Acute Glomerulo Nephritis V

8/3/2019 Acute Glomerulo Nephritis V

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BSN IV-CEFI

GROUP 4


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INTRODUCTION

A. Background of the study

During our 1st & 2rd week of hospital exposure atQuezon Medical Center Pedia Ward, we

encountered a patient with Acute Glomerulonephritis

VS Nephrotic Syndrome, Urinary Tract Infection.

Mr. x, 15 years old, was admitted with the chiefcomplaint of abdominal pain, fever &

edema last July 21, 2010.


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Acute glomerulonephritis refers to a specific set

of renal diseases in which an immunologicmechanism triggers inflammation and proliferation ofglomerular tissue that can result in damage to thebasement membrane, mesangium, or capillaryendothelium.

There are many diseases that cause an activeinflammation within the glomeruli. Some of thesediseases are systemic and some occur solely in the

glomeruli. When there is active inflammation withinthe kidney, scar tissue may replace normal,functional kidney tissue and cause irreversible renalimpairment.


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Most original research focuses on the poststreptococcal patient. Acute glomerulonephritis is defined

as the sudden onset of hematuria, proteinuria,and redblood cell casts.

This clinical picture is often accompanied byhypertension, edema, and impaired

renal function.

Although this is primarily a disease of children,with ages 4-12 being at high risk, it can occur at almostany age. Males are more susceptible than females, with

a ratio of 1.7-2:1. No specific race is considered at highrisk of acquiring this illness, though those in lowersocioeconomic brackets are more prone to this due toenvironmental and sanitary conditions


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Nephrotic syndrome is a group of symptoms including proteinin the urine (more than 3.5 grams per day), low blood proteinlevels, high cholesterol levels, high triglyceride levels, andswelling. Autoimmune process leading to structural alterationof glomerular membrane that results in increasedpermeability to plasma proteins, particulary albumin.

Nephrotic syndrome is a disorder of the glomeruli (clusters ofmicroscopic blood vessels in the kidneys that have small

pores through which blood is filtered) in which excessiveamounts of protein are excreted in the urine. This typicallyleads to accumulation of fluid in the body (edema) and lowlevels of the protein albumin and high levels of fats in theblood.

Nephrotic syndrome is not a specific glomerular disease but acluster of clinical findings, including:Marked increase inprotein (particularly albumin) in the urine (proteinuria),Decrease in albumin in the blood (hypoalbuminemia), Edema,High serum cholesterol and low-density lipoproteins(hyperlipidemia).


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This clinical picture is often accompanied byAlbuminuria (s1), Edema(s2), Hyperlipidemia(s3) &Hypoalbuminemia(s4)

Although this is primarily a disease of children,with

1 12 and 4 yr at high risk, it can occur at almostany age. Males are more susceptible than females,with a ratio of 1.7-2:1. No specific race isconsidered at high risk of acquiring this illness,though those in lower socioeconomic brackets aremore prone to this due to environmental andsanitary conditions. People with family history ofnephrotic syndrome increases likelihood ofdeveloping nephrotic syndrome.


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Urinary tract infection (UTI) is a bacterial

infection that affects any part of the urinarytract.Although urine contains a variety offluids, salts, and waste products, it usuallydoes not have bacteria in it. When bacteriaget into the bladder or kidney and multiply

in the urine, they cause a UTI. The mostcommon type of UTI is a bladder infectionwhich is also often called cystitis.Anotherkind of UTI is a kidney infection, known as

pyelonphritis, and is much more serious.The major problem here is that urinary tractinfection causes discomfort and pain onurination.


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Incidence:

Most common renal disease in children.Almost 10 times more common in females thanin males, except in the neonatal period.Bladder is the most common site of infection25% of all women (cystitis)

Men before the age of 50 years

Risk Factors: Location of the female meatus

Sexual intercourse

y Urinary stasis and reflux in pregnant women causedby pressure on the ureters and hormonal changes.

y Tight and synthetic clothing (causes irritation)

y Presence of an indwelling catheter.


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B. Objectives of the Study

GeneralThe general objective of this case presentationis to foster and develop knowledge and skills inproviding care and management for a patient withacute glomerulonephritis vs nephrotic syndrome, urinarytract infection

Specific

KNOWLEDGE

To define acute glomerulonephritis, nephrotic syndrome,urinary tract infection

To know the clinical manifestations, nursing

management and interventions for patients who

have this disease.

To know the different medications that needs to be

taken including its side effects which can be harmful tothe patient


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SKILLS

To be able to obtain, document, and present a

comprehensive medical history. To perform initial physical examination such as

general assessment of the patientsappearance,

position and degree of comfort.

To apply necessary skills in providing care for aclient with acute glomerulonephritis VSnephrotic syndrome, UTI

ATTITUDES

To learn how to establish rapport with the clientand significant others.

to be able to recognize the importance of patient

and familial preferences when selecting among

treatment options


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C. Scope and Limitation of the Study

The scope of the study encompasses theanatomy, physiology, and pathophysiology of thedisease acute glomerulonephritis VS nephroticsyndrome, UTI. While dealing withMr. xcase, we are subjected with the followinglimitations of our study:

The group only had 2 days (July 2010) ofactual interaction with the patient at Quezon MedicalCenter, Lucena City.

The group credited the study on the referencesprior to books, researches in the internet and datacollected from the interview with the client/familymembers, physical assessment and the patientschart.


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CLINICAL SUMMARYCLINICAL SUMMARY


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A. GeneralData

Case # 10071323Name :Mr. x

Address :Brgy. Poblacion, L.C.

Age :15 y/o

Religion :Roman catholicCivil Status :Child

Nationality :Filipino

Date of Birth :July 21, 1995

Date of Admission :July 21,2010Ward and Room :PAW 04

AdmittingDiagnosis :AGN VS. NS, UTI

Attending Physician :Dra Tagle


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B. CHIEF COMPLAINT

abdominal pain, fever &

edema last July 21, 2010.


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C. History of Present Illness


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D. PAST MEDICAL HISTORY


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E. FAMILY HISTORY


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F. Physical Assessment

General Appearance

Presence of edema on both extremities

The client looks weak and pale. Hesleeps a lot and

talks only when asked.

The client experiences cold andclammy perspiration.


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Head to Toe Assessment

Head- normocephalic

no presence of lumps

Eye- no abnormal eye discharge

PERRLA (+)

Nose - symmetric

Without nasal discharge

Lips - slightly dry and pale

uvula and tongue centrally located


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Ears equal size

no swelling

upper pinna is in line with outer cantus

Neck able to move freely

no lumps upon palpation

Chest symmetrical expansion

with clear breath sound on both lung

field upon auscultation

Abdomen with tender abdomen uponpalpation


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G. Laboratory/Diagnostic Exams


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ANATOMY


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2 kidneys a pair of purplish-

brown organs located below the

ribs toward the middle of theback. Their function is to:

>remove liquid waste from the

blood in the form of urine.

>keep a stable balance of salts

and other substances in the

blood.

>produce erythropoietin, ahormone that aids the formation

of red blood cells.


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The kidneys remove urea from the blood

through tiny filtering units called nephrons.

Each nephron consists of a ball formed of small

blood capillaries, called a glomerulus, and a

small tube called a renal tubule.

Urea, together with water and other waste

substances, forms the urine as it passesthrough the nephrons and down the renal

tubules of the kidney.


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The Nephron

Is the basic structural and functional unit of the kidney.

Its chief function is to regulate the concentration of

water and soluble substances like sodium salts by

filtering the blood, reabsorbing what is needed and

excreting the rest as urine. A nephron eliminateswastes from the body, regulates blood volume and

blood pressure, controls levels of electrolytes and

metabolites, and regulates blood pH. Its functions are

vital to life and are regulated by the endocrine system

by hormones such as antidiuretic hormone,

aldosterone, and parathyroid hormone. In humans, a

normal kidney contains 800,000 to one million

nephrons.


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The GlomerulusThe glomerulus is themain filter of the nephron and is

located within the Bowman's capsule.The glomerulus

resembles a twisted mass of tiny tubes through which

the blood passes.The glomerulus is semipermeable,allowing water and soluble wastes to pass through and

be excreted out of the Bowman's capsule as urine.The

filtered blood passes out of the glomerulus into the

efferent arteriole to be returned through the medullary

plexus to the intralobular vein


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Bowman'sCapsule

The Bowman's capsule contains the

primary filtering device of the nephron, the

glomerulus. Blood is transported into the

Bowman's capsule from the afferent arteriole(branching off of the interlobular artery). Within

the capsule, the blood is filtered through the

glomerulus and then passes out via the efferent

arteriole. Meanwhile, the filtered water andaqueous wastes are passed out of the

Bowman's capsule into the proximal convoluted

tubule


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PATHOPHYSIOLOGY


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UTI

Post-streptococcal infection

(group-A, beta hemolytic)

Release of material from the organism,

into the circulation (antigen)

Formation ofantibody


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Immune complex reaction in the

glomerular capillary

Inflammatory response

Proliferation of epithelial cells lining

glomerolus & cells betweenendothelium & epithelium of capillary

membrane

Swelling capillary membrane &

infiltration with leukocytes


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Permeability of base membrane

Glomerular filtration rate

Occlusion of the capillaries of the

glomeruli vasospasm of afferent

ventrioles

Ability to form filtrate fromglomeruli plasma flow


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Retention of H2O & Na; hypovolemia;

circulatory congestion

NEPHROTIC SYNDROME

Renal injury

Excessive lost of protein in urination


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ACUTE GLOMERULOACUTE GLOMERULO--NEPHRITISNEPHRITIS

Common manifestations of the syndrome are:Proteinuria, hypoalbumenia,hypercoagulability,hypoalbuminemia,

hyperlipideminemia,hypercoagulability

Edema

Hypertension

urinary outputUrine dark in color

Anorexia

Irritability lethargy


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CLINICAL MANIFESTATIONSCLINICAL MANIFESTATIONS

Oliguria/anuria, due to decreased glomerular filtrationrate (GFR)

Elevated BUN and serum creatinine, due to decreased

urine output

Hematuria (microscopic or gross), occurs in

approximately 30% of cases; urine may appear dark,

cola-colored or tea-like

Proteinuria, primarily albumin, due to increased

permeability of glomerular membrane

Edema (facial, periorbital and/or pedal), hypertension,

anemia, increased ICP, pulmonary edema, all related to

increased circulating blood volume/excess extra-cellular fluid (ECF)

Tenderness over the costo-vertebral angle ( + kidney

punch), due to swelling of kidneys


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ASSESSMENT AND DIAGNOSTICS

History taking; 1-3 weeks post-streptococcal infection (1-2 weeks post-pharyngitis)

Urinalysis; dark urine, (+) RBC, albumin,casts; specific gravity > 1.020

CBC; decreased Hgb, HctBlood chemistry; elevated BUN and serumcreatinineKidney biopsy, electron microscopy and

immunofluorescent analysis Antistreptolysin O; increased in 60-80% of

patients

KUB; enlarged kidneys


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POSSIBLE NURSING DIAGNOSIS

Fluid volume excessrelated to decreased glomerular

filtration rate as evidenced by decreased urine output,

edema and hypertension

Imbalanced body temperature related to unknown etiology

(possible infection) as evidenced by Temp=38.4 C

Imbalanced nutrition: less than body requirementsrelatedto increased glomerular permeability as evidenced by proteinuria

Knowledge deficitrelated to medical management of the

disease as evidenced by questioning attitude by the mother

Anxietyrelated to outcome of treatment

Impaired parent-child interactionrelated to irritability of child Risk for impaired skin integrityrelated to edema/altered

skin turgor

Risk for infectionrelated ongoing disease process

(immunocompromised)


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DRUG STUDY


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Ranitidine

Therapeutic Classification

y Antiulcer Drug

Action

y Reduces gastric secretion and increases gastric mucus and

bicarbonate production, creating a protective coating on gastricmucosa

Contraindication

y Hypersensitivity to drug and its component

Toxic/Side Effects

y Nausea, vomiting, diarrhea, constipation, abdominal discomfort

or pain.

Indications

y To maintain healing of duodenal and gastric ulcers

Safety

y Renal or hepatic impairment, heart rhythm disturbances


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FUROSEMIDE

Therapeutic Classificationy Diuretic

Action

y Increases potassium excretion and plasma volume,

promoting renal excretion of water.

Contraindications

y Hypersensitivity to drug or other sulfonamides

Toxic/Side effects

y Nausea, vomiting, diarrhea, constipation, dyspepsia, oral

and gastric irritation, cramping, anorexia, dry mouth.

Indications

y For hypertension.

Safety

y Diabetes melitus, severe hepatic disease, neonates


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Asessment Nursing

Diagnosis

Planning Interventio

n

Rati

onal

e

Evaluation

S>

Namamanas na ang

kamay at

paa ko as

verbalized

by the

patient

O>

-fluppy face

-edema on

both lower

and upperextremities

-tender

abdomen

-pale in

appearance

-bodymalaise

Fluid volume

excess relatedto renal failure

After 8 hours of

nursingintervention

patient can

demonstrate

behaviors to

monitor fluid

stasus andreduce

recurrence of

fluid excess

INDEPEND

ENT-

reinstructed

patient on

NPO

-monitor

intake andouput

-elevate

edematous

extremities

-Provide

adequateactivity or

position

changes

-to

avoid

exce

ssive

fluid

reten

tion-to

mea

sure

the

intak

eand

outp

ut

-to

incre

aseveno

Goal

partially metseen patient

elevating

both legs

using pillow


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Asessment Nursing

Diagnosis

Planning Interventio

n

Rati

onal

e

Evaluation

-DEPENDENT

-Administer

diuretic as

ordered

us

return

-to

prev

ent

fluid

accumula

tion

in

depe

nden

tarea

s

-to

prom

ote

offluid

diuresis

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Acute Glomerulo Nephritis V