark in the nephrotic syndrome okay so we are going to eliminate this one easy right no Ketone in the urine now letter D reduction in the blood pressure remember here what clinical signs would the nurse anticipate assessing remember guys that there was an activation of the the RAS the renin andot and aldosterone system and this is going to cause a reabsorption of the sodium ions and this is going to cause the blood pressure to go up and so hypertension is a common manifestation at this point so don't forget about the rest this time now for the test taking skills so we we have our answer here letter B let's Circle that the rest they're erroneous so for the test taking skills here what I want you to focus here is to understand the picology of the nephrotic syndrome and so if you're really solid into understanding not just about pneumonics because I've tried this way in the P way back in the past um I've tried cramming studying in nursing tests when I was back in College I try to cram my brain with all those pneumonics it just doesn't work for me as soon as I forget that one letter everything will be lost so lucky you if you were going to be able to memorize these demonics but for me it just doesn't work and so that's why I really need to go deeper into the picology so I can understand better and so I can um generate those nursing processes because I'm understanding the the disease process pretty well and so um I would really recommend that you do that as well instead of just memorizing the pneumonics because if you're just going to rely on the letters pneumonics this is some kind of like a shortterm kind of assistance and so most of the time this will be lost um when you're going to get gain some more information and that is um really uh proven that some of these will be easily forgotten so I really want you to go back into the concept and really understand the disease process all right now another thing that we need to understand uh part of the test taking strategy here is to recognize common clinical manifestations and again we're going to look for the Hallmark signs those uh symptoms that is associated with the nephrotic syndrome and also we are talking about the weight gain right and so again this is something that you would really associate with this diagnosis okay this will also narrow down your options now again you are going to employ the use of the process of elimination uh you have to rule out those incorrect options uh like the skin turer elevated ketones um based on the picology Okay so so like I've said always do it by the elimination process look for those incorrect answers all right you have to do some kind of a self- debate is this present in this dis order is this not so you have to think over and make sure that you go through that elimination process before you look for that answer okay now that is it we're going to move on to the next question question number three the nurse is tending to a 28-year-old patient with acute inflammation of the glome which is basically lrtis what symptoms would the nurse anticipate in this client select all that apply 28-year-old patient with acute inflammation of the glumi and we are being asked about what possible symptoms that we will be looking into this patient and we are going to answer as much answers that we can as we can rather so options here are your tiredness B we have swelling around the eyes or in some uh in some this could refer to the periorbital edema right around the eyes pus around the eyes or is it blood clots traveling through the vessels letter D urine with dark Cola like appearance letter e high blood pressure and F presence of protein in the urine and then H is it H or G rather elevated levels of lipids in the blood again is it tiredness swelling around the eyes is it blood cluts traveling through the vessels is it urine with a dark Cola like appearance or high blood pressure presence of protein in urine or elevated lipids in the blood now pay close attention we are talking about the inflammation of the glome acute inflammation okay I want you to think ahead so what are the symptoms of this patient all right let's go through the options here what about letter A tiredness this is a common report a common complaint by the patient when they come into the hospital or let's say if they're going to see the doctor so if you're the nurse um seeing this patient for the first time they're going to complain about the fatigue and this is a common manifestation in a patient with the sudden onset of gloomo nefritis and the reason for that is because of the inflammatory process and also the effects of these inflammatory process into the body so tiredness is possibly one of the answers here what about letter B swelling around the ice let's take a look is that part of it yes possibly because the par orbital edema or let's say the swelling around the eyes these are your classic manifestations of a sudden gluma nephritis and this is going to be caused by the fluid retention and the altered kidney function okay now let's take a look on letter C blood clots traveling through the vessels I want you to recall the concept about the glal nefritis did we talk about possible cluding in those different classifications that I mentioned about yesterday no and so thromboembolism is not a typical manifestation of the Glon nefritis it's not okay but you will see the thrombosis in the patient with the nephrotic syndrome we just talked about this about close to an hour ago and so we are going to have to eliminate this one than again about the pysiology now letter D urine with a dark Cola like appearance did we mention about that yesterday yes so the presence of the cola colored urine this is basically what hematuria is all about there is leaking of the red blood cells into the urine it will be cloudy kind of looking and this is a typical manifestation in acute glumer NE frus and this is because of the inflammation and the damage to the gline and of course the blood cells the red blood cells allowed to leak into the urine that's why we're going to see that frothy call a colored urine now let's take a look onto so this is a possible answer and letter e high blood pressure so what is all about that well the high blood pressure is going to accompany acute glumer nephritis because there is fluid retention there's also retention of the sodium and the activation of the renin andot tensin aldosterone system because of the RASS okay so this is quite similar with the nephrotic syndrome there is an activation of the R so there's also so some form of high blood pressure and then let's talk about letter F presence of protein in the urine so this is the Hallmark feature of the acute glum netis again because there is increasing permeability of the glum filtration barrier the pyes those slit membrane the glome basement membrane are now allowing those proteins to leak out that is why we have protein Nua in the spacal okay now we're going to talk about letter G elevated levels of lipids in the blood hyper lipidemia is it part of the nephrotic syndrome or is it with acute glal nefritis well yeah we did not talk about hyper lipidemia in acute glal nefritis we only talked about this today as a complication right and so this is not a characteristic uh assessment find finding in the glumer nefritis uh this is more associated with the nephrotic syndrome and again because of the livers responsible of converting more synthesizing more lipids and that's causing the um hyper triglyceridemia now at this point we're going to have to focus onto your test taking skill here so again you need to be familiar to be familiar with the different signs and symptoms of the acute glum lrtis um also those fluid overload edema kidney dysfunction hematuria protein UA you need to it's very important and also use the process of elimination in order that you can eliminate those distractors those manifestations that are not typically associate with acute glal nefritis so here we have the uh blood clots thrombo Uli or thromboembolism it's not present in acute glom nephritis it's only in nephrotic syndrome so you need to eliminate that same thing with the hyper lipidemia in letter G eliminate that because we've never talked about that part of the theology in acute glim lrtis all right now another uh tip for you is to make sure that you are really capturing the entire context of the test question um make sure that you are really capturing it well we are talking about the gloo nefritis so you can narrow down the search of those manifestations when you're going to be asked with of course with the options available okay now let's move on to the next uh question here it states when instructing a client on preventing further occurrences of acute glal in fritis what guidance should the nurse provide again when instructing a client on preventing further occurrences of acute gloal fritis what guidance should the nurse provide is it a limit vigorous physical activity or is it B filter all urine through a strainer or is it C promptly address respiratory infections or D measure urine density daily or actually measuring the urine specific gravity take your pick all right time is up so what you can do when you're reviewing this video later on what you can do is just stop and so you can think about the possible answer and then proceed now what is the question here again we are uh being asked ask about what guidance should the nurse provide into the patient that has uh a possible recurrence of the gloin frus so instruction on preventing further occurrences of acute glumer ltis so is it a limit vigorous physical activity well avoiding the vigorous or strenuous physical activity may help at some degree in reducing the strain on the kidneys but it is not directly uh going to address the underlying uh issue with the glumer lrtis it will not okay now what about letter B we are filtering all urine through a strainer so straining the urine is beneficial for us to make sure we can capture if there is any kidney stone but we are not talking about kidney stones at this point we are talking about glum netis so it will not prevent the recurrence of glum netis so eliminate that one right away what about promptly address respiratory infections seems like it well the reason for that is because with the glum lrtis acute glal lrtis this is something that actually can occur because of a prior strepto coal infection right right it could be a throat a strep throat or it could be in a form of a skin strepto coal infection the empo and so weeks or days before the patient develops glal lrtis usually the patient is known to have these infections to happen before that and so when you answered um promptly address respiratory infections this is actually a good instruction in order that those recurring infections will be prevented there is proper treatment with the use of the recommended antibiotics in order to prevent further damage of the kidneys now let's take a look at letter D measure urine specific gravity this is an instruction well monitoring the urine specific gravity really is going to assist um in hydration status but it does not play a role in preventing the GL L frus it doesn't Okay so again our Focus here is to teach our patient regarding what to observe if in case they have been admitted for acute globber fritis and so make sure that you're teaching them about reporting these type of infections it could be in a form of a skin infection or it could be in a form of an upper respiratory infection like a strp throat tonsilitis strp throat faringitis those those are the same issues that we need to address right away now what we need to do here our test taking scale here is to really recognize the the connection between the respiratory infection and also the uh diagnosis that has been established for this patient which is acute glal and the fritis so your knowledge about the picology is much needed around this time okay now we also need to use the process of elimination so you are going to disregard those options that are not going to directly address the problem then also we have to focus on those options that will really Target preventing or let's say management of the respiratory infection all right now let's move on to the next question here the client with a new diagnosis of gloomier lyritis seeks clarification on complete protein foods and which examples of such foods should the nurse discuss with the client or the spouse so select all that apply so what are those food items because they're asking for a clarification on the complete protein foods protein complete all right so which of these food items have the complete protein is it a nuts is it chicken eggs or is it C seafood or is it D beans and lentils or is it e soy or so take your pick all right your time is up so let's go into the different options here letter a well nuts can have some protein content in there but they are not considered to have complete protein in it it's lacking those basic amino acids all right so we are going to eliminate nuts what about chicken eggs well yeah chicken eggs will contain all those essential amino acids that will be helpful in um doing its bodily processes and this is going to be one of the best choice for this patient all right so we're going to apply a check mark here now what about seafood or fish well remember Seafood such as fish uh it can actually also offer so many amino acids that will be required by the body and so this is also referred to as one of the complete protein Source we're going to check sorry we are going to check that as well and so let's move on to letter D so what is that beans and lentils so this is going to include those um legumes that are rich in protein but again they do not provide all the essential amino acids so again they are not classified as complete protein sources so we are going to get rid of that let's take a look at letter e this can become tricky what's in E well soy beans or soya they are going to provide with the essential amino acids they're also plant-based and also complete protein source so this is one of the options that we can um include in their diet and that is something that needs to be part of their um dietary intake so we're left up with letter B chicken eggs Seafoods and soy so these are known to have the essential amino acids while the rest of them they have protein content but they lack the essential amino acids now we're going to move on to the next question here so a patient hospital is hospitalized with an early stage diagnosis of chronic renal failure what should the nurse anticipate finding a on assessment of the patient is it a increased urination or is it B excessive thirst or is it C decreased urinary output or is it D absence of urine output pay attention here we are talking about the chronic renal failure or known as the CKD okay it's not about the Aki because the Aki has the different phases right we're talking about CKD right now so what are those manifestation in the early stage of chronic renal failure or chronic or CKD so let's go through the options here letter A increased urination well in the patient with the early stage diagnosis of CRF or CKD the kidneys will often lose their ability to concentrate the urine that is the first U occurrence it will lose its ability to concentrate the urine and so this will now cause the person to pee a whole L poly UA okay and so they don't have that ability to reabsorb the water this time so our patient now has holy Ura we're talking about early stage CKD we're not talking about the diuretic phase of acute kidney injury that is a totally different um disease process and so possibly letter a is one of the answer or the answer uh letter B excessive thirst what is that well while maybe there is polyurea the in increased thirst or the excessive thirst in the chronic renal failure could happen as well but the point here is that the the primary assessment finding with this patient especially the kidney um The Thirst is only a compensatory mechanism or compensatory response to the increased urination rather than a direct indicator of the renal function that is why we're going to we are not going to select excessive thirst because this is only a compensatory response okay eliminate that one what about letter C decrease urinary output again we are talking about early stage chronic renal failure or CKD there is a lack of the kidney to concentrate the urine so they have poly UA so letter c means po UA so that is contradicting remove that right away what about letter D absence of urinary output that is anura this is something that can happen into those patient um especially towards the end stage renal disease and so at this point in the early stage we are not going to ex expect the anura at this point so we are going to eliminate that one as well so for the test taking skill here that you need to to be doing uh we have to again understand the disease progression you have to uh understand the different stages especially in The Chronic re failure so we're going to start with the polyurea in the early stage and Then followed by the igua and anuria all right now another is we're going to have to recognize the primary symptoms that are being presented and so we are going to Target that right away it said your early stage so again increase urination is the hmark for this disorder okay and again we're going to have to also eliminate those U illogical options uh when we're going to do the process by elimination so for those manifestations that are the exact opposites immediately take them away disregard them okay all right so that is the end of our presentation to today and tomorrow I'll be continuing the discussion in the renal system for The Med Surge and we will be talking about the Rena calculi and also some Q&A and nursing management so I really thank you for your participation today and I will see you in the next video series