KDIGO Clinical Practice Guideline For Glomerulonephritis: Discussion And Management For Children With Nephrotic Syndrome

Actions Necessary for Treating Children with Nephrotic Syndrome According to NSW Health between the Flags Paediatric CERS and Escalation Matrix

According to the NSW Health between the Flags Paediatric CERS and Escalation Matrix, the actions that are required to be taken if the observations fall between the yellow zone include treatment on an immediate basis in accordance to the NSW Rural Emergency Clinical Guidelines for Children. There is a need of consultation that should be within 30 minutes with the local medical referral network or the RFDS. This is followed by a complete set of full observations with increased frequency of observations in addition to consultation with the Pediatrician at local referral facility.  Additionally in case the mechanism of clinical reviews fail or the time frame is not met, escalation is required to a rapid response (Www1.health.nsw.gov.au 2018).

In case the observations fall within the red zone, then the actions required to be taken involve treatment on an immediate basis along with resuscitation in accordance to the NSW Rural Emergency Clinical Guidelines for Children. This needs to be followed by initializing of the local mechanism in order to gain additional help which might include CERS Assistance or on-call staff. On the dependence of the need for immediate resuscitation, the NETS needs to be called on the number 1300 36 2500. There might also be a rapid consultation along with local medical referral network. Finally monitoring on a continual basis is highly required.

The yellow zone designates the discretionary zone. The activation of the yellow zone is based on the facility’s activation of the CERS or the criteria of discretionary additionally. The yellow zone is also based on the Clinical Judgment according to the patient’s condition. In this zone it is the decision of the nurse in charge to take the decision whether to escalate or not escalate the consultation. In cases the escalation is required then the nurse should initiate a proper clinical care and elevate the number of observations as required by the condition of the patient. The frequency must ensure to be above the minimum requirement of 8 hours. The nurses are required to document the relevant information which includes the actions taken in addition to the rationale for not considering escalation for the patient’s health care record. However if a clinical review is called then the steps that are needed to be taken should include initiating significant clinical care, repetition of the patient’s observations, increasing the number of observations as shown by the patient’s condition, documentation of an A-G assessment along with reasons for escalation, and treatment in the Health Care Record and finally informing the AMO as soon as possible. This is indifference with the red zone where a mandatory escalation is required. This requires call for rapid action along with initiation of proper clinical acre. The nurse in charge is informed for rapid response and the frequency of full observations is increased. Everything is documented and the AMO is informed as soon as it is possible. There is a requirement to be always present with the patient (Slhd.nsw.gov.au 2018). 

Documentation and Management Policy Maintained by NSW Healthcare to Uphold High Standards of Documentation and Health Management

In accordance to the NSW healthcare, the documentation and management policy aims to ensure that the highest standards for documentation and health management and care records are maintained. This is in consistent with the law that is common along with the ethical, legislative and requirements of best practice currently present. The standards of documentation and management include:

1. Being clear and accurate.
2. The documents must be legible and in English language.
3. The documents must use proper abbreviations and symbols which are approved.
4. The documents must be written in dark ink so that it must be readily reproducible, as well as be legible. Additionally it must be difficult to erase or write over.
5. The time of entry must be maintained using a 24-hour clock – hhmm format.
6. The Date of entry must be maintained using ddmmyy or ddmmyyyy format.
7. The documents should be signed by the author which needs to include the designation as well as the printed name. In case of computerized system, this is a need for the use of an proper identification system like the electronic signature.
8. In case of entries by the students who are involved in the care giving and the treatment of a patient or client, the document must be cosigned by the clinician who is supervising the student.
9. In the document the entries by different professional groups are generally integrated which means that there are no sections which are separated for making entry by each professional group.
10. In the documents there should be accurate statements regarding the clinical interactions occurring between the patient or the client and their other significant. In addition the health services that are related to assessment along with the diagnosis, the care planning; and the management or the care or the treatment and also the services provided and response or outcomes, there is a requirement for professional advice to be sought and provided in addition to the observations taken and the results.
11. The documents should be clear with proper structure and details to allow other members of the healthcare team to presume care of the patient or client and to provide service at any time.
12. The documents need to be written in an objective way. It should not include demeaning or any derogatory remarks.
13. There is a need to distinguish between the observed circumstances or performed from what was reported by others as incidents or professional opinion.
14. The documents should be noted down during the time of the occurrence of the event or as soon as the event took place. There should be distinction between the time of the incident and the observation that is reported..

• Loss of plasma proteins in the urine of nephrotic children
• Complications of those with steroid-resistant NS
• Treatment-related complications from corticosteroids, alkylating agents, cyclosporin A, and mycophenolate mofetil (Samuel et al. 2013).

• Thromboembolism
• Hypovolemic crisis
• Cardiovascular problems (Kodner  2016).

The pathological changes that occur due to nephrotic syndrome include kidney damage along with the increase of proteins in the urine and low albumin levels in the blood. There is also high level of lipids and swelling seen in the kidney (Niaudet and Boyer 2016). The patient shows weight gain along with foamy urine. This is caused due to a number of kidney disorders such as focal segmental glomerulosclerosis along with membranous nephropathy along with the minimal change disease. There are also incidences of complication of diabetes or lupus.  There is an underlying mechanism which generally inflicts damage to the glomeruli of the kidney (Ruggenenti et al. 2014). The pathological changes often also include complications such as blood clots and high blood pressure in the patient. The changes also often include vascular collapse due to low plasma volume from lack of serum proteins. There are also incidences of protein malnutrition that leads to muscle wasting and growth retardation mostly in cases of children (Samuel et al. 2013).

References

de Fátima Pereira, W., Brito-Melo, G.E.A., Guimaraes, F.T.L., Carvalho, T.G.R., Mateo, E.C. and e Silva, A.C.S., 2014. The role of the immune system in idiopathic nephrotic syndrome: a review of clinical and experimental studies. Inflammation Research, 63(1), pp.1-12.

Health.nsw.gov.au. (2018). NSW Health. [online] Available at: https://www.health.nsw.gov.au/ [Accessed 6 Sep. 2018].

Keane, W.F., Tomassini, J.E. and Neff, D.R., 2013. Lipid abnormalities in patients with chronic kidney disease: implications for the pathophysiology of atherosclerosis. Journal of atherosclerosis and thrombosis, 20(2), pp.123-133.

Kodner, C.H.A.R.L.E.S., 2016. Diagnosis and management of nephrotic syndrome in adults. Am Fam Physician, 93(6), pp.479-85

Lombel, R.M., Gipson, D.S. and Hodson, E.M., 2013. Treatment of steroid-sensitive nephrotic syndrome: new guidelines from KDIGO. Pediatric nephrology, 28(3), pp.415-426.

Niaudet, P. and Boyer, O., 2016. Idiopathic nephrotic syndrome in children: clinical aspects. Pediatric nephrology, pp.1-52.

Ruggenenti, P., Ruggiero, B., Cravedi, P., Vivarelli, M., Massella, L., Marasà, M., Chianca, A., Rubis, N., Ene-Iordache, B., Rudnicki, M. and Pollastro, R.M., 2014. Rituximab in steroid-dependent or frequently relapsing idiopathic nephrotic syndrome. Journal of the American Society of Nephrology, 25(4), pp.850-863.

Samuel, S., Bitzan, M., Zappitelli, M., Dart, A., Mammen, C., Pinsk, M., Cybulsky, A.V., Walsh, M., Knoll, G., Hladunewich, M. and Bargman, J., 2014. Canadian Society of Nephrology Commentary on the 2012 KDIGO clinical practice guideline for glomerulonephritis: management of nephrotic syndrome in children. American Journal of Kidney Diseases, 63(3), pp.354-362.

Samuel, S., Morgan, C.J., Bitzan, M., Mammen, C., Dart, A.B., Manns, B.J., Alexander, R.T., Erickson, R.L., Grisaru, S., Wade, A.W. and Blydt-Hansen, T., 2013. Substantial practice variation exists in the management of childhood nephrotic syndrome. Pediatric Nephrology, 28(12), pp.2289-2298.

Slhd.nsw.gov.au. (2018). Sydney Local Health District. [online] Available at: https://www.slhd.nsw.gov.au [Accessed 6 Sep. 2018].

Www1.health.nsw.gov.au. (2018). Active PDS Documents – All Items. [online] Available at: https://www1.health.nsw.gov.au/pds/ActivePDSDocuments [Accessed 6 Sep. 2018].