case+study agn mine

ANGELES UNIVERSITY FOUNDATIONCOLLEGE OF NURSING

ANGELES CITY

Nursing Care Management

Of A Pediatric Patient

Diagnosed with AGN

SUBMITTED TOMr. Arnold Esguerra, RN

PREPARED BYDe Vera ,Jerome

Indiongco, Cristine Libres, Mary Angelica Teoffy

Meneses, Maria Cristina

BSN III-4GROUP # 15

I. Introduction

Acute Glomerulonephritis

Acute glomerulonephritis (AGN) refers to a specific set of renal diseases in

which an immunologic mechanism triggers inflammation and proliferation of

glomerular tissue that can result in damage to the basement membrane,

mesangium, or capillary endothelium. Hippocrates originally described the

manifestation of back pain and hematuria, which lead to oliguria or anuria. With the

development of the microscope, Langhans was later able to describe these

pathophysiologic glomerular changes.

Most research focuses on the post streptococcal patient. Acute

glomerulonephritis is defined as the sudden onset of hematuria, proteinuria, and

red blood cell casts. This clinical picture is often accompanied by hypertension,

edema, and impaired renal function. AGN can be due to a primary renal or systemic

disease.

Studies by two leading hospitals in Metro Manila indicate that the most

common underlying diseases for ESRD (end-stage renal disease) are chronic

glomerulonephritis, chronic pyelonephritis, diabetes mellitus and hypertensive

nephrosclerosis. In short, deaths from renal causes are the consequences of

prolonged or uncontrolled assault of infectious or metabolic agents on the kidneys

and are regarded as degenerative. Studies indicate that around 9,500 Filipinos

develop fatal diseases of the kidneys annually. It is expected to increase

proportionately with the incidence of degenerative or lifestyle-related diseases like

poor hygiene practices. In the United States, Glomerulonephritis represents 10-15%

of glomerular diseases. Variable incidence has been reported due in part to the

subclinical nature of the disease in more than one half the affected populations.

Despite sporadic outbreaks, incidence of poststreptococcal glomerulonephritis has

fallen over the last few decades. In the international view it has been found that

with some exceptions, a reduction in the incident of post streptococcal

glomerulonephritis has occurred in most western countries. It remains much more

common in regions such as Africa, the Caribbean, India, Pakistan, Malaysia, Papua

New Guinea and South America.

Most epidemic cases follow a course ending in complete patient recovery (as

many as 100%). Sporadic cases of acute nephritis often progress to a chronic form.

This progression occurs in as many as 30% of adult patients and 10% of pediatric

patients. Glomerulonephritis is the most common cause of chronic renal failure

(25%). The mortality rate of acute glomerulonephritis in the most commonly af-

fected age group, pediatric patients, has been reported at 0-7%.

A male-to-female ratio of 2:1 has been reported which means that males tend

to become more affected by the condition rather than the females. Most cases

occur in patients aged 5-15 years. Only 10% occur in patients older than 40 years.

Acute nephritis may occur at any age, including infancy.

“No More Dialysis”

Immunologists Develop Method to Decrease Rejections of Kidney Transplants

October 1, 2007 — A nephrologist has found that a specialized type of anti-rejection

therapy using intravenous immunoglobulin can make kidney transplants possible for

patients with high 'anti-donor' antibodies. 25 to 30 percent of patients on the kidney

transplant list could benefit from this therapy. Tissue compatibility issues exist with

any organ transplant, but the risk is greatly increased for those with high exposure

to antigens received through blood transfusions, previous transplantation, or even

pregnancy. Seventy-thousand Americans are waiting for a kidney transplant. A third

of them are parked on dialysis because their antibody levels are too high for a

transplant. But that's no longer a barrier for some people. Dialysis is something

Kohanzadeh would rather forget, but if telling her story saves lives, it's worth it.

Kohanzadeh -- like many kidney failure patients -- developed high levels of "anti-

donor" antibodies through blood transfusions. Her highly sensitized immune system

would likely reject any donated kidney. But Kohanzadeh is no longer here, thanks to

intravenous immunoglobulin therapy or IVIG. Here's how it works: during dialysis,

patients are given blood containing a mix of immunoglobulins, which "turn-off" the

anti-donor antibodies' attack response without suppressing the patient's immune

system.

Through their website, this mother-daughter team works to spread the word

of a little known therapy that could save thousands in need of a kidney. IVIG is

covered by Medicare and can be used in both living and cadaver-donor transplants.

Nearly 30 percent of patients on the kidney transplant list might benefit from this

therapy.

BACKGROUND: About one-third of kidney patients are often told they cannot

have a transplant even if they have a donor with an otherwise perfectly matched

tissue and blood type. Their anti-donor antibody levels are so high that any

transplanted organ would be rejected by their highly sensitized immune system.

Now there is a specialized type of anti-rejection therapy using intravenous

immunoglobin (IVIG), which injects antibodies from healthy people into the blood

supply, to modulate the immune system without suppressing it. This makes kidney

transplant possible for as much as 25-30% of this group of patients, who would

otherwise not be eligible for a transplant because of their high antibody levels.

DEALING WITH REJECTION: Tissue compatibility is an issue for all patients

receiving organ transplants, but rejection risks are much higher for those with high

exposure to human leukocyte antigens (HLAs) that are not produced by their own

bodies. Exposure may be the result of blood transfusions, previous transplantation,

or even pregnancy if the mother is exposed to the father's antigens, which are then

expressed in the cells of the developing fetus. The immune system is then

'sensitized' to those antigens -- primed with antibodies that attack any foreign

tissue, even if the antigens arrive in the form of a life-saving donated organ.

Reasons why the group chose acute glomerulonephritis are to have an

overview and to know the factors which primarily may cause the disease.

Knowledge regarding the disease is very important to aid in the prevention and

possible treatment of its occurrence.

This case study leads to a broader knowledge regarding the disease and to

understand the factors that lead in the occurrence of the disease. This may be

useful for future nurses to be equipped with adequate knowledge in the care of

patients with the disease and may apply certain preventive measures.

Objectives:

After the completion of the study, the student nurses shall have:

Able to know the risk factors about the disease condition

Knowledge about the disease condition

Determine the degree of impairment

Assess level of progress

Assess causative/contributing factors about the underlying disease condition

Correct/minimize growth deviations and associated complications.

Determine degree of deviation from growth/developmental norms

After the completion of the study, the patient/SO shall have:

Patient/SO is able to express feelings and concerns appropriately.

Patient/SO be able to identify precipitating factors contributed to the patient

disease

Patient/SO be able to verbalized ability to cope adequately with existing

situation, provide support/monitoring

Patient/SO be able to adopt lifestyle changes necessary for the patients

wellness and recovery as well as to prevent further complication of the

disease.

Patient/SO will verbalize desire to seek higher level of wellness

Patient/SO will be able to set their own progress short-term goals that could

had to the patient recovery, wellness and prevention of further complications.

Patient/SO will able to identify long-range needs of the client and who will be

responsible for actions to be taken

Patient/SO is able to verbalize understanding of illness, treatment regimen

and prognosis.

II. Nursing Assessment

1. Personal Data

Our patient is Baby AGN, female, five years of age and currently residing at

Baliti, Arayat Pampanga. A Filipino and naturally born Kapampangan on August 05,

2002 at Magalang Pampanga. Her parents are Mr. AGN and Mrs. AGN. She was

admitted last June 20, 2008 (Friday) 7:15 pm at a secondary type of government

hospital. The patient was discharged last June 26, 2008. The group had their

assessment, patient, interaction & interview for 2 days in the Pedia Ward of the said

hospital.

2. Pertinent Family History

After establishing rapport with the patient and her significant others, we

interviewed the SO and asked some question about their family history. The family

of Baby AGN is a nuclear type of family. Mr. & Mrs. AGN are blessed for having five

children, two girls & three boys. Baby AGN is the fourth child of her parents. She is

a preparatory student at the Baliti, Arayat Elementary School. Mrs. AGN gave birth

to her five children by a Normal Spontaneous Delivery (NSD) in a hospital at Arayat

Pampanga. All of her children were delivered through a NSD in the said hospital.

Mrs. AGN still believes in the possible complications of pregnancy that’s why she

doesn’t want to have a home delivery.

Mr. AGN is a farmer in Baliti, Arayat. He was also diagnosed to have a kidney

disease together with his brother (uncle of Baby AGN) but had been treated, the

informant doesn’t know the specific kidney disease, according to him he manifested

malaise, nausea and abdominal cramps) last 1998. Mrs. AGN is a housewife. The

family lives in a 200 square meter house with an adequate ventilation due to the

presence of five windows. The house is concrete built surrounded by some farm

land. Total number of members in the family is seven with five children, the eldest

is a thirteen year old male, next is a eleven year old male, nine year old female, five

year old female and four year old male. Mr. AGN earns around Php 2,000 a month.

The family’s religion is Catholic. Mrs. AGN included that they attend the mass. About

their cultural beliefs and practices, they do not consult herbularios/ albularios but

rather choose to seek for medical advice from the physician when someone in the

family experiences some illness.

SCHEMATIC DIAGRAM OF THE FAMILY HEALTH-ILLNESS HISTORY

Father side Mother side

Grandfather Grandmother Grandfather Grandmother

Uncle Uncle Father Aunt Aunt (Mr. AGN) Mother (Mrs. AGN)

Legend:

Male Female

No health problem Died

With kidney disease With AGN

Looking at the legend of the family history of Baby AGN, her grandfather in

mother side died because of old age and her grandparents in her father side doesn’t

have any health problem and are still living. Her parents are still alive, and her

father was diagnosed with a kidney disease. Among the five children, only baby

AGN have been diagnosed with acute glomerulonephritis.

3. Personal History

According to Mrs. AGN, her menarche started at the age of twelve years old

during sixth grade. During the pregnancy of Mrs. AGN, she didn’t experience any

problem in giving birth to her five children. She gave birth to her children with no

specific birth gap. Her eldest was born in the year 1994, next child was born in the

year 1996, the third child was born in year 1998, the fourth child was born in 2002

and the youngest was born in the year 2003. As said in the family history, she gave

birth through Normal Spontaneous Delivery (NSD) in the hospital. She doesn’t

consult a “hilot” or “kamadrona”. Mrs. AGN had a full age of gestation (the

informant has forgotten her LMP). Mrs. AGN breastfed her five children. According to

Baby AGN’s mother, she had a complete immunization during her infancy stage at

their Health center in Baliti, Arayat.

Frued’s Personal Development: Preschooler: Phallic stage

Child’s personality development appears to be non-reactive or dormant. Help

the child to have positive experiences as his/her self-esteem continues to

grow and child prepares for the conflict of adolescence.

In this stage, child learns sexual identity through awareness of genital area.

Baby AGN is assisted by Mrs. AGN on the meticulous guidance on what to

know and expect about her sexual identity to prevent confusion and establish

understanding. In addition, Mrs. AGN practices Baby AGN on the proper care

towards the child’s genital area.

Erickson’s Personality Development: Initiative vs. Guilt

Preschooler child development task is to form a sense of initiative versus

guilt. Child is introduced to the teachers. Mrs. AGN accompanies her daughter

for several days in school since in this stage the child fears to be left out.

Baby AGN enjoys playing games when she gets home from school. She is a

talkative child but seems silent when she feels sick or ill. On the days of

hospitalization of Baby AGN, she was silent primarily because she was weak

and the condition that she had was making her feel uncomfortable.

Piaget’s Stage of Cognitive Development: Preconventional Thought(2-7 y)

Preconventional thought has not yet developed the sense of time. It also

includes that the child must be presented of a specific activity to be able to

know what will happen by that time. Baby AGN achieve this development by

telling her other family members that her father is about to leave for work

whenever she sees him gathering his things for work.

Baby AGN is capable of drawing a straight line, circle, square and triangle

or diamond. She can drive a three wheel bike.

Baby AGN takes a bath and brushes her teeth before she goes to school

and takes a half bath before going to sleep but she does not brushes her teeth

anymore.

Kohlberg’s Stage of Moral Development: Preconventional (Level 1) (4-7)

Preconventional includes individualism. Starts to develop sense of

instrumental purpose and exchange.

Baby AGN shows a characteristic of being possessive. Whenever she

arranges her things for school she wanted to elaborate her “own” things not

to be used by her other siblings .

4. History of Past Illness

Based on our interviews, Mrs. AGN told us that Baby AGN had no minor

hospitalization prior to admission and claims (she wasn’t diagnose and didn’t take

any medications) to have asthma when she was 3 years old. They used to not allow

Baby AGN become exhausted and kept her from allergic causing objects. Baby AGN

had some minor illnesses such as fever, colds and chicken pox. The family consults

the Health Care Provider for medical assistance.

5. History of Present Illness

Days before Baby AGN’s hospitalization, she had acquired a streptococcal

infection which resulted to an Upper Respiratory Tract Infection. Due to a bad

hygienic practices which includes a once a day routine of brushing of teeth that lead

to streptococcal infection.

Few hours prior to admission, Baby AGN had an undocumented fever and

edema. This prompted the family to consult a clinic in Arayat, Pampanga. The

assessment in the clinic revealed an elevated blood pressure and diagnosed that

the patient have an Acute Glumerulonephritis. The hospital didn’t do any treatment

because they can no longer handle the condition of Baby AGN (we don’t know the

specific medications but according to our informant, they gave some medications.

But our informant was not there so she can’t tell the specific medications that Baby

AGN had taken) so Baby AGN was referred to the secondary type of government

hospital.

Upon admission, Baby AGN still manifested fever accompanied by facial

edema, hematuria and elevated BP 140/80. She was admitted last June 20, 2008

with a diagnosed of an Acute Glumerulonephritis versus Nephrotic Syndrome.

6. Physical Examination:

June 20, 2008 (Upon Admission)

LIFTED FROM THE CHART:

Vital signs: T- 38.40C PR- 84bpm RR- 22cpm BP- 140/80

Skin: (-) pallor, (+) edema, warm to touch

Head EENT: pinkish palpebral conjunctiva, (-) icteric sclera, (+) periorbital edema

Lymph nodes: (-) swelling/ enlargement

Chest: symmetrical, no retractions

Lungs: normal breathing pattern and clear breath sounds

June 24, 2008

ACTUAL NURSE-PATIENT INTERACTION:

Vital signs: T- 36.70C PR- 68 bpm RR- 60 cpm BP- 110/80

Appearance and Behavior

Mental state: patient is conscious and coherent

Language: patient is able to speak

Posture: with good posture

Built: normal built

Integumentary: patient has a fair complexion, good skin turgor.

Head: normal contour; (+) periorbital edema.

Eyes: no discoloration, (+)periorbital edema, pinkish palpebral conjunctiva, (-)

icteric sclera, pupils equally reactive to light, eye movement synchronous in all

directions, eye brows are symmetrical.

Ears: symmetrical, no discharged noted.

Nose: symmetrical, no discharges note.

Mouth: no dentures, able to move tongue.

Neck: able to move neck and no engorgement of veins.

Chest and lungs: clear breathe sounds.

Heart: normal rate and rhythm.

Abdomen: no rebound tenderness, no abdominal distention, normal bowel sounds.

Extremities: able to move hands and feet, no fractures and deformities, with dry

nails, and edema noted.

Bowel and Bladder: no difficulty during urination and defecation.

Genitalia: no lesions and no pubic hair noted.

June 25, 2008

Vital signs: T-36.10C PR- 97bpm RR-18cpm BP- 90/60

Appearance and Behavior

Mental state: patient is conscious and coherent

Language: patient is able to speak

Posture: with good posture

Built: normal built

Integumentary: patient has a fair complexion, good skin turgor.

Head: normal contour, (+) periorbital edema.

Eyes: no discoloration, (+) periorbital edema, pinkish palpebral conjunctiva, (-)

icteric sclera, pupils equally reactive to light, eye movement synchronous in all

directions, eye brows are symmetrical.

Ears: symmetrical, no discharged noted.

Nose: symmetrical, no discharges note.

Mouth: no dentures, able to move tongue.

Neck: able to move neck and no engorgement of veins.

Chest and lungs: clear breath sounds.

Heart: normal rate and rhythm.

Abdomen: (-) rebound tenderness, (-) abdominal distention, normal bowel sounds.

Extremities: able to move hands and feet, no fractures and deformities, with dry

nails and edema noted.

Bowel and Bladder: doesn’t have difficulty in urination and defecation.

Genitalia: no lesions and no pubic hair noted.

7. Diagnostic and Laboratory Procedure

Diagnostic/Laboratory Procedure

Date Ordered

Date Result

Indications or Purpose

Results Normal Values

Analysis and

Interpretation

1.)CBC

A.Hemoglobin

(hgb)

D.O: 06-20-08

D.R: 06-20-08

The amount of hgb

determines how much

118.9 125-155 g/L Indication of anemia due to hematuria because of


Date Ordered

Date Result



Analysis and

Interpretation

oxygen the RBC's are capable of carrying to other cells.

decreaseerythropoietinleads to damage in the kidney.

B.Hematocrit

(hct)

D.O: 06-20-08

D.R: 06-20-08

The hct shows the oxygen-carrying

capacity of the blood. This value also tells

whether the blood is too thick or too

thin.

0.35 M: 0.40-0.52F: 0.38-0.48

Indication of anemia due to hematuria because of

decrease erythropoietin

leads to damage in the kidney.

C.White Blood Cells (WBC)

D.O: 06-20-08

D.R: 06-20-08

WBC count is the count of the so-called leukocytes.

WBC's defend the

body against infection and make up part

of the immune system.

10.20 6-10 g/L More than required

WBC count. Indicates infection.

D.Lymphocytes

D.O: 06-20-08

D.R: 06-20-08

The second most type,

are cells that produce

antibodies, regulate the

immune system and

fight viruses.

0.41 0.20-0.60 Range is within normal range.

Indicative of antibody

production.


Date Ordered

Date Result



Analysis and

Interpretation

E. Platelet

D.O: 06-20-08

D.R: 06-20-08

Responsible for blood

coagulation and

determines bleeding

tendencies.

358 150-400 x 108L

Range is within normal range.

Indicative of coagulation.

F.Segmenters

D.O: 06-20-08

D.R: 06-20-08

0.57 .55-.70 Range is within normal range.

G.Eosinophils

D.O: 06-20-08

D.R: 06-20-08

Eosinophils become active when you have certain allergic diseases, infections, and other medical conditions.

0.02 0 – 0.02 Range is within normal

range. Fights parasitic and

allergic reaction.


Date Ordered

Date Result



Analysis and

Interpretation

CBC

A.Hemoglobin

(hgb)

D.O: 06-24-08

D.R: 06-24-08

The amount of hgb

determines how much

10.0 12-16 Indication of anemia due to hematuria because of


Date Ordered

Date Result



Analysis and

Interpretation

oxygen the RBC's are capable of carrying to other cells.


B.Hematocrit

(hct)

D.O: 06-24-08

D.R: 06-24-08

The hct shows the oxygen-carrying

capacity of the blood. This value also tells

whether the blood is too thick or too

thin.

0.32 M: 0.40-0.52F: 0.38-0.48

Indication of anemia due to hematuria because of


C.White Blood Cells (WBC)

D.O: 06-24-08

D.R: 06-24-08

WBC count is the count of the so-called leukocytes.

WBC's defend the

body against infection and make up part

of the immune system.

4,000 5-10x 10 to the 3rd power

Indicates infection.

D.Lymphocytes

D.O: 06-24-08

D.R: 06-24-08

The second most type,

are cells that produce

antibodies, regulate the

immune system and

fight viruses.

54 25-40 Body have adequate amt. of

lymphocytes to produce antibodies, regulate the

immune system and

fight viruses.


Date Ordered

Date Result



Analysis and

Interpretation

E.Platelet

D.O: 06-24-08

D.R: 06-24-08

Responsible for blood

coagulation and

determines bleeding

tendencies.

218 150-450 x 108L

Range is within normal range.

Indicative of coagulation.

F.Segmenters

D.O: 06-24-08

D.R: 06-24-08

40 50-70

G.Eosinophils

D.O: 06-24-08

D.R: 06-24-08

Eosinophils become active when you have certain allergic diseases, infections, and other medical conditions.

6 1-4 Active. Indicative of

certain allergic

diseases, infections, and other medical

conditions.

Nursing Responsibilities:

Explain the procedure to the patient's significant others that these test

assess response to treatment.

Tell the patient's significant others that blood sample or specimen will be

taken.

Plan to obtain the specimen when the patient is calm and physically still.

Ensure the specimen/blood sample is not taken from the hand or arm that

has an intravenous line in the vein because of the dilution effect on the red

blood cells concentration.


Date Ordered

Date Result



Analysis and

Interpretation

2) Serum CreatinineA.

CreatinineD.O: 06-20-

08D.R: 06-20-

08

To evaluate any type of

renal dysfunctions

.

.86 .3-.7 g/dl Result is within normal values.

Indicative of (+)renal

dysfunction.





taken.






Date Ordered

Date Result



Analysis and

Interpretation

3) Blood Chemistry

A.Total Protein

D.O:06-21-08D.R: 06-21-08

To determine nutritional status or to screen for certain liver and kidney disorders as well as other diseases. To determine the extent of protein loss.

69.0 64-83 gm/L Range is within normal range.

B.Albumin

D.O:06-21-08D.R: 06-21-08

Albumin maintains the amount of blood in the veins and arteries. When albumin levels become very low, fluid can leak out from the blood vessels into nearby tissues, causing swelling in the feet and ankles. Very low levels of albumin may indicate liver damage.

34.0 35—50 g/L Range is below the

normal range.

Indicative of proteinuria and edema.

C.Globulin

D.O:06-21-08D.R: 06-21-08

Globulin is carrier of some hormones,

35.0 20-35 g/L Range is within normal range.

http://www.labtestsonline.org/understanding/conditions/kidney.html

http://www.labtestsonline.org/understanding/conditions/kidney.html

http://www.labtestsonline.org/understanding/conditions/liver_disease.html

lipids, metal & antibodies.

D.A/G Ratio

D.O:06-21-08D.R: 06-21-08

1.5-1 0.8-2.0 Result is within normal values.





taken.






Date Ordered

Date Result



Analysis and

Interpretation

4) Serum ElectrolyteA. Na D.O:06-21-

08D.R: 06-21-08

Sodium is both an electrolyte and mineral. It helps keep the water (the amount of fluid inside and outside the body's cells) and electrolyte balance of

162.0 136–145

milliequivale

nts per liter

(mEq/L) or

136–145

millimoles

per liter

(mmol/L)

Solutes absorbed by the kidney results to damage

anddecrease

reabsorption

http://health.yahoo.com/other-other/millimoles-per-liter-mmoll/healthwise--stm159571.html



http://health.yahoo.com/other-other/milliequivalents-per-liter-meql/healthwise--stm159429.html;_ylt=Av3ds7f7vxGCuya3tSrdnjv3tMUF



http://health.yahoo.com/other-other/electrolyte/healthwise--ste122049.html

the body. Sodium is also important in how nerves and muscles work.

B. K D.O:06-21-08D.R: 06-21-08

It helps keep the water (the amount of fluid inside and outside the body's cells) and electrolyte balance of the body.

4.0 3.4–4.7

mEq/L or

3.4–4.7

mmol/L

(in children)

Result is within normal values.





taken.






Date Ordered

Date Result



Analysis and

Interpretation

5) RoutineUrinalysis

D.O: 06-23-08

D.R: 06-23-08

Urinalysis was ordered for Baby AGN to determine whether the

urine

Color: yellow

Transparency: sl. Tubid

Sugar:

Color: light yellow to

dark amber

Sugar:

Color: Normal

Transparancy:Normal


Date Ordered

Date Result



Analysis and

Interpretation

contains substances indicative or

normally absent from

urine and detected by

urinalysis are proteins, glucose, acetone,

blood, pus and casts.

negative

Albumin: +1

Reaction: acidic

Specific gravity: 1.000

Pus cells:4-6

Bacteria: negative

negative

Albumin: negative

Reaction: acidic

Specific

gravity: 1.001-1.035

Pus cells: 0-3

Bacteria: none

Sugar: Normal

Microalbiminuria. It

indicates spillage of

protein from the damaged glumerulus.

Normal.ReactionNormal.

Gravity slightly lower than normal.

Pus cells increased

value indicates infection.

Bacteria: Normal





taken.





For urinalysis, instruct the SO to collect urine specimen.

Collect urine by clean catching.

If there is a necessary urine collection, instruct SO to collect the urine in

every urination and put it in the bedside.

III. Anatomy and Physiology

The Urinary System

The urinary tract is composed of four structures:

Kidney

Ureters

Bladder

Urethra

The kidneys balance the urinary excretion of substances against the

accumulation within the body through ingestion or production. Consequently, they

are a major controller of fluid and electrolytes homeostasis. The kidneys also have

several no excretory metabolic and endocrine functions, including blood pressure

regulations, erythropoietin regulation and vitamin D metabolism.

Filtration at the renal glumerulus is the first steps in urine formation.

Normally, a volume equal to plasma volume is filtered every 24 minutes and a

volume equal to total body water is filtered every 6 hours. This glomerular filtrate is

similar to plasma, but it lack cells and large-molecular-weight proteins. The

glomerular filtrate is modified by active transport, diffusion and osmosis as it passes

through the renal tubules. Reabsorption of filtrate components enhances

elimination of organic acids and bases (and some drugs). The remnants of the

glomerular filtrate exit the kidney through the uterus.

The ureters conduct urine from the kidney to the bladder by peristaltic

contraction. The bladder is distensible chamber that stores urine until it is excreted.

The urethra is the exit passageway from the bladder that carries urine for

elimination from the body.

Structures of the Urinary System

The kidneys are located retro peritoneal, in the posterior aspects of the

abdomen, on either side of the vertebral column. They lie between the 12th thoracic

and the third lumbar vertebrae. The left kidney is usually positioned slightly higher

than the right. Adult kidney average approximately 11 cm in length, 5 to 7.5 cm in

width and 2.5 cm in thickness. Affixing the kidneys in position behind the parietal

peritoneum is a mass of perirenal fat (adipose capsule) and connective tissue called

Gerota's (subserosa) fascia. A fibrous capsule (renal capsule) forms the external

covering of the kidney except for the hilum. The kidney is further protected by

layers of muscles of the back. Flank abdomen as well as by layer of fat,

subcutaneous tissues and the skin.

The kidney has a characteristics curve shape, with a convex distal edge and a

concave medial boundary. In the innermost part of the concave section is hilus,

through which pass the renal artery, renal vein, lymphatic, nerves and renal pelvis

(the natural upper extension of the ureter). A fibrous capsule surrounds each kidney

and adheres the renal parenchyma. Each kidney is divided in to three major areas:

(1) cortex, (2) medulla and (3) pelvis.

The cortex of the kidney lies just under the fibrous capsule, and portions of

the extend down into the medulla layer to form the renal columns (columns of

Bertin) or cortical tissue that separates the pyramids. The medulla is divided into

eight to 18 cone shaped masses of collecting ducts called the renal pyramids. The

bases of the pyramids are positioned on the corticomedullary boundary. Their

apices extend toward the renal pelvis, forming papillae. The papillae have 10-25

openings each on the surface, through which the urine empties into the renal pelvis.

Eight or more groups of papillae are present in each pyramid; each empties into a

minor calix and several minor calices join to form a major calix. The two or three

major calices are outpouching of the renal pelvis (inner area of the kidney). They

channel urine from the pyramids to the renal pelvis. The renal pelvis is a cavity

lined with transitional epithelium. The combined volume of the pelvis and calices is

approximately 8 ml. Volumes in excess of this amount damage the renal

parenchyma tissue. The renal pelvis narrows and reaches the hilus and becomes

the proximal end of the ureter.

Within the cortex lies the nephron, the functional unit of the kidney,

consisting both vascular and tubular elements. Filtration begins at the glumerulus.

The glomerular tuft (glumerulus) contains capillaries and the beginning of the

tubule system, Bowman's capsule. Filtrate from the glumerulus enters the

Bowman's capsule and the passes through a series of tubule segments that modify

the filtrate as it passes through the renal cortex and medulla and finally, flows into

the renal calices. A second capillary bed, the peritubular capillaries, carries the

reabsorbed water and solutes back towards the vena cava..

Renal Blood Flow, Glomerular Filtration

The kidneys receive 20% to 25% of the cardiac output under resting

conditions, averaging more that 1 L of the arterial blood per minute. The renal

arteries branch from the abdominal aorta at the level of the second lumbar of

vertebra, enter the kidney, and progressively branch into lobar arteries, inner lobar

arteries, accurate arteries and interlobular arteries. Blood flows from the inerlobular

arteries through the afferent arteriole and the peritubular capillaries carry a small

amount of blood (5% of renal blood flow) to the renal medulla in the vasa recta

(long, straight blood vessels) before entering the venous drainage. The blood leaves

the kidney in a venous system closely corresponding to the arterial system:

interlobular veins, accurate veins, interlobular veins, and the renal vein. The renal

circulation then empties the inferior vena cava.

Ureters

The ureters from the medial tapering of the renal pelvis at the hilus of the

kidney. Usually 25-35 cm long in the adult, the ureters lie in the extraperitoneal

connective tissue and descend vertically along the psoas muscle towards the pelvic

cavity. After dipping into the pelvic cavity, the ureters course anteriorly to join the

bladder in its posterolateral aspect. At each ureterovesical junction, the ureter runs

obliquely through the bladder wall for about 1.5 to 2 cm before opening into the

lumen of the bladder.

Each ureter has elastic characteristics and is made of three tissues layers; (1)

an inner mucosa (transitional epithelial membrane) lining the lumen, (2) a muscular

layer and (3) a fibrous outer layer. The musculature is generally designed as inner

longitudinal and outer circular. Along most of the ureter, however, the muscle fiber

actually run obliquely and blends with one another to form a mesh-like tissue. The

muscle arrangement allows urine to propel down by the ureter by peristaltic action.

Peristalsis is regulated by a myogenic pacemaker located near the renal calices.

Blood is supplied to ureters by one or more vessels that run longitudinal

along the tube. The number and assortment of articles anastomosing with the

ureteric vessels vary with each individual. Because the ureters travel through

several anatomic areas, the urethral vessels are fed several of the following

arteries: (1) renal (frequently), (2) testicular or ovarian, (3) aorta and common iliac,

(4) internal iliac (frequently), (5) vesical, (6) umbilical and (7) uterine.

Bladder

The urinary bladder is a hallow organ located in the anterior half of the pelvis

behind the symphisis pubis. The space between the bladder and symphisis pubis is

filled with a loose connective tissue that allows the bladder to stretch cranially as it

fills. The peritoneum covers the top border of the bladder, and the base is held

loosely in place by the true ligaments. The bladder is also enveloped by a loose

fascia.

Urethra

The urethra differs greatly in females and males. The urethra is a muscular

tube that connects the bladder with the outside of the body. The function of the

urethra is to remove urine from the body. It measures about 1.5 inches (3.8 cm) in a

woman but up to 8 inches (20 cm) in a man. Because the urethra is so much shorter

in a woman it makes it much easier for a woman to get harmful bacteria in her

bladder this is commonly called a bladder infection or a UTI. The most common

bacteria of a UTI is E-coli from the large intestines that have been excreted in fecal

matter. Female urethra. In the human female, the urethra is about 1-2 inches long

and opens in the vulva between the clitoris and the vaginal opening.

Men have a longer urethra than women. This means that women tend to be more

susceptible to infections of the bladder (cystitis) and the urinary tract.

Pathophysiology (client-centered)

A. Schematic Diagram

Non Modifiable Factors Modifiable Factors1.) Female 1.) Streptococcal infections (URTI)2.) Age (5 years old) 2.) Skin infections (presence of lesions)3.) Familial history of kidney disease 3.) Poor personal hygiene

4.) Lack of Financial Support 5.) Compromise Defense Mechanism

Antigen Anti-body reaction

Insoluble immune complexes develop and become entrapped in glomerular tissue

Renal function is destruction and inflammation of kidneys inflammatory depressed. Response of the body.

(hyperthermia)(Date: reported by

S.O; occurred prior admission)

Decreased in circulating lysosomes released duringplasma the inflammatory response

triggered stimulation damage top glomerular basement membrane Presence of pus isof renin may be due to presence of

Streptococcus

Angiotensin I

Angiotensin ConvertingEnzyme

Angiotensin II

Increased aldosterone secretion increase permeability

of protein in urine leaking RBC in urinepromoted renalretention of Na and H2O

` Hematuria Volume Signs & increased

Sumptoms ofcirculating fluid serum albumin is

Anemiadecreased and released (UA dated:06-23-08)( + 1 albumin)(UA Dated:06-23-08)

Hemoglobin &

hematocrit count decreased(CBC

dated:06-20-08)(CBC

dated:06-24-08)

increased cardiac transient inworkload uremic &

fluid shifted from intravascular +3 RBC in urine into interstitial spaces (UA Dated:06-23-

08)decrease osmotic pressure

Elevated Blood pressure(Date: upon admission) Tea-colored

edema (+ facial edema) urine (UA Dated:06-23-08)

(Date: apparent upon admission June 20&still slight apparent until discharge June 26,2008)

IV. Patient’s Illness

Synthesis of the Disease

a. Definition of the disease

Acute glomerulonephritis is the term generally reserved for the variety of

renal disease in which inflammation of the glomerulus. Manifested by

proliferation of the cellular elements, is secondary to an immunologic

mechanism. Most incidence of AGN appears to be associated with a post

infection state. Several bacterial and viral infections have been incriminated in

its causation. It follows streptococcal infections of the respiratory tract or less

commonly, skin infections such as impetigo. AGN is most common in males ages

6-10 but can occur at any age. Up to 95% of children and up to 10% of adults

with AGN recover fully; the remainder of patients may progress to chronic renal

failure within months.

Acute glomerulonephritis results from the entrapment and collection of

antigen-body complexes produced as an immunologic mechanism in response to

streptococci in the glomerular capillary membranes, including the inflammatory

damage and impending glomerular function. Sometimes the immune

complement further damages the glomerular membrane. The damage and

inflamed glomerulus loses the ability to be selectively permeable and allow RBC

and CHON’s to filter through as the glomerular filtration rate falls.

b. Modifiable:

Patient ages 5 years old has familial history of kidney disease. During this

age she acquired streptococcal infection. According to Black, streptococcal

infection is one of the factors that may cause acute glomerulonephritis. According

to the informant, she acquired sore throat and also skin infection, due to this

factors these may contribute to the disease condition of the patient. Although she

is suffering infection, the patient did not seek medical attention instead just

neglect it and continue her poor personal hygiene.

c. Signs and Symptoms and its Rationale:

1.) Shortness of breath and cough- due to extra fluid in the lungs.

(Date: June 20, 2008)

2.) Elevated Blood Pressure- due to impaired renal function results to decrease

circulating plasma that triggered the stimulation of renin, to angiotensin I converted

by Angiotensin Converting Enzyme to Angiotensin II that acts on adrenal cortex

causing secretion of aldosterone. Increased in aldosterone promoted renal retention

of Na and H2O which means that there would be increased in circulating fluid that

would increase the heart's workload resulting to increased Blood Pressure.

(Date: June 20, 2008)

3.) Hematuria – due to increased permeability that lead to leaking RBC in urine.

(CBC dated: June 20, 2008)

(CBC Dated: June 24, 2008)

4.) Fever – due to the inflammatory response, swelling and death of some tissues.

(Date: June 20, 2008)

5. ) Edema- due to the leakage of proteins in the urine that resulted in decreased

serum osmotic pressure that leads to retention of fluid in interstitial spaces. Also

due to the increase in aldosterone that promoted the retention of Na and H2O

resulted to edema.

(Date: apparent upon admission June 20 & still slight apparent until discharge June 26,2008)

6.) Abnormal Neurological examination or altered level of consciousness-because of

malignant hypertension or hypertensive encephalopathy.

(Date: June 20, 2008)

d. Health promotion And Preventive Aspects

When glomerulonephritis is caused by an infection, the first step in treatment

is to eliminate the infection. If bacteria caused the infection, antibiotics may be

given. However, children who develop the disease following a streptococcal

infection often recover without any specific treatment.

When glomerulonephritis has slowed the amount of urine a person is

producing, he or she may be given medications called diuretics, which help the

body to rid itself of excess water and salt by producing more urine. More severe

forms of the disease are treated with medications to control high blood pressure, as

well as changes in diet to reduce the work of the kidneys. A small percentage of

people with severe glomerulonephritis may be treated with medications called

immunosuppressive drugs, which decrease the activity of the immune system, such

as corticosteroids and/or cyclophosphamide (Cytoxan).

To prevent glomerulonephritis following an infection, the infection must be

treated promptly. Most forms of glomerulonephritis cannot be prevented.

V. PATIENT AND HIS CARE

A. Medical Management Medical

ManagementDate

orderedDate

Performed

Date Changed

General Description

Indication(s)Or

Purposes

Client’s initial rxn to

treatment

Client’sresponse to

the treatment

D5 0.3 NaCl 500 cc x KVO

DO: 06-20-08DP: 06-20-08DC: 06-26-08

Hypertonic solution which causes “cell shrinkage”

To replace fluid loss and serve as a vehicle for administration of drugs.

Patient cried when IV insertion is done.

Patient was able to maintain hydration status.KVO: To not aggravate fluid retention.

Nursing Responsibilities in IVF insertion:

Wash hands before preparing the equipment.Check the health practitioner’s order for the type and amount of solution.Check integrity of the IV solution and equipment.Prepare IV solution label with client’s name, date, time, additives, and initial of the administering nurse.Explain to the client what you are doing before taking the equipment into the client’s room.

Instruct the patient to limit his movement of puncture site and notify for any problems or discomfort.Assess patient for any signs of edema and swelling.

Nursing Responsibilities on the patient with IVF:

Explain the procedures to the patient.Assist patient with care since mobility is limited.Check solution for clarity and correct IV type.Regulate flow.Monitor intake

B. Drugs

Name of drug Date ordered/Date taken

Route of administration/dosage and frequency of administration

General action/Functional classification/ Mechanism of Action

Initial reaction Client’s response to the medication

GN: Penicillin G. Sodium

DO: 06-20-08 DP: 06-20-08 D/ C: 06-26-08

IV 375,000 U every 6 hours

To treat moderate to severe systemic infections caused by penicillin-sensitive microorganisms

Patient dislikes the feeling of IV administration of drugs

Patient’s WBC count decreased

GN: Paracetamol

DO: 06-20-08 DP: 06-20-08 D/C: 06-24-08

IV 200 mg every 4 hours

Antipyretic Patient dislikes the feeling of IV administration of drugs

Patient’s temperature decreased

GN: Metoclopramide

DO: 06-20-08 DP: 06-20-08 D/C: 06-21-08

IV ½ amp now Increases sensitivity to acetylcholine; re-

Patient dislikes the feeling of IV administration of drugs

Patient did not vomit.

sultsin increased motility of the upper GI tract and relaxation of the pyloric sphincter and duodenal bulb.


Check name of patient before administering any medications

Check right dosage and route before administration

Check expiration date of medications

Prepare medications aseptically

Administer medications at the right time

Observe patient for any manifestation of adverse effect

C. Diet Type of Diet Date ordered

Date PerformedDate Changed

General Description

Indication(s)Or

Purposes

Specific foods taken

Client’sresponse

and/or rxn tothe diet

Low salt, Low fat DO: 06-20-08 (Patient was advised to maintain this type of diet even after discharge)

A type of diet wherein foods provided to the patient are low in fat and sodium content.

To prevent fluid retention, decrease metabolic demand and help decrease blood pressure

Rice, fish Development of further edema was prevented.

Low Protein DO: 06-26-08 (Patient was advised to maintain this type of diet after discharge)

A type of diet wherein foods provided to the patient are low in protein content.

To allow kidney function to rest.

Bread, chocolate Development of further edema kidney disfunction will be prevented.

High Protein DO: 06-26-08 (Patient was advised to maintain this type of diet after discharge)

A type of diet wherein foods provided to the patient are high in protein content.

To allow tissue repair.

Fish, cheese Stronger and healthier body will be achieved.

Nursing Responsibilities:Explain the reason for suggested diet and exercise Monitor foods taken by the patient

D. Activity/Exercise

Type of exercise

Date orderedDate

PerformedDate Changed

General Description

Indication(s)Or

Purposes

Client’sresponse to the activity/exercise

Bed rest DO: 06-20-08 (Patient was advised to maintain this type of exercise even after discharge)

A type of activity wherein the patient is kept on bed with limitations to activity

To reduce oxygen demand and prevent fatigue

Patient shows gradual increase in strength.

Nursing Responsibilities:Explain the reason for suggested exercise

C. Nursing Management

1. Nursing Care PlanAssessme

nt

Nursing

diagnosis

Scientific

explanation

Objectives Interventi

on

Rationale Expected

Outcome

S=

O= patient

manifests:

-body

malaise

-pale

palpebral

conjunctiva

-pale skin

-activity

intoleran

ce

VS as

follows:

T - 38.40C

PR –

84bpm, RR

– 22 bpm

Hyperthermia People suffer heat-

related illness when

the body's

temperature control

system is overloaded.

The body normally

cools itself by

sweating. But under

some conditions,

sweating just isn't

enough. In such

cases, a person's

body temperature

rises rapidly. Very

high body

temperatures can

damage the brain or

other vital organs.

SHORT TERM:

After 4º of NI,

patient’s boby

temp. will

decrease rom

38.40C to 370C.

LONG TERM:

After 8 days of

NI, patient’s SO

verbalize

understanding

o the underlying

cause factors

and importance

of treatment

- Monitor

VS and

note level

of

consciousn

ess

- performed

TSB (tepid

sponge

bath)

-instructed

patient

increase

fluid intake

-Instruct

patient to

avoid

strenuous

- To have a

baseline

data and to

reveal

alteration

- to

promote

wellness

- to

promote

wellness

-To

conserve

SHORT TERM:

Patient’s body

temperature

shall have

decreased

from 38.40C to

370C

LONG TERM:

patient’s SO

shall have

verbalized

understanding

o the

underlying

cause factors

and

importance of

treatment

activity

-Provide

foods rich

in Iron and

Vitamin C

-Encourage

use of

relaxation

techniques

energy

- To

promote

wellness

-To avoid

fatigue

Assessme

nt

Nursing

diagnosis

Scientific

explanation


on

Rationale Expected

Outcome

S=

O= patient

manifests:

-appears

weak

-body

malaise

-pale

palpebral

conjunctiva

-pale skin

-activity

intoleran

ce

Activity intolerance The kidneys are re-

markable in their

ability to compensate

for problems in their

function. That is why

chronic kidney dis-

ease may progress

without symptoms for

a long time until only

very minimal kidney

function is left.

Because the kidneys

perform so many

functions for the

body, kidney disease

can affect the body in

a large number of

different ways. Symp-

toms vary greatly.

Several different

SHORT TERM:

Ater 4º o NI the

pt’s SO will use

identified

techniques to

enhance activity

tolerance

LONG TERM:

After 5 days of

NI the pt. will

actively or

willingly

participate in

necessary

activities

- adjust

activities

- encourage

rest periods

-promote

comfort

measures

-assist

client in

learning

safety

measures

-Encourage

use of

- to prevent

overexertio

n

- to reduce

fatigue

- to

enhance

ability to

participate

in activities

- to prevent

injuries

-To avoid

fatigue

SHORT TERM:

the pt’s SO

shall have used

identified

techniques to

enhance

activity

tolerance

LONG TERM:

pt. shall have

actively or

willingly

participated in

necessary

activities

body systems may be

affected.

relaxation

techniques

-plan

maximal

activity

within the

client’s

ability

- to

promote

wellness

Assessme

nt

Nursing

diagnosis

Scientific

explanation


on

Rationale Expected

Outcome

S=

O= patient

manifests:

-appears

weak

-body

malaise

-pale

palpebral

conjunctiva

-pale skin

-with facial

edema

Poor personal

hygiene

It is generally known

that unclean

conditions and poor

hygiene are the main

promoters of

bacterial growth.

SHORT TERM:

After 4º the pt.’s

SO will verbalize

understanding

of proper

hygiene

LONG TERM:

After 3-4 days of

NI the pt. will

perform self-

care activities

within level of

own ability

- instruct

proper

bathing

-implement

proper

bowel/

bladder

training

- instruct

proper

handwashin

g

- encourage

food and

fluids

choices that

meets

nutritional

- to

promote

wellness

-to assist in

correcting

situations

- to

promote

wellness

-to assist in

correcting

situations

SHORT TERM:

the pt’s SO

shall have

verbalized

understanding

of proper

hygiene

LONG TERM:

pt. shall have

performed self-

care activities

within level of

own ability

needs

-make

home visit

- to assess

environmen

tal needs

Assessme

nt

Nursing

diagnosis

Scientific

explanation


on

Rationale Expected

Outcome

S=

O= patient

manifests:

-body

malaise

-pale

palpebral

conjunctiva

-pale skin

-with facial

edema

Fluid volume

excess r/t

disruption of

regulatory

mechanism

The inflammation

disrupts the

functioning of the

glomerulus, which is

the part of the kidney

that controls filtering

and excretion. This

disruption results in

blood and protein

appearing in the

urine, and the build

up of excess fluid in

the body.

SHORT TERM:


SO will verbalize

understanding

of individual

fluid restrictions

LONG TERM:

After 3-4 days of

NI the pt. will

stabilized fluid

volume as

evidenced by

balance I&O

- Establish

rapport

- Monitor

VS and

note level

of

consciousn

ess

-Monitor I &

O

- Restrict

fluid/sodiu

m intake as

indicated

- To gain

the trust of

the client

- To have a

baseline

data and to

reveal

alteration

- To reveal

alteration in

fluid status

-To reduce

further

edema

SHORT TERM:

the pt’s SO

shall have

verbalized

understanding

of individual

fluid

restrictions

LONG TERM:

pt. shall have

stabilized fluid

volume as

evidenced by

balance I&O

-Administer

diuretics as

ordered

-To

promote

fluid

excretion

Assessmen

t

Nursing diagnosis Scientific

explanation

Objectives Interventio

n

Rationale Expected

Outcome

S=

O= patient

manifested:

-body

malaise

-pale skin

-activity

intolerance

-decreased

performanc

e

-with

periorbital

edema

-vital signs

taken as

follows:

T:36.10C

PR:97

RR:18

BP: 90/60

Altered tissue

perfusion related to

decreased

hemoglobin

level/concentration

in the blood

Patients with

kidney problems

manifest anemia

due to the

interruption in

the release of

erythropoietin, an

enzyme

responsible for

RBC production

and presence of

hematuria.

SHORT TERM:

After 6º of NI,

patient’s SO will

be able to

verbalize

understanding

of condition and

therapy

regimen

LONG TERM:

After 8 days of

NI, patient will

be able to

demonstrate

increased

perfusion as

individually

appropriate

-Establish

rapport

- Monitor VS

and

note level of

consciousnes

s

-Elevate HOB

-Check for

calf

tenderness

-Provide

quiet, restful

environment

-Instruct

patient to

avoid

-To gain

trust of the

client

- To have a

baseline

data and to

reveal

alteration

-To increase

gravitationa

l blood flow

- May

indicate

thrombus

formation

-To promote

relaxation

-To

conserve

SHORT TERM:

Patient’s SO

was able to

verbalize

understanding

of condition

and therapy

regimen

LONG TERM:

Patient was

able to

demonstrate

increased

perfusion as

individually

appropriate

The patient

may

manifest:

-

dehydration

-inappropri-

ate urine

output for

intake

strenuous

activity

-Provide

foods rich in

Iron and

Vitamin C

-Encourage

use of

relaxation

techniques

energy

- To

promote

RBC

production

-To avoid

fatigue

Assessme

nt

Nursing

diagnosis

Scientific explanation Objectives Interventio

n

Rationale Expected

Outcome

S=

O= patient

manifest:

-body

malaise

-pale skin

-activity

intolerance

-decreased

performanc

e

-with

periorbital

edema

-vital signs

taken as

follows:

T:36.10C

PR:97

RR:18

BP: 90/60

The patient

may

manifest:

Fatigue

related to

increased

metabolic

demands

and

anemia

Patients with anemia

experience fatigue which is

due to increased oxygen

demand caused by decreased

ability of the blood to provide

adequate tissue perfusion.

Moreover, presence of edema

may increase level of fatigue

due to hematuria which

decreases oxygen and leads

to a decrease in cerebral

tissue perfusion.

SHORT TERM:

After 6º of NI,

patient will be

able to report

an improved

sense of

energy

LONG TERM:

After 8 days of

NI, patient will

be able to

report

improved

sense of

energy

- Establish

rapport

- Monitor VS

and

note level of

consciousnes

s

-Accept

reality of

patient’s

report of

fatigue

- Provide

supplementa

l oxygen as

indicated

-Provide

environment

conducive to

- To gain

the trust of

the client

- To have a

baseline

data and

to reveal

alteration

- For

proper

assessmen

t

-To

support

oxygen

demand

SHORT TERM:

Patient was

able to report

an improved

sense of

energy

LONG TERM:

Patient was

able to report

improved

sense of

energy

-

dehydratio

n

-inappropri-

ate urine

output for

intake

relief of

fatigue

-Assist

patient with

activity

-Assist

patient to

identify

appropriate

coping

behaviors

-To reduce

exhaustion

And to

promote

comfort

-For safety

measures

- To

promote

sense of

control

Assessme

nt

Nursing

diagnosis

Scientific explanation Objectives Interventio

n

Rationale Expected

Outcome

S=

O= patient

manifested:

-with

history of

hematuria

-with

history of

frequent

urination

but small

amount of

urine in

yellow color

-appears

weak

-with good

skin turgor

-decreased

food intake

-VS taken

as follows:

T:36.80C

Decreased

cardiac

output

related to

altered

blood

pressure

The excessive urine output of

the patient is due to failure of

regulatory mechanism

resulted to altered circulation/

increased in blood pressure

due to albuminuria which

causes edema and leads to an

increase in blood volume that

triggered the stimulation of

renin, to angiotensin I

converted by Angiotensin

Converting Enzyme to

Angiotensin II that acts on

adrenal cortex causing

secretion of aldosterone.

Increased in aldosterone

promoted renal retention of

Na and H2O which means that

there would be increased in

circulating fluid that would

increase the heart's workload

resulting to increased blood

pressure.

SHORT TERM:

After 6º of NI,

patient will be

able to display

hemodynamic

stability

LONG TERM:

After 3-4 days

of NI, patient

will be to

demonstrate

an increase in

activity

tolerance

- Establish

rapport

- Monitor VS

-Promote

adequate

rest by

decreasing

stimuli,

providing

quiet

environment

. Schedule

activities

and

assessments

- Provide

supplementa

l oxygen as

- To gain the trust of the client

- To have a baseline data and to reveal alteration

- To maximize sleep periods

-To increase oxygen available to the

SHORT TERM:

After 6º of NI,

patient was

able to

display

hemodynamic

stability

LONG TERM:

After 3-4 days

of NI, patient

was able to

demonstrate

an increase in

activity

tolerance

PR:72

RR: 19

BP: 80/72

The patient

may

manifest:

-

dehydratio

n

-

inappropria

te urine

output for

intake

indicated

-Encourage

relaxation

techniques

-Provide for

diet

restrictions

(e.g. low

sodium,

bland, soft,

low calorie/

residue/ fat

diet, with

frequent

small

feedings as

indicated

tissues

-To reduce anxiety

-To

maintain

adequate

nutrition

and fluid

valance

Assessm

ent

Nursing

diagnosis

Scientific

explanation

Objectives Interventio

n

Rationale Expected

Outcome

S= Risk for The presence of SHORT TERM: - Establish - To gain the SHORT TERM:

O= patient

manifeste

d:

--with

history of

hematuria

-with

history of

frequent

urination

but small

amount of

urine in

yellow

color

-appears

weak

-with good

skin turgor

-

decreased

food

intake

-VS taken

impaired

Skin

Integrity

related to

edema

edema interferes

with cellular

nutrition, which

makes the patient

more susceptible

to skin breakdown.

After 6º of NI,

patient will

demonstrate

behaviors to

prevent skin

breakdown

LONG TERM:

After 6 days of NI,

patient’s edema

will

decrease/subside

rapport

- Monitor VS

and

note level of

consciousne

ss

-Assess skin

condition

- Monitor

weight daily

-Provide

meticulous

skin care

-Keep bed

trust of the client

- To have a

baseline data

and to reveal

alteration

- To reveal

abnormality/skin

disruption

-To monitor

presence of

edema

-To prevent skin

breakdown

-To prevent

Patient was able

to demonstrate

behaviors to

prevent skin

breakdown

LONG TERM:

Patient’s edema

was able to

decrease/subsid

e

as follows:

T:36.80C

PR:72

RR: 19

BP: 80/72

The

patient

may

manifest:

-

dehydratio

n

-

inappropri-

ate urine

output for

intake

linens dry

-Frequently

change

patient’s

position

moisture which

may promote

skin breakdown

-To promote

proper circulation

and prevent

excessive

pressure on skin

Assessme

nt

Nursing

diagnosis

Scientific

explanation


on

Rationale Expected

Outcome

S=

O= patient

manifests:

-appears

weak

-body

malaise

-pale

palpebral

conjunctiva

-pale skin

-with facial

edema

Risk for spread of

infection

Viruses and bacteria

both enter your body

through your mouth

or nose — either

because you breathe

in particles that are

released into the air

when someone

coughs or sneezes, or

because you have

hand-to-hand contact

with an infected

person or use shared

objects such as

utensils, towels, toys,

doorknobs or a

telephone.

SHORT TERM:


SO will identify

interventions to

reduce spread

of infection

LONG TERM:

After 3-4 days of

NI the pt.’s SO

will demonstrate

techniques,

lifestyles

changes to

promote safe

environment

- instruct

proper

hygiene

- instruct

proper

handwashin

g

- promote

clean

environmen

t

- change

linens an

dressings

as needed

- to reduce

existing risk

factors

- to reduce

existing risk

factors

- to prevent

inection

- to correct

existing risk

factors

- to

SHORT TERM:

the pt’s SO

shall have

identified

interventions

to reduce

spread of

infection

LONG TERM:

pt. shall have

demonstrated

techniques,

lifestyles

changes to

promote safe

environment

-emphasize

necessity of

taking

antibiotics

as directed

-encourage

proper

nutrition,

appropriate

exercise

program

and need

for rest

promote

wellness

- to

promote

wellness

C. Nursing Management (Actual SOAPIER’S)

June 24, 2008 (Tuesday)

A.1)

S > Ø

O > received patient sitting in bed with ongoing IVF of D5.3 NaCl 500 cc x 10-11

ugtts/min at 100 cc level, appears weak with periorbital edema good skin turgor

moist mucous membrane decreased food intake, vital signs taken as follows: T-

36.80C PR-72bpm RR-19cpm

A > Excess fluid volume related to albuminuria secondary to acute

glomerulonephritis

P > After 6 hours of nursing interventions, the patient will be able to stabilize fluid

volume as evidenced by absence of edema

I>

Established rapport.

Monitored and recorded vital signs.

Checked patency of IVF.

Regulated IVF x 10-11 ugtts/min at 9:24am.

Noted amount or rate of fluid intake from sources.

Noted presence of edema (puffy eyelids dependent swelling ankles/feet if

ambulatory or up in chair; sacrum and posterior thighs when recumbent),

anasarca

Set an appropriate rate of fluid intake infusion 24 hour period.

Discussed the importance of fluid restrictions ad :hidden sources of intake

(such as foods high in water content).

Provided adequate rest periods.

Due meds given.

Attended needs.

Endorsed.

E > Goal met after 6 hours of NI, as evidenced by stabilized fluid volume of the

patient which is evident by absence of edema

June 24, 2008 (Tuesday)

A.2)

S > Ø


ugtts/min at 100 cc level, appears weak with periorbital edema good skin turgor

moist mucous membrane decreased food intake, vital signs taken as follows: T-

36.80C PR-72bpm RR-19cpm

A > Activity intolerance due to prolonged bedrest

P > After 6 hours of nursing interventions, the patient will be able to identify

negative factors affecting activity tolerance and eliminate or reduce their effects

when possible

I>


Monitored and recorded vital signs.

Encourage expression of feelings contributing to condition.

Increase exercise or activity levels gradually; teach methods to conserve

energy, such as stopping to rest for three minutes during a 10-minute walk.

Encourage participation in recreation or social activities hobbies appropriate

for situation.

Due meds given.

Attended needs.

Endorsed.

E > Goal met after 6 hours of NI, as evidenced by patient’s capability to identify

negative factors affecting activity tolerance and eliminate or reduce their effects

when possible

June 25, 2008 (Wednesday)

B.1)

S > Ø


ugtts/min at 100 cc level, appears weak with periorbital edema with reduced

interaction with people and environment with polyuria, vital signs taken as follows:

T-36.10C PR-97bpm RR-18cpm

A > Risk for deficient fluid volume AEB frequent urination related to disease

condition

P > After 6 hours of nursing interventions, the patient will not be able to manifest

signs and symptoms of dehydration

I>


Monitored vital signs.


Seen on rounds by Dra. Aguillar with new order made and recorded (Order:

KVO)

IVF to KVO

Due meds given.

Attended needs.

Endorsed.

E > Goal met after 6 hours of NI, as evidenced by patient was not able to manifest

the signs and symptoms of dehydration

June 25, 2008 (Wednesday)

B.2)

S > Ø


ugtts/min at 100 cc level, appears weak with periorbital edema with reduced

interaction with people and environment with polyuria, vital signs taken as follows:

T-36.10C PR-97bpm RR-18cpm

A > Social isolation related to altered state of wellness

P > After 6 hours of nursing interventions, the patient will be able to verbalize

willingness to interact with others

I>


Monitored vital signs.


Introduce client to those with similar or shared interests and other supportive

people.

Provide environmental stimuli (open curtains, TV, radio and pictures).

Due meds given.

Attended needs.

Endorsed.

E > Goal met after 6 hours of NI, as evidenced by patient was able to verbalize

willingness to interact with others

VI. Client’s Daily Progress in the Hospital

1. Client’s Daily Progress Chart

Client’s daily ProgressNursing Problems Admission

(06-20-08)06-21-08 06-22-08 06-23-

0806-24-08 06-25-08 Discharge

Hyperthermia √

Activity intolerance √ √ √ √ √ √ √

Poor personal hygiene √ √ √ √ √ √ √

Fluid volume excess r/t disruption of regulatory

mechanism

√ √ √ √ √ √ √

Altered Tissue Perfusion

√ √ √ √ √ √ √

Fatigue √ √ √ √ √ √ √

Decreased cardiac output

√ √ √ √ √ √ √

Risk for impaired Skin Integrity related to

edema

√ √ √ √ √ √ √

Risk for spread of infection

√ √ √ √ √ √ √

Vital Signs

TemperaturePulse rate

Respiratory rateBlood Pressure

38.4ºC8422

37.3

90/60 80/60

37

70/60

36.8ºC7219

80/72

36.1ºC9718

90/60

*Temp, PR, RR and BP were not available in the chart for some dates

Diagnostic Procedure

CBCSerum CreatinineBlood Chemistry

Serum ElectrolyteRoutine Urinalysis

√

√√√

√

√

Medical Management

A. IVFD5 0.3 NaCl

√ √ √ √ √ √ √

B. DrugsPen G Sodium

Metoclopramide

Paracetamol

√

√

√

√

√

√

√

√

√

√ √ √

C. DietLow salt, Low fat √ √ √ √ √ √ √

Low Protein √

High Protein √

D. ActivityBed rest √ √ √ √ √ √ √

2. Discharge Planning

a. General condition of the client upon discharge

Baby AGN was discharged last June 26, 2008 (Thursday). She still has slight

facial edema, normal body temperature, (-) hematuria and stable vital signs. She

has still lesions on her scalp and minimal lesions on her extremities.

b. Method

S > Ø

O > Received patient sitting on bed; pt. still has slight facial edema; (-) hematuria,

pt. still has lesions on her scalp and minimal lesions on her extremities; appears

slightly weak; with stable vital signs.

A > For home maintenance and health management.

P > After 1 hour of nursing interventions, the patient and SO will verbalize

understanding of health teachings.

I>

M > Instructed patient to take the following home medications

E > Instruct the patient to do some activities of daily living.

T > Instruct the patient to take the medications religiously.

H > Instructs patients to eat nutritious foods such as fruits and vegetables

that are not contraindicated.

> Instructs patient to have proper personal hygiene.

O > Instructed patient to come back for follow-up check

D > Instructed patient’s SO to provide foods that are low in salt and fat.

E > Goal met as evidenced by patient’s SO verbalized understanding of health

teachings.

VII. Conclusions

Acute Glomerulonephritis is relatively common bilateral inflammation of the

glomeruli. It follows a streptococcal infection of the respiratory tract or less

commonly, a skin infection. It is a must that we shouldgive enough attention to

those suffering of such disease so as to prevent aggravation and further

complications that could possibly occur.To help patient to cope up with his/her

condition we are to perform proper monitoring and treatment.

As a student nurse, the student should be competetive enough, equipt with

enough and accurate knowledge of the disease. Not just with learning through

lectures and theories is the way to understand these diseases. Through interaction,

knowledge acquired from theories was much appreciated by the students since

he/she can actually assess the patient’s condition. Equipt with enough and accurate

information and enhance skills, she/he may be able to be competetive enough to

handle future situations and patients suffering from the mentioned condition.

Bibliography:

www.yahoo.com

www.emedicine.com

Medical Surgical Nursing

PDR Nurses Drug Handbook 2005

Nurse’s Pocket Guide

http://en.wikibooks.org/wiki/Human_Physiology/The_Urinary_

System#Urethra

http://www.emedicine.com/

http://www.yahoo.com/

case+study agn mine

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