1. presentation: nephrotic syndromeج

2. Out line: Definition Pathophysiology Sign and symptom
Clinical manifestation
Assessment and diagnosis
Complication
Medical management
Nursing management
Article

3. Physiology of the Upper and Lower Urinary Tracts
The healthy human body is composed of approximately 60% water. Water balance is regulated by the kidneys and results in the formation of urine. Urine is formed in the nephrons through a complex three-step process :

4. three-step process : glomerular filtration
absorption into peritubular capillaries
reabsorption into tubule

5. Glomerular Filtration
about 20% of the blood passing through the glomeruli is filtered . The filtrate normally consists of water, electrolytes, and other small molecules, because water and small molecules are allowed to pass, whereas larger molecules stay in the bloodstream. Efficient filtration depends on adequate blood flow that maintains a consistent pressure through the glomerulus. Many factors such hypotension can alter this blood flow and pressure.

6. Tubular absorption and Tubular reabsorption for excretion in urine
capillaries into tubular filtrate, 99% is reabsorbed into the bloodstream, resulting in the formation of 1000 to 1500 mL of urine each day. Although most reabsorption occurs in the proximal tubule, reabsorption occurs along the entire tubule. Reabsorption and secretion in the tubule frequently involve passive and active transport and may require the use of energy. Filtrate becomes concentrated in the distal tubule and collecting ducts under hormonal influence and becomes urine, which then enters the renal pelvis.

7. Nephrotic syndrome Definition :
is a type of renal failure characterized by increased glomercular permeability

8. Pathophysiology
Nephrotic syndrome can occur with almost any intrinsic renal disease or systemic disease that affects the glomerulus. Although generally considered a disorder of childhood, nephrotic syndrome also occurs in adults, including the elderly. Causes include chronic glomerulonephritis, diabetes mellitus with intercapillary glomerulosclerosis, and renal vein thrombosis.

9. Sign and symptoms:
1.Marked increase in protein (particularly albumin) in the urine (proteinuria)
2. Decrease in albumin in the blood (hypoalbuminemia)
3. Edema
4. High serum cholesterol

10. Clinical Manifestations
The major manifestation of nephrotic syndrome is
1- edema commonly occurs around the eyes (periorbital), ankles, and hands, and in the abdomen (ascites).
2- irritability
3- headache
4- malaise.

11. Assessment and Diagnostic Findings
Proteinuria (predominately albumin) exceeding 3.5 g/day is the hallmark of the diagnosis of nephrotic syndrome . The urine may also contain increased white blood cells (WBCs) as well as granular and epithelial casts.
A needle biopsy of the kidney may be performed for histologic examination of renal tissue to confirm the diagnosis.

12. complication: Complications of nephrotic syndrome include:
1- infection (due to a deficient immune response)
2- Thromboembolism (especially of the renal vein)
3- pulmonary emboli
4- accelerated atherosclerosis (due to hyperlipidemia).

13. Medical managements:
1- Diuretics may be prescribed for the patient with severe edema.
2- The use of angiotensin-converting enzyme (ACE) inhibitors in combination with loop diuretics often reduces the degree of proteinuria
3- Other medications used in treating nephrotic syndrome include antineoplastic agents (cyclophosphamide ) or immunosuppressant medications (azathioprine

14. Nursing Management:
1- In the early stages of nephrotic syndrome, nursing management is similar to that of the patient with acute glomerulonephritis, but as the condition worsens, management is similar to that of the patient with chronic renal failure
2- The patient who is receiving corticosteroids or cyclosporine requires instructions about the medications and signs and symptoms
3-. When indications of an acute infection, such as an acute respiratory tract infection, are first apparent, increased maintenance doses of corticosteroids

15. Regulation of Acid–Base Balance:
The normal serum pH is about 7.35 to 7.45 and must be maintained within this narrow range
The first is to reabsorb and return to the body's circulation any bicarbonate from the urinary filtrate
the second is to excrete acid in the urine. Because bicarbonate is a small ion, it is freely filtered at the glomerulus. The renal tubules actively reabsorb most of the bicarbonate in the urinary filtrate. To replace any lost bicarbonate, new bicarbonate is generated by the renal tubular cells through a variety of chemical reactions. This newly generated bicarbonate is then reabsorbed by the tubules and returned to the body.