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case study on acute glomerulonephritis
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Table of contents
I. Introductiona. Overview of the Caseb. Objective of the Studyc. Scope and Limitation of the Study
II. Health Historya. Profile of patientb. Personal Health Historyc. History of Present Illnessd. Chief Complaint
III. Developmental Data
IV. Medical Managementa. Medical Orders and rationaleb. Drug study
V. Pathophysiology with Anatomy and Physiology
VI. Nursing Assessment (System Review & Nursing Assessment II)
VII. Nursing Managementa. Ideal Nursing Management (NCP)b. Actual Nursing Management (SOAPIE)
VIII. Referrals & Follow-up
IX. Evaluation and Implications
X. Bibliography
I. INTRODUCTION
A. Overview of the Case
Acute Glomerulonephritis is the disease of the kidney in which there is an
inflammation of the glomerular capillaries. In most cases, the stimulus of the reaction is
group A streptococcal infection, which ordinarily precedes the onset of
glomerulonephritis by 2 to 3 weeks.
B. Objective of the Study
The study generally aims to investigate the condition of an adult man and further
understand the extent of the case.
Specifically, the health care provider sought to;
Perform Physical Assessment,
Data Base and History taking that solidifies the present diagnosis of the client.
Identify the development and changes encountered by the client.
Identify the nursing problems which will be the basis of the care plan.
Develop Plan of the Care and Implement nursing interventions relevant and
suitable for the case.
As nursing students they will be able to improve their skills in accordance to patient’s
needs and condition.
The purpose of the study is to gather significant data to broaden our knowledge with
regards to the condition of the patient and to improve our abilities as future health care
providers. Moreover, this case study will enable us to apply the acquired skills we
obtained in the classroom set-up.
C. Scope and Limitation of the Study
The study focuses only on one of the many problems of the kidney, mainly the
glomerulonephritis and its causes and effects on patients that are being diagnosed to it.
Also, the study tackles on how this problem is being acquired.
II. HEALTH HISTORY
A. Client’s ProfileName : Lisdan, Elpedio N.Wife : Lisdan, Jemma Address : San Rafael, Talakag, Bukinon provinceCivil Status : MarriedSex : MaleAge : 42 years oldReligion : Roman CatholicEducational Status : Elementary level
Income : 2,000 php/monthNationality : FilipinoDate of Admission : January 27, 2009Time of Admission : 9:10 amInformant : PatientHeight : 158 centimetresWeight : 52 kgVital Signs during AssessmentTemperature : 36.7 °CPulse Rate : 55 bpmRespiratory rate : 20 cpmBlood Pressure : 150/110 mmHg
Admitting Diagnosis : Acute Glomerulonephritis related to nephritic syndrome; hypertension
Attending Physician : Dr. Joseph Borong
B. Family and Personal Health
Patient’s History
Allergies:- No known allergies on foods and drugs.
Injuries/ Accident in the past:- Patient had not experience injuries or accident in the past.
Blood Transfusion:- Patient didn’t receive blood in the past.
Family health history:- Experienced Hypertension and Kidney disorder (2006)
Social History
Alcohol use:- Patient occasionally drinks alcoholic beverages, as seldom as once in 2 months.
Tobacco use:- Patient often smokes.
Home and Environment:- Resides at San Rafael, Talakag- Living status is just enough for their family needs
C. Chief Complaint and History of Present Illness
Noted to have edema; condition noted for a week – prior to admission as onset of
fever on and off associated with dysuria – tea colored urine.
III. DEVELOPMENTAL DATA
The Developmental Stages of Erik Erickson
Middle Adulthood: 35 to 65:
Generativity vs. Self absorption or Stagnation
Now work is most crucial. Erickson observed that middle-age is when we tend to
be occupied with creative and meaningful work and with issues surrounding our family.
Also, middle adulthood is when we can expect to "be in charge," the role we've longer
envied. The significant task is to perpetuate culture and transmit values of the culture
through the family (taming the kids) and working to establish a stable environment.
Strength comes through care of others and production of something that contributes to the
betterment of society, which Erikson calls generativity, so when we're in this stage we
often fear inactivity and meaninglessness.
Freud's Psychosexual Stages of Development
The Genital Stage
In the genital stage, as the child's energy once again focuses on his genitals,
interest turns to heterosexual relationships. The less energy the child has left invested in
unresolved psychosexual developments, the greater his capacity will be to develop
normal relationships with the opposite sex. If, however, he remains fixated, particularly
on the phallic stage, his development will be troubled as he struggles with further
repression and defenses.
Robert Havighurst Developmental Task Theory
Middle Adulthood (30-60 years)
Achieving adult social and civic responsibility; Reaching and maintaining
satisfactory performance in one’s occupational career; Developing adult leisure time
activities; Relating oneself to one’s spouse as a person; To accept and adjust to the
physiological changes of middle age; Adjusting to aging parents. Assisting teenage
children to become responsible and happy adults; achieving adult social and civic
responsibility.
Piaget's Theory of Cognitive Development
Formal operational stage (Adolescence and adulthood)
In this stage, intelligence is demonstrated through the logical use of symbols
related to abstract concepts. Early in the period there is a return to egocentric thought.
Many people do not think formally during adulthood.
IV. MEDICAL MANAGEMENT
A. Medical Orders and Rationale
Doctor’s Order Rationale
01/27/09
Please admit
TPR q 4h
Full low salt, low fat diet
Give 1 egg white a day
0.9 NaCl @ KVO rate
Furosemide i amp q 12h x 3doses
To monitor patient’s medical condition and proper management.
To monitor any abnormal changes in vital signs
For proper nourishment and for prevention of disease that may lead to severity of the condition
To promote good nutritional status
To monitor body fluids & prevent dehydration
For treatment of hypertension, edema associated with CHF, cirrhosis and renal disease
For treatment of lower respiratory
Cefuroxime 750 mg q 8h IVTT
Omeprazole 20mg icap OD P.O.
Captopril 25mg itab BID P.O.
I & O q shift
01/28/09
IVF 0.9 NaCl @ KVO rate
Spironolactone 50mg itab TID P.O.
Continue meds.
Weight patient daily pre-breakfast
01/29/09
Continue meds.
IVF of D5nm iL @ KVO rate
infection, UTI & dermatologic infection
First line treatment for heartburn
and short term treatment of active duodenal ulcer
Treatment for pulmonary tuberculosis that is not responsible to 1st line antituberculosis
For proper hydration of the patient and carefully monitor the fluid losses
To monitor body fluids & prevent dehydration
To counteract potassium loss caused by other diuretics
To treat the disease & remove the symptoms
To monitor if the symptoms are relieved
To treat the disease & remove the symptoms
To monitor fluids
B. Drug StudyGeneric Name of Ordered
Drug
Date Ordered
Classi-fication
Dose/Frequency/
Route
Mechanism of Action
Specific Indication
Contra-indication
Side Effects/Toxic
Effects
Nursing Precaution
Cefuroxime 01/27/09 Antibiotic(Cephalos porin – 2nd
generation)
750 mg q 8h IVTT
Inhibits synthesis of bacterial cell wall, causing
cell death.
For lower respiratory infection,
UTI & dermatologic
infection
Contra indicated with
allergy to cephalosporin or penicillins
Hypersen-sitivity,
nephrotoxicity, pain
at injection site
Assess for hepatic or
renal impairment
Assess for skin status
Check for sensitivity
tests
Generic Name of Ordered
Drug
Date Ordered
Classi-fication
Dose/Frequency/
Route
Mechanism of Action
Specific Indication
Contra-indication
Side Effects/Toxic
Effects
Nursing Precaution
Furosemide 01/27/09 Loop Diuretic
Amp of 12h x 3 doses
Inhibits reabsoption of Na and Cl from
the proximal and distal tubules and ascending
limb of the loop of Henle,
leading to a Na-reach diuresis
Hyperten-sion,
Edema associated with CHF, cirrhosis and renal disease
Contraindicates allergy to
furosemide; anuria, hepatic
coma
Polyuna, Nocturia,
Rash, Anemia, Muscle spasms, Cardiac
arrythmias
Assess for allergy to
furosemide
Assess for skin color, lesions and edemaCBC, serium electrolytes
Generic Name of Ordered
Drug
Date Ordered
Classi-fication
Dose/Frequency/
Route
Mechanism of Action
Specific Indication
Contra-indication
Side Effects/Toxic
Effects
Nursing Precaution
Omeprazole 01/27/09 Antisecretory drug;
Proton Pump
Inhibitor
20mg icap OD P.O.
Gastric acid pump inhibitor:
Supresses gastric acid secretion by
specific inhibition of hydrogen- K
ATPase enzymes system
at secretory surface of the gastric parietal
cells.
First line treatment
for heartburn and short
term treatment of active duodenal
ulcer
Contra-indicated with
hyper-sensitivity to
omeprazole or its component. Use cautiously
pregnancy lactation
Rash, alopecia, nausea,
vomitingEpistasis,
fever
Assess for hypersensit
ivity to omeprazole
Assess for skin lesionsAssess for
urinary output
Generic Name of Ordered
Drug
Date Ordered
Classi-fication
Dose/Frequency/
Route
Mechanism of Action
Specific Indication
Contra-indication
Side Effects/Toxic
Effects
Nursing Precaution
Captropil 01/27/09 ACE inhibitor
25mg itabBID P.O.
PolypeptideAntibactic;
against Mycobacterium
tuberculosis
Treatment hyper-tension
Contra-indicated allergy to
capreomycin; pre-existing
auditory impairment
Polyuria, Tachy-cardia,
proteinuriacough
dry mouth
Assess for allergy to captropil
Assess for skin color and lesions
For CBC and
differential
Generic Name of Ordered
Drug
Date Ordered
Classi-fication
Dose/Frequency/
Route
Mechanism of Action
Specific Indication
Contra-indication
Side Effects/Toxic
Effects
Nursing Precaution
Spirono-lactone
01/28/09 Diuretics 50mg itab TID P.O.
Cause loss of sodium
bicarbonate and calcium while
saving potassium and hydrogen ions
To counteract potassium
loss caused by
other diuretics
Hyper-sensitivity;
Hyperkalemia
ClumsyHeadacheDyscrasias
Monitor intake & output
Daily weight during therapy
Monitor BP before adminis-
tering
V. PATHOPHYSIOLOGY
Post-streptococcal infection (group-A, beta hemolytic)
Release of material from the organism, into the circulation (antigen)
Formation of antibody
Immune complex reaction in the glomerular capillary
Inflammatory response
Proliferation of epithelial cells lining glomerolus & cells between
endothelium & epithelium of capillary membrane
Swelling capillary membrane & infiltration with leukocytes
↑ Permeability of base membrane
↓ Glomerular filtration rate
Occlusion of the capillaries of the glomeruli vasospasm of afferent
ventrioles
↓ Ability to form filtrate from glomeeruli plasma flow
Retention of H2O & Na; hypovolemia; circulatory congestion
Edema Hypertension
↓ urinary outputUrine dark in color
AnorexiaIrritability lethargy
ACUTE GLOMERULO-
NEPHRITIS
VI. ASSESSMENT
EENT:
[ ] impaired vision [ ] blind
[ ] pain [ ] reddened [ ] drainage
[ ] gums [ ] hard of hearing
[ ] deaf [ ] burning [x] edema
[ ] lesion [ ] teeth [ ] no problem
RESPIRATORY:
[ ] asymmetric [ ] tachypnea
[ ] apnea [ ] rales [x] cough
[ ] barrel chest [ ] bradypnea
[ ] shallow [ ] rhonchi [x] sputum
[ ] diminished [ ] dyspnea
[ ] orthopnea [ ] labored [ ] wheezing
[ ] pain [ ] cyanotic [ ] no problem
CARDIO VASCULAR:
[ ] arrhythmia [ ] tachycardia [ ] numbness
[ ] diminished pulses [ ] edema [ ] fatigue
[ ] irregular [ ] bradycardia [ ] murmur
[ ] tingling [ ] absent pulses [x] pain
[ ] no problem
GASTRO INTESTINAL TRACT:
[ ] obese [ ] distension [ ] mass
[ ] dysphagia [ ] rigidly [ ] pain
[x] no problem
GENITO URINARY and GYNE:
[x] pain [x] urine color [ ] vaginal bleeding
[ ] hermaturia [ ] discharge [ ] nocturia
[ ] no problem
NEUROLOGICAL:
[ ] paralysis [ ] stuporous [ ] unsteady
[ ] seizures [ ] lethargic [ ] comatose
[ ] vertigo [ ] tremors [ ] confused
[ ] vision [ ] grip [x] no problem
MUSCULOSKELETAL:
[ ] appliance [ ] stiffness [ ] itching
[ ] petechiae [ ] hot [ ] drainage
[ ] prosthesis [ ] swelling [ ] lesion
[ ] poor turgor [ ] cool [ ] deformity
[ ] wound [ ] rash [ ] skin color
[ ] flushed [ ] atrophy [x] pain
[ ] ecchymosis [ ] diaphoretic [ ] moist
[ ] no problem
NURSING ASSESSMENT IISUBJECTIVE OBJECTIVE
COMMUNICATION:[ ] Hearing Loss Comments: “wala [ ] Visual Changes man – wala [x] Denied gihapon” As verbalized by the husband
[ ] Glasses [ ] Language[ ] Contact lens [ ] Hearing Aide
R L Pupil Size: 3-5 mm [ ] Speech difficultiesReaction: PERRLA
OXYGENATION:[ ] dyspnea Comments: “Nah! [ ] smoking history gapanigarilyo Oftentimes mana siya -giubo[x] cough pd siya karon oh.’ [x] sputum As verbalized by[ ] denied the wife
Respiratory: [x] regular [ ] irregularDescribe: regular breathing but associated with
pain
Right: Right lung is symmetrical to left lung. Left: Left lung is symmetrical to right lung.
CIRCULATION:[ ] chest pain Comments: “Sakit! [x] leg pain bug-at… [x] numbness of extremities nanghubag na [ ] denied man gni ako mga tiil” As verbalized by the patient
Heart Rhythm [x]regular [ ] irregularAnkle Edema: present in lower extremitiesPulse Carotid Radial DP FemoralRight: 62 65 60 not assessedLeft: 62 65 60 not assessed
Comments: Pulse sites are palpable and its rate are within normal range.
NUTRITION:Diet: DAT but decreased fluid intake[ ] N [ ] V Comments: “Wala Character man…perma- [ ] recent charge nente nay gana” in weight, appetite As verbalized [ ] swallowing by the patient Difficulty [x] denied
[ ] dentures [x] none
Full Partial With PatientUpper [√] [ ] [ ]
Lower [√] [ ] [ ]
ELIMINATION:Usual bowel pattern [ ] urinary frequency Once a day once daily [ ] constipation [ ] urgency Remedy [x] dysuria [ ] hematuria January 27, 2009 [ ] incontinence Date of last BM [ ] polyuria
[ ] diarrhea character [ ] foly in place [ ] denied
Comments: urinate once Bowel Sounds: daily due to pain Audible sounds and excrete small Abdominal Distention: amount. Present [ ] Yes [x] No Urine (color, consistency, odor) tea color of urine, inconsistent
MANAGEMENT OF HEALTH & ILLNESS:[x] alcohol [ ] denied (amount, frequency) Occasionally – once in 2 months
[ ] SBE Last Pap Smear: N/A LMP:
Briefly describe the patient’s ability to follow treatments (diet, meds, etc.) for chronic health problems (if present):
The patient is properly following her medications
SUBJECTIVE OBJECTIVE SKIN INTEGRITY:[ ] dry Comments: “ wala man [ ] itching - nanghupong[x] other - edematous lang ko” as [ ] denied verbalized by the Patient.
[ ] dry [x] cold [ ] pale[ ] flushed [ ] warm [ ] moist [ ] cyanotic
* rashes, ulcers, decubitus (describe size, location, drainage): No presence of any ulcers, decubitus or rashes.
ACTIVITY/SAFETY:[ ] convulsions Comments: “ dili man[ ] dizziness hinuon, bug-at lang [ ] limited motion of joints gyud ako tiil Kay nanghupong Naman – kaya Limitation in man hinuon nako.” ability to as verbalized by the[ ] ambulate patient [ ] bathe self[ ] other[x] denied
[ ] LOC and orientation: Oriented to time and space Gait: [ ] walker [ ] cane [ ] other
[x] steady [ ] unsteady[ ] sensory and motor losses in face or extremities None
[ ] ROM limitations: patient can performed range of motion
COMFORT/SLEEP/AWAKE:[ ] pain Comments: “ok (location, raman hinuon” Frequency, As verbalized Remedies) by the patient.[ ] nocturia [ ] sleep difficulties[x] denied
[ ] facial grimaces[ ] guarding[ ] other signs of pain Edema on both extremities
[ ] siderail release form signed (60 + years) None
COPING:Occupation : Farmer Members of household: 6Most supportive person: Wife
Observed non-verbal behavior None
The person and his phone number that can be reached any time
SPECIAL PATIENT INFORMATION_______________ Daily weight _______________ PT/OT ________________________________ BP q shift _______________ Irradiation _______________ Neuro VS ______________ Urine test ______________________________ CVP/SG. Reading ________ ______________ 24 hour urine collection
Date Ordered
Diagnostic/laboratory exams
Date done Date ordered
I.V. Fluids/Blood
Date disc.
01/27/09 CBC 01/27/09 01/27/09 0.9 Nacl iL @ KVO rate
VII. NURSING MANAGEMENT
A. Ideal Nursing Management
Nursing Diagnosis:
Excessive fluid volume related to glomerulonephritis
INTERVENTIONS RATIONALE
Monitor intake and output To check fluid balance and prevent dehydration
Observe for fever To check for infection since the patient has a greater risk
Elevate edematous extremities, change position frequently To reduce tissue pressure and risk of skin breakdown
After elevating, place in semi-fowlers position To facilitate movement of diaphragm, thus improving respiratory effort
Provide quiet environment To promote ventilation and limits external stimuli
Administer furosemide I amp of 12h as prescribed by the
physician
For the treatment for edema
Nursing Diagnosis:
Ineffective airway clearance related to productive cough
INTERVENTIONS RATIONALE
Assess the airway patency To check the effectivity of the airway & to plan for further
management
Elevate the head part of the bed/change position q 2h To enhance drainage of/ventilation to different lung
segments
Encourage deep-breathing and coughing exercise To mobilize secretions
Monitored the fluid intake To help liquefy secretions and not to severe the edema
Instruct to have proper clothing, not too tight and not too
loose
To provide warm body/environment
Nursing Diagnosis:
Acute pain related to edema
INTERVENTIONS RATIONALE
Monitor vital signs Because vital signs are altered in acute pain experienced
Acknowledge patient’s verbalization of pain & allow him to describe it
Pain is subjective experience of a person that no other one can felt about it
Perform pain assessment each time occurs To rule out worsening of underlying condition/developing complication
Elevate edematous extremities, change position frequently To reduce tissue pressure and risk of skin breakdown
Provide quiet environment To promote ventilation and limits external stimuli
Administer Spironolactone 50mg itab TID P.O. as prescribed by the physician
For the treatment for edema
B. Actual Nursing Management
S “Bug-at lang akong tiil kay nanghupong naman ko.”As verbalized by the patient
O
Edema Oliguria Restlessness
A Fluid volume excess related to Glomerulonephritis
P
Long term: At the end of 2 days, pt. will be able to lessen or diminished the symptoms of glomerulonephritis that produces excessive fluid.
Short term: At the end of 8 hours, the pt. will be able to reduce the excessive fluid volume.
I
1) Monitor vital signs especially temperature To check & assess for infection since the pt. has a higher
risk2) Monitor intake & output
To monitor & check fluid volume & prevent dehydration3) Elevate the edematous extremities
To reduce tissue pressure & risk in skin breakdown4) Place in a semi-fowlers position, change position frequently
To facilitate movement of diaphragm & improve respiratory effort
5) Administer furosemide 1 ampule every 12h as prescribed by the physician
For the treatment of edema
E At the end of 8 hrs, the pt reduces the excess fluid in his body thru excretion of stored fluids.
HEALTH TEACHINGS
Name of Patient: Gloria Yabo
MEDICATIONSEncourage to follow the dosages and proper timing of his meds. Such as the Furosemide 1 ampule every 12hours x 3doses, Omeprazole 20mg 1capsule once a day, Captopril 25mg 1tablet twice a day, & Spironolactone 50mg 1 tablet thrice a day. As prescribed by his physician.
EXERCISEEncourage bed rest and frequent changes of position, early ambulation, and deep breathing exercise.
TREATMENT
Encourage/instruct to keep the edematous extremities to elevate as often; limit of water intake; monitor intake and output; provide warm environment; provide egg white a day; weight the pt. daily, at the same time.
OUT-PATIENT(Check-up)
Encourage pt. that when his discharged, he must have a regular check-up to his physician until it’s needed. To evaluate the progress of his condition.
DIETInstruct to limit intake of salty & fatty foodsand enrich/increase the intake of foods rich in potassium such as bananas…
VIII. REFERRALS AND FOLLOW-UP
Since the patient is suffering from Acute Glomerulonephritis, it is advised for him
to stay in the hospital for a better and thorough management regarding on her condition.
Acute Glomerulonephritis are very critical in a man’s condition that is why the patient
needs an urgent hospital service for him to be monitored every now and then.
If the doctor has already approved the release or discharge of the patient from the
hospital, the patient is highly advised to have a regular check-up on her personal
physician to take out the risk from the said ailment.
If the patient will again suffer the Acute Glomerulonephritis, it is best for him to
be admitted to a tertiary-leveled hospital for better monitoring of his critical condition,
knowing that even a single mistake worsen his condition.
IX. EVALUATION AND IMPLICATIONS
After conducting this care study, I was able to appreciate more the
essence of utilizing the nursing process in the care and management of my
patient. It was indeed a tough job on conducting this study yet, it gave me a
big impact regarding how useful it is in my chosen profession. Nursing really
demands a tender loving care attitude. It demands patience and it is calling
that cannot be merely taken for granted.
Moreover, this care study taught us to stand on our own by not depending
on others just to make this. This provides us, the students, a big learning
regarding on how well we take care of or patients in the real clinical setting.
Most of all, this study teaches the students to provide clients care more
efficiently and competently to achieve an effective and quality nursing care.
X. BIBLIOGRAPHY
Doenges, Marilyn E. et.al Nurses Pocket Guide: Diagnoses, Interventions and Rationale. 9th edition pages 278-279, 472-477, 576-578 F. A Davis Company Philadelphia, 2004.
Lippincott Williams & Wilkins, Manual of Nursing Practice, 8th edition, volume 1.
Deglin, et al. Davis’s Drug Guide for nurses, 9th edition.
Smeltzer, Suzanne C. et al. Textbook of Medical-Surgical Nursing, 11th edition, volume 2.