Nephrotic Syndrome

BBC Nephrotic Syndrome

^ ASSESSMENT

HISTORY. Patients may report no illness before the onset of symptoms; others have a history of systemic multisystem disease, such as lupus erythematosus, diabetes mellitus, amyloidosis, or multiple myeloma or have a history of an insect sting or venomous animal bite. Symptoms usually appear insidiously and may include lethargy, depression, and weight gain. The patient may describe gastrointestinal (GI) symptoms of nausea, anorexia, and diarrhea. Initially, patients report periorbital edema in the morning and abdominal or extremity edema in the evening.

PHYSICAL EXAMINATION. In the early stages, inspect the patient's appearance for periorbital edema, ascites, and peripheral edema. In later stages, inspect the patient for massive generalized edema of the scrotum, labia, and abdomen. Pitting edema is usually present in dependent areas. The patient's skin appears extremely pale and fragile. You may note areas of skin erosion and breakdown. Often, urine output is decreased from normal and may appear characteristically dark, frothy, or opalescent. Some patients have hematuria as well. Patients with severe ascites may be in acute respiratory distress, with an increase in respiratory rate and effort. When you auscultate the patient's lungs, you may hear adventitious breath sounds, such as crackles, or the breath sounds may be distant because of a pleural effusion. When you auscultate the patient's blood pressure, you may find orthostatic changes.

During the acute phases of the illness, assess the patient's fluid status by ongoing monitoring of the patient's weight, fluid intake and output, and degree of pitting edema. Measure the patient's abdominal girth daily and record changes. Monitor for signs of complications, particularly throm-boembolic complications such as renal vein thrombosis (sudden flank pain, a tender costoverte-bral angle, macroscopic hematuria, and decreased urine output) and extremity arterial occlusion (decreased distal pulses, blanched and cold extremities, delayed capillary refill).

PSYCHOSOCIAL. Patients and family members may express fear or display signs of anxiety related to changes in the patient's appearance. The uncertain prognosis and the possibility of lifestyle changes add to their stress. Because of the insidious onset of symptoms, parents and significant others often verbalize guilt over not seeking medical attention sooner.

Diagnostic Highlights

Test

Normal Result

Abnormality with Condition

Explanation

Urinalysis

Minimal red blood cells;

Increased proteinuria

Protein is lost in urine caused

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