Again we’re going to do inflammation listed on your slide as Chapter 31. It is not really your Chapter 31 (laughing) alright. Go by your readings. This is when we were using the catalog it was Chapter 31, so. I was kind of stealing from my old presentations to make this work for a snow day cause yea, but we’ll make it work. So the first is just a number for you to be aware of. This is not a number that you need to memorize and this is just urinary output by age. It partially reflects with nephritis but it more so reflects with clinical because think about what you’re looking at. When we’re looking at, what do we consider to be normal output for an adult? (Student) At least 30mls an hour. (Instructor) 30mls an hour, right? That’s what we consider to be normal. In kids because they are so unique based on what their size is, we also do their urinary outputs and what is expected by weight just like we do their meds just like we do some of their other pieces, right? Their growth and development. So infants 2 milliliters per kilogram hour, children so anything 1-8 right? We’re going to say 1-13th because our next category is adolescent but one day it works and we can lower adolescent. But 0.5 to 1 milliliters per kilogram per hour. So what do you notice? (Students) Increased (Instructor) Yea, it decreases. So how is that possible? Why are we decreasing the volume? (Student) to circulate. (Instructor) I saw a hand here first. (Student) They need some maturing a little bit more. (Instructor) Right. So what can the kidneys then do? (Student) Filter. (Instructor) Filter and concentrate. Right? Your specific gravity is going to be different in older than in infants because infants have immature kidneys and they need to clear and mark forward to get the same amount of stuff, right? …. So, we know that infants have to put out more. Does that mean they’re going to have more physical volume than kids? No. Because they still, they’re still talking about a 5 kilogram kid vs. a 50 kilogram kid, right? But yes correct It’s still going to be a year old, alright? Um, but so the actual amount that you weigh and measure is still going to be less than an infant because it’s based on their weight but by proportion for what you would expect, infants put out more volume by weight, does that make sense? And then look at adolescents, 40-80 milliliters per hour. It still more than an adult. (Student) And up to what age (Instructor) Yea. (Student) So it wouldn’t be of an adult, like 18, for 30 milliliters an hour. (Instructor) Sure, this is still ball park. But we want them to put out more because they still have more physical maturing to do and there is still differences in their body. Simply because they are still growing. Think about it, um, we don’t get to talk about cancer in kids here, we talk about in other courses. But think about kids are designed to grow. Their cells divide more rapidly. They need more oxygen. They need more energy because they are growing. We don’t have to lay down and sleep and grow more hepatic cells. But kids do. Right? They have to grow more bone. While they sleep is usually when most happen because that you know that process. But, we don’t have to do that as adults, we’re still growing in other ways (laughing), right? But, different than what these kids need to do which is why they have a higher oxygen demand, which is why they have higher metabolic rate because they are growing. They have to do that in addition to their everyday running around that they as well, right? So they still are going to be putting out more fluid and more solutes. Ok, so let’s get into nephrotic syndrome. So there’s two main processes with nephrotic syndrome what do you think about? So does what does most of the filtering inside the kidney? What part? (Student) Glomeruli. (Instructors) Glomeruli, right? So the glomeruli becomes really important in nephrotic syndrome because the glomeruli are doing the filtering which allow things to pass or not pass into the urine, right? So when we’re talking about nephrotic syndrome in general, this one I want you to think chronic. And I think in your book it might even say chronic. But think chronic because this is not something goes away for these kids. There is a second part, there is actually a variety of other types of nephrotic syndrome in your book. I just want you to know the two. Nephrotic chronic and acute post infectious glomeruli nephritis, yes we’ll get to it, alright. But those are the two that we’re going to talk about. So with these guys, obviously an alteration in kidney, hence the nephro, right? Nephrotic Syndrome. But this is not simply a disease that they have a few weeks or months and it goes away. This is a chronic condition that they then have to deal with. It will have periods of exacerbations and remissions like a lot of things do. But what I want you to think about with any kind of nephrotic syndrome, acute or non-acute, think edema. There are different reasons why they have edema but think edema. So when I say edema in kids where does it happen first? Does it do hands and feet like it does in adults. Do we have +2 pitting edema in kids usually? No. We’re going to get puffy. Maybe, don’t think foot though, abdomen, face. Face happens first. Think about those eyes look puffy, they have edema in their face a lot appear sick then they do in adults. Peri-orbital edema is what it’s called, alright? So they are going to start being puffy here and then their belly’s tend to get a little puffy, right? And then their hands and feet get puffy get puffy and then their tends to be how they are. Now, are there differences if it is a heart disease condition kid versus a nephrotic syndrome kid, yea. Then you’re going to have heart failure versus fluid retention. So back to nephrotic syndrome. Glomeruli filters, right? Think of it like the trapped door. It opens to let things in and out as it’s supposed to right? There’s that membrane. It’s a membrane that covers that glomeruli. When we’re in nephrotic syndrome, the chronic, they have in terms of the glomeruli basement membrane. What that means is the doors are too open. Alright. And so what it’s doing is letting out one of the really big molecules that we want them to keep. We want them to keep protein. Right? What happens is these kids because they have inflammation which means that the inflammation their membrane actually inflates which allows for it to be open. So it’s all happening at the glomeruli. When they have this opening proteins get out. So hows does that leave with them? Think about the relationship between protein and clear. (Student) Protein is out of cells, (Instructor) Proteins going to, (Student) leave the bodies (Instructor) Right, and where does your fluid go? (Student) and it goes to where (laughing) it comes out of the cell like the third space affect (Instructor) Yea, but in this actually staying in the third spacing. They have edema because the proteins is going to not pull into the vasculature, right? Protein has left the body so it can’t pull the fluid out of the tissues so it says there. So do they have fluid in their body? Yes. Is it in their circulation? No. So, it tends to be out in their tissues, third spacing, because the protein is gone. Think about the little seven tips in right? What do you see? The big ole pop belly. Why do they have a big ole pop belly if they’re starving? Why? Protein deficiency. It all goes back to protein deficiency. If they don’t have protein in their diet, which they don’t, if they are getting aid it is probably rice, is no, very little protein. Right? We want them to have things like beans and meat and things like that in order to have protein, nuts those kinds of things. If they don’t have protein then the fluid that they are able to get in doesn’t get out through their kidneys, it stays in their tissues because the protein isn’t there to draw into the vasculature. Ok? So all of this is because of protein deficiency. These guys are peeing out the protein. The kids in the commercials don’t forget the protein in their diet, right? But these guys are peeing out the protein, that’s the bottom line patho of nephrotic syndrome. The protein. So, they have edema. They have massive proteinuria because they’re peeing out the protein. They have hypoalbuminemia. What is albumin? Protein. (Students) That helps heal. (Instructor) Right. It’s based on nutrition, often but is your protein. Albumin is a protein. So if someone is low on protein, what do we give them? (Student) Iron. (Instructor) Maybe. That’s irone deficient. If they’re low on protein, we’re going to give them a high protein diet. And if that’s not enough we’re going to give them albumin which we have to yup, it’s usually in a glass bottle. Glass bottle because it’s a blood product, right? And albumin is something that we’re going to give as a binding expander. Because now we’ve put albumin, we put protein in their vessels. So what’s it going to their fluids? Draw in from the tissues. And put it in the vasculature. So albumin is a volume expander in the vessels. Does that makes sense? Ok. Hypoproteinemia they don’t have enough protein in their blood. You’re good on the urea, right? The protein urea is in the urine, emia is in the blood, alright? I want to make sure we are good on our definitions. Then we get this odd hyperlipidemia. Any idea why the, why the body now is like oh, you don’t have enough proteins, I think I’ll make you have some it is trigylercerides that will, you know, go through the roof. They have hyperlipidemia. This is the livers response to protein deficiency, ok? So if there is protein deficiency one of the things that may happen is the liver is going to go, oh you don’t have enough protein, I’ll give you some extra lipids. Does it really help them? No, not in any way. But it’s still a body response. And so why do they have altered immunity? Yea, it always goes back to that protein. What fights infection? (Student) Hemoglobin. (Instructor) Ok, that’s one type of a antibody, right? Antibodies fight infection. IGG is one type of an antibody that’s your immunoglobulin, right? But your antibodies fight off infection. What is the antibody made out of? Protein. So if you don’t have protein you can’t have antibodies to fight infection and your body is already working hard on the other bodies system, alright but that’s how that patho ties together. (Student) No hemoglobin (Instructor) Protein. Right. So you won’t have nothing but you will have less because you’re protein deficient. Yup, no antibodies. No immunoglobulin. Immunoglobulins are just one type of antibodies, you’re going to put out antibodies too. Right. You guys must have just heard something about immunoglobulins because it’s stuck up there. Yea. Ok. Yea. Alright so. We know that it is increased in prevalent and in strength in African American and Hispanics don’t know this in particular, but minimal change nephrotic syndrome is the most common in 85% of cases are that. It occurs between ages 2 years and 7 but what did we say it was? (Student) Chronic. (Instructor) Chronic. It doesn’t go away. (Student) So they have it the rest of their life? (Instructor) Yea. Some out grow it in adulthood as their kidneys are more mature but some do not. Yea. And we don’t know why it happens. We think it’s triggered by an upper respiratory infection, blah, blah, blah. So are you going to have a question that says what’s the cause of nephrotic syndrome? No. Because we don’t know it, right? It’s like autoimmune, we don’t know. So what are you going to see? Edema, pale, hypertension. Why hypertension? You would think hypotension and then maybe you might have some hypertension now though as a result of the body clamping down because without the gluten and the heart They are fussy, they’re not going to be hungry, here’s another key of chronic. Hematuria. Because as those big proteins are popping through the membranes, it is irritating the membrane and bleeding, right? But this is key with the chronic that it’s hematuria. Deep urine output and drop bone and they’re just going to be tired. (Student) Sorry, one wasn’t that hypotension? (Instructor) Hyper, hypertension, high blood pressure because they’re clamping down because they don’t have enough fluid. Hyper, always hyper. Yup. HTN is hyper, ok? Here is something you won’t usually see, while we are talking urine, right? You usually have urine that looks like it has a … on it, but no but you will with these guys because again, what is it? Protein. Because they are peeing out the protein. (Student asking a question) (Instructor) Yes, because again that goes back to protein and if you have any protein in your iron that’s what your hemoglobin hematocrit. Yea. Yea but there also heme concentrated, so they are probably going to be high anyway because they don’t have the fluid or the plasma to dilute it out so there’s not going to appear on their labs to be anemic. Once you get the fluid, they might be but that’s not the primary concern. But because of that peeing blood, could they be anemic? Sure. Right, because they have that hematuria, they are losing something as well as not being able to make what they need. Respiratory distress because they have fluid now in their lungs because there’s not, um, the protein to be able to pull it from their lungs. Protein loss. It seems rudimentary doesn’t it? Their hair might break. But don’t you know this is the thing that brings most parents in. I found hair on their pillow. What’s happening? Not the fact that they gained 10 pounds for the last three weeks from fluid, no, we bring them in because their hair is breaking (chuckling), alright? Um, increased risk for thrombosis. First of what’s thrombosis? (Student) Blood. Clot. (Instructor) Blood clot, right? So why would they clot? (Student) Not enough fluids, but (Instructor) Yea, their blood is thick because the plasma is low. Because they don’t have the fluid. So increased blood viscosity is increased thickness of the blood. (Student) So what happens to your platelets it’s going to spike isn’t it? (Instructor). It’s, yea, everything will be concentrated. Alright? And they will be gaining weight because of that fluid. Don’t worry about the rest. So what are we going to do? What kind of test? UA, urinalysis, a UA. We’re going to look to see what’s in the urine. Where is that albumin, we’re going to look at the other because what is we know that they’re going to have, likely, have high sodium because their not clearing it. What does BUN tell you? (Student) Hematocrit. (Instructor) Yup. and BUN creatinine together tell you kidney function. Why are we looking at cholesterol? (Student) For (Instructor) How about hyperlipidemia and the fact that their triglycerides might go through the roof. And just general electrolytes. If their hypoalbuminemia they don’t have enough protein in the blood, that is our diagnostic, don’t memorize it, we would look that, right? It’s just for your reference. And the same thing, urinary protein excretion, greater than or equal to 40, what should it be? (Student) As in a baby to child, right? (Instructor) Eh, sort of. That’s almost a safe answer. They shouldn’t have any. Shouldn’t be out of protein, right? So, you might have a little just from tissue break down and injury those kinds of things. But you really shouldn’t have protein in your urine, right? And these guys have bring up a point. (Student) So they would be doing the albumin (Instructor) Maybe, we would try other things, let’s look at what we would do. (Student) No, no, no, the test it would be like (Instructor) We would like at albumin and yea, we’d look more at albumin, because pre-albumin is going to be more nutrition versus you blood work, blood count. Alright so treatment, how do we get rid of inflammation? (Student) Steroid (Instructor) Steroids, right? So, steroids how do we know which steroid? (Student) We don’t. (Instructor) Uh, huh. O-N-E, right? Maybe? Prednisolone, methylprednisolone, prednisone, right? So you may have, you may have an S So, That’s your ending for your steroids, ok. Let’s talk about steroids for a moment. Tell me what you know. What are the good things? (Student) Reduces inflammation. (Instructor) Reduces inflammation. What else? Bad … is why we use it, right? What is the side effects? High blood sugar, what else? (Students) In kids, severe skin and ear. (Instructor) They are fussy as all get out. Yes. (Student) Yes. Fluid (Instructor) Low immune system, fluid. Sometimes fluid retention. We don’t want more of that, but this is our treatment. Weight gain, (Student) Long-term glaucoma. (Instructor) Could have some blood pressure changes. (Student) What about tachycardia? (Instructor) Ehh, Yea but not direct. One other thing is the skin. Right? Poor wound healing certainly but also thinning of the skin with chronic blah, blah, blah. The other things you don’t really think about but is important especially in teenagers skin? (Student) Acne. (Instructor) Acne. Alright. Now look at the treatment. Corticosteroids to help decrease that protein they’re peeing. Six weeks, six weeks of steroids. Everyday and then six more weeks of every other day and this is during periods of exacerbation. (Student) Well, this isn’t a chronic condition. (Instructor) There are some don’t have to be on it all the time. So now you have a teenager, right? Yea, we said they would start 2 to 7. Now we have a teenager that’s going to have weight gain, their going to be fussy, their going to be eating a lot, their going to have acne, their going to have poor wounds healing, their going to be at risk for infection. Are they going to want to be compliant with this medication? (Student) No. (Instructor) No. And if they don’t do it now they’re going to have protein deficiency because they are peeing out the protein. Alright? So it is really hard to get these kids to take the meds because they know the side effects. It is part of what we have to deal with. Alright? Alright, so the other things that we are doing. Diet restrictions and this leads to sodium restrictions so tell those teenagers no fries or chips or packaged food? Right? Ok, good luck. Alright. Diuretics. You are going to need to give them diuretics once they have, make sure that they have enough fluid circulating, right. Once they get the protein up, you’re going to give them diuretics, probably right from the start anyway, diuretics to get that extra fluid off. Correct the underlying cause, we said we don’t necessarily know what it is, but sometimes it secondary to something else that we could fix. Albumin if need. Albumin is always going to be IV, so this is going to be an inpatient treatment. And then there’s a few other things we do to help with inflammation and medication wise. (Student) Is there like a specific diuretic that we normally start with because (Instructor) What’s your heavy hitter? What’s a heavy hitter for diuretics? (Student) Furosemide. (Instructor) Furosemide. Good job. Because that’s your heavy hitter. Do you want them on maintenance, just one sec, do you want them on maintenance Furosemide? Why? (Student) Because it’s Um, it keeps your urine um, (Instructor) Potassium, right? It is not a potassium sparing diuretic. So what diuretics are you going to want to use? Spironolactone, aldactone, hydrochlorothiazide, (Student) HCT. (Instructor) Might be one but then that has, that’s a combination cause now that’s a cardiac med and a diuretic, so HCT is a combination med so the aldactone, spironolactone, aldactone, those are your potassium spiro diuretics. Maintenance, yes. As far as think about of it like rescue maintenance, I like to put meds into two categories. Is it a rescue med or is it a maintenance med? So if it’s rescue? Which one are we using? (Student) Spiro (Instructor) Yea, and if it’s maintenance, now we’re talking potassium spiron, ok? We’ll talk the same thing when we talk asthma. What’s a rescue med for asthma? (Student) Albuterol. (Instructor) Albuterol, right? I’ll switch for a second. So Albuterol, rescue med for asthma. What’s the maintenance med? Proair, antrovent something along those lines, right? Proair, um something along those lines. So think about meds in a rescue or maintenance category and it will help you think, remember what do I do right now. We will talk about it about with seizure meds, rescue meds for seizure vs. a maintenance med. for seizures, they are very different meds, alright? Are some people on albuterol as maintenance? Yea, they are polly controlled asthmatic. Because this should be a rescue med but it’s not always used that way, alright? Ok. Yea, yea. Oh I didn’t finish. Yea, let’s go. (Students) The diuretics. (Instructor) Yea. (Student) You’re talking a young child. (Instructor) Yup. (Student) Don’t you, if you give a diuretic to a young, don’t you worry about fluid loss? (Instructor) Absolutely. (Student) The problem is dehydration, is that common in a diuretic? (Instructor) In a cardiac that are in nephrotic syndrome, yes. So yes, we use diuretics in kids, but we have to watch what they are doing fluid wise. (Student) How do you monitor that? (Instructor) These guys are going to be inpatient and their going to be first line. Yea, for this. Yes, absolutely, daily weights, if it’s a baby what else are we going to do measurement wise? Ok. What else. Measurement. Ok. Head and appetite, right? Because we said ascites they get a lot of their food retained in their abdomen so we want to do abdominal circumference, etc. Good? Alright. So nursing interventions. What are we known to do? We said, making sure we’re doing daily weights, making sure we’re doing measurements, balance with your eyes and nose. Vital signs? These are not critical hypertension kids. The next disease process we talk about is this, skin breakdown not only because of the steroids, but what else? What else puts them at risk for skin issues? Protein deficiency and probably in bed, yup one more. What’s the hallmark symptom. (Student) Edema. (Instructor) Edema, and if you have fluid between your skin and your tissues, you’re at risk for skin breakdown. So simply having edema that all nephrotic kids are going to have, nephritis kids, ok. All nephritis kids are going to have edema when they’re having exacerbations. Good. Alright. Here’s the contrasting nephritis. So, yes this is a good study technique do a chronic vs. acute chart. Alright? Do a comparison. So, now we’re doing acute post infectious glomerulonephritis otherwise known as a pigon. I won’t usually say acute post infectious glomerulonephritis, that is cause I want you to hear the word acute, right? Because that’s what makes it different than chronic. So when you’re talking about acute, oh look it’s the same kind of thing. Glomeruli have inflammation but it’s a different cause. Ok? So we know that the problem is with glomeruli but these guys do not have open eyes and they are not peeing as much as protein. Yes, they are still losing some but not as much but I will tell you why in a sec. Ok. We also know the cause. We know the cause alright. If we know the cause for something we also know how to treat it. Let’s look at the cause. Group A, beta hemolytic strep. The A is the important part, beta is just one of the types of Group A. The group A beta hemolytic strep. So what’s strep? Virus? Fungus? Oh good, it’s bacteria. Right? So if we know if strep is a bacteria how do we treat bacterial infections? (Students) Antibiotics. (Instructor) You know the treatment for a pigon. Ok? Yes there is still more to it, of course. But did we talk about antibiotics with chronic at all? (Student) No. (Instructor) We already know a major difference between the two. Ok. It can also be a few others but this is the one to know, group A, beta hemolytic strep. Again, same ages, ages between 2 and 6. But look at the patho for these guys. These guys have a strep infection, where does a strep infection usually happen? (Student) Throat. (Instructor) Throat and where is your secondary? Yea. A lot of skin infection. It could be. But usually it’s going to or so they are going to have a strep infection. It doesn’t mean that they didn’t get it treated. They could have had strep and they were on they’re antibiotics and their throat got better. But 10 to 21 days after that, then we would start seeing symptoms, re-look. Ok? Fifty percent of the time you never know what happened because the kids are symptomatic enough that they didn’t tell their parents they were peeing dark urine, right? They didn’t even think about it? Do most kids look at the urine? No. Right? Especially when we’re in the 2 to 7 age. They get sucked into a diaper. Do you know you have dark urine? Not really. Alright. So if there is a still a diapered kid, it’s hard to see concentration of urine in the diaper. (Student) Does it, wouldn’t it have that concentration smell? (Instructor) Yea, but not everybody picks up on that. I think I blame it on nursing but my nasal, so, my perceive for smell was burned out years ago. I can smell but yea, it’s just gone. Right. So is that something that I pick up on with my kids? No. I’m going to have to look at the the targeted…., but yes you will smell concentrated urine but we will talk about why that is. (Student) But this is when the symptoms start, because normally the course of antibiotics for about 10 days so after that. (Instructor) Yup and here is where the glomeruli come in, remember before we said chronic, they were open door proteins without apps. Look at what it is now, damaged to the glomeruli itself, right, to the membrane? And now we have antibody antigen complexes. That should sound familiar for something. You have an antibody, it’s suppose to func the antigen, right? What happens when the antibody combines with antigen? What kind of disorder are you having? (Student) Autoimmune. (Instructor) Perfect and when you have autoimmune they form these complexes and I want you to think about it of c under grit because if we have something with, give me an example of an autoimmune disorder. Ok. Eh, yea but that’s what was that? Down Syndrome? Not autoimmune. Think about ok, think about things like lupus right? MS, multiple sclerosis, things like that. Right? I just want to give you a clear picture cause yes some of your other ones are good examples but they don’t have the same prone, is the body attacking itself it doesn’t have the same to it. So somebody with rheumatoid arthritis somebody with lupus, somebody with MS, what’s the biggest complaints? Pain. Joint point alright? And that’s because of the antibody/antigen complex are like grits sitting in their joints, alright. So. these antigen/antibodies complexes here are the grit that’s filling up the glomerulonephritis so instead of peeing out protein, now they have a blocked membrane and so the fluids stays, it called edema, it’s got all the presence of edema, but they have it because the fluid can’t get out. See the difference of the patho? Ok. They are not going to pee as much. This isn’t going to be clogging every glomeruli they have but they will have decreased urine output, yes. Ok. So it becomes concentrated because of. So they have inflammation and obstruction of the glomeruli because of this antigen/antibody complex. Is this an autoimmune disorder? Yes. It is. If there is antigen/antibody complexes. However, all these examples of the autoimmune disorders that you gave, were chronic. This is not . There are a few cases other examples of autoimmune disorders that are short-lived, they have run its course almost like a virus and then they are done. This is one of those. Kids do not have acute post infectious glomerulonephritis forever is it something that comes back? Run and done, ok. So it’s a weird autoimmune. (Student) Do you become sepsis? Just have sepsis because you’re retaining all of that (Instructor) I wouldn’t call it sepsis. Could they have neuro sepsis and have infections of the kidney because the kidney because the urine’s not getting out? Sure. But not, this isn’t going to be lead to sepsis usually. I’ll show you what it does lead to. So again, 50% of them you’re never going to know they have it cause they’re going to have it they’re going to have concentrated urine for a few weeks and then it goes away. Right? But the other 50% of kids are going to be symptomatic to the point that it’s obvious and needs follow-up. It happens all of a sudden. It’s not, we don’t know why some kids this and some kids don’t but we know that it’s often linked with that group A, hemolytic strip. They’re going to have flank pain why? That’s where your kidneys are (laughing), right? So that’s why it hurts there. They are fussy, tired and they have a fever. Do we see fever with chronic? No. But nor do we see bacterial, right? These guys are known for the hematuria that comes with because of the damage that is happening to the glomeruli. When you think autoimmune, all those things you said, crohns, lupus, MS, all of them are tissue break down. That’s autoimmune disorders. Here it’s glomeruli breakdown, that’s the tissue that’s being affected. Because the bladder is going to be bleeding. So when it says microscopic hematuria in nearly all case, that means 95% or more of these kids are going to have microscopic hematuria. How is that different than gross hematuria? (Student) You can’t see it. (Instructor) Right. It just shows up like concentrated urine. Is it still there? Yea, you do a dip stick it’s going to turn that bright purple, alright? If that’s what your indicator is on that brand of dipsticks. When you see gross hematuria, these guys are peeing blood. Alright? So 50% of these cases, they are going to be peeing blood. It doesn’t come out red because it’s already being process through the glomeruli so it comes out smoke or tea colored. So again so it’s concentrated but it’s dark, almost like a dark red like digested blood. Ok? So what were they peeing in nephrotic syndrome? (Student) Protein. (Instructor) Protein. What are they peeing out here? (Student) Blood. (Instructor) Blood, ok? Again, edema, edema, edema cause they guys can’t pee it out so they’re going to have extra fluids periorbital happens first. These guys are more likely to have dependent edema of the feet and ankles than the others. So there is just extra fluid and it’s not the protein deficiency where it’s third space fell over. Edema may progress so that it is in the lungs or the belly. But these guys are at risk for acute hypertension. We said hypertension in the other, but this is acute hypertension to the point that you could have a kid with a blood pressure of 200/100 when they’re suppose to be 70/40, alright? So these guys might have neuro symptoms, that’s your encephalopathy nausea, vomiting, irritability, lethargy, seizures, you know, things like that. Alright? As a result of this hypertension. What’s allegoria? Not enough fluid. What would no fluid anuria right? (Student) Do the acute retention because of the volume? (Instructor) Yes, fluid volume. Absolutely. The other thing that is happening as there is inflammation happening in the kidneys. There is certainly a very direct link with kidney pressure and blood pressure, right? If your blood pressure is low in your body, what’s your first body system to be affected? (Students) Kidneys. (Instructor) Your extremities followed by your kidneys. Right? Same thing if you have high pressure in the kidney, it’s going to the body is going to respond of having some high pressure as well. Sometimes in the liver. But just know that there is a link with kidneys and blood pressure. Alright? That’s all, that works, don’t get into specifics. Alright. Test. BUN and creatinine to see what the kidney function is doing. UA to see if its protein or hematuria. They might still be having some protein certainly not the 40 that was on the other. Why are there white blood cells and are going to be up? Yup and not just bacterial but inflammation. So tell me what ESR is. Ok. erythrocyte sedimentation rate. Right. Sed rates. What’s another measure of inflammation? (Student) CRP. (Instructor) Yup and what’s your CRP stand for? (Student) C-Reactive Protein. (Instructor) Uh huh, C-Reactive Protein. Both of these um both of these indicate inflammation, ok? H&H might have anemia more so here, than the other. Yes. Ok. So they’re going to have this more than your chronic nephritis patient. Serum lipids are going to be up because the livers still going to pop it up. Serum proteins are going to be down because they’re peeing some. Then bed rest because of the fluid. You rarely see this is in peds. Bed rest, sodium restriction, fluid restriction. Diuretics. Why antibiotics? (Students) Bacterial infection. (Instructor) Bacteria, right? The other thing we got to do is check your family members to see who all has been exposed to who may have strep. And again watch for that hypertension. (Student) What if there is a complication of untreated strep so if it is caught early and treated you can’t (Instructor) You don’t have to do it whether or not is treated. It’s not like scarlet fever that happens because of untreated strep, it just happens. Yea. Good question. Yea, after the antibiotics have been done or if it’s been on treatment. (Student) Can you actually give them a different type of antibiotic? (Instructor) Might have to repeat the course, but not necessarily. Ok, eyes, nose, weight, vital signs, you see it’s not pro routine or q shift, it’s q 2 and diet education because of that sodium. Ok? Ok. Toddlers admitted to the facility with nephrotic syndrome. The nurse carefully monitors the fluid intake, checks the urine regularly with a reagent strip which finding is the nurse most likely to see? Proteinuria? Absolutely. Ok? Let me stop here.