Clinical Manifestations: 1.

Puffiness of the face especially around the eyes (periorbital edema) which is more prominent in the face in the morning but spreads during the day to involve the extremities and the abdomen 2. Anorexia 3. Passage of dark-colored urine: cloudy, smoky brown resembling tea or cola and is severely reduced in volume 4. The child is pale, irritable, and lethargic and appears unwell but seldom expresses specific complaints 5. Older children may complain of headaches, abdominal discomfort, and dysuria 6. Mild to moderate elevation in blood pressure compared with normal values for age 7. Occasionally, a child will have an onset with severe symptoms such as seizures from hypertensive encephalopathy, pulmonary and circulatory congestion, or hematuria in the absence of hypertension and edema Clinical course The acute edematous phase of glomerulonephritis usually persists from 4 to 10 days but may persist for 2 to 3 weeks, during which time the child remains listless, anorexic and apathetic. Weight fluctuates, urine remains smoky brown and blood pressure may suddenly reach dangerously high levels at any time during this phase. Prognosis Almost all children correctly diagnosed as having AGN recover completely, and specific immunity is conferred so that subsequent recurrences are uncommon. Deaths from complications still occur but fortunately are rare. A few of these children may develop chronic disease, but many of the cases are believed to be different glomerular diseases misdiagnosed as poststreptococcal disease. Complications Major complications: 1. Hypertensive encephalopathy -normally, cerebral blood flow responds to acute arterial hypertension by vasoconstriction. However, acute and severe hypertension may cause this protective autoregulation of cerebral blood flow to fail, leading to hyperperfusion of the brain and cerebral edema 2. Acute cardiac decompensation -caused by hypervolemia and not by cardiac failure. The heart is enlarged, and increase pulmonary vascular markings are evident on X-ray examination. Increase capillary permeability is also believed to be an important factor in the development of pulmonary edema 3. Acute renal failure with persistent oliguria or anuria -is an uncommon complication but one that requires an appropriate treatment regimen. Diagnostic Evaluation: A. Urinalysis findings: 1. Hematuria 2. Proteinuria -when proteinuria is heavy, there may be changes associated with nephrotic syndrome (transient hypoproteinemia and hyperlipidemia) 3. Increased specific gravity (seldom exceeds 1.020)

4. Gross discoloration of urine -reflects its red blood cell and hemoglobin content 5. Microscopic examination of the sediment shows many red blood cells, leukocytes, epithelial cells, and granular and red blood cells casts 6. Azotemia reflected in elevated blood urea nitrogen and creatinine levels -results from impaired glomerular filtration B. Blood examination 1. Unless the disease has progresses to renal failure, the blood examination reveals normal electrolyte (sodium, potassium, and chloride ions) and carbon dioxide levels C. Bacterial cultures 1. Bacteria are not seen, and urine cultures are negative 2. Cultures of the pharynx are positive for streptococci in only a few cases D. Serologic tests 1. Antibody responses to the extracellular products of the streptococci provide indirect evidence of previous streptococcal infection. Includes: a. Antistreptolysin O (ASO) -appears in the serum approximately 10 days after the initial infection; an ASO titer of 250 Todd units or higher is of diagnostic significance, as is a rising titer in two samples taken 1 week apart; useful diagnostic tool when nephritis follows a pharyngeal infection but is of less value after pyoderma b. Antistreptokinase (ASKinase) c. Antihyaluronidase (AHase) d. Antideoxyribonuclease B (ADNase-B) e. Antinicotyladenine dinucleotidase (ANADase) -elevated AHase and ADNase are more consistent and reliable antibody tests following streptococcal skin infections 2. Of more importance for clinical serologic diagnosis is measurement of the serum complement level (C3). -decreased initially but returns to normal 8 to 10 weeks after onset of the glomerulonephritis E. Chest X-ray examination 1. Characteristic generalized cardiac enlargement 2. Pulmonary congestion 3. Pleural effusion During the edematous phase of acute disease Nursing Management: No specific treatment is available for AGN, but recovery is spontaneous an uneventful in most cases. General measures - Bed rest is no longer recommended during the acute phase because ambulation does not seem to have an adverse effect on the course of disease once the gross hematuria, edema, hypertension, and azotemia have abated. Because they are generally listless and experience fatigue and malaise, most children voluntarily restrict their activities during the most active phase of the disease.

Fluid balance y Regular measurement of: -vital signs: essential to monitor the disease s progress and detect complications -Body weight: a record of daily weight is the most useful means to assess fluid balance and should be kept for children treated at home and for those who are hospitalized -Intake and output: sodium and water restriction is useful when the output is significantly reduced (<2-3 dl/24hr). In these children the water allowed is equivalent to the calculated insensible loss plus the volume of urine excreted Nutrition Give health teaching that parents and friends should not bring items such as potato chips (junk foods in general) or pretzels Antibiotics Administer antibiotics as indicated only for those children with evidence of persistent streptococcal infection Reference: Hockenberry, M et al. (2007). Wong's Nursing care of Infants and Children (8th ed., Vol. 2). Singapore: Elsevier Pte Ltd.