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COLEGIO de DAGUPAN

College of Nursing

ACUTE GLOMERULONEPHRITIS

Grand Case Presentation

Submitted to:

Sir Renee Jesee Lopez, RN

Blessed Family Doctors' Hospital,

San Carlos City

General Ward

Submitted by:

Albay, MichaelaBugayong, John lorence

Casingal, Mary Joy

De Francia, Sheryllyne Anne

Ellamil, ArleneRemegio, Rhea

BSN-III Block-I

October 17, 2012


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ACUTE

GLOMERULARNEPHRITIS

BY: IIIBSN/ Block 1


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Table of Contents

I. Statement of ObjectivesII. Clients ProfileIII. Chief complaintIV. Present History of IllnessV. Past History of IllnessVI. Family Health HistoryVII. Developmental HistoryVIII. Social & Environmental HistoryIX. Lifestyle and Health PracticesX. Health AssessmentXI. DiagnosticsXII. Anatomy and PhysiologyXIII. Comprehensive PathophysiologyXIV. Treatment/ ManagementXV. Nursing Care Plan ( NCP)XVI. List of References


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Statement of Objectives

I. Statement of Objectives

A. General Objectives

This case analysis aims to increase the understanding and knowledge of student nurses on how to care for

patients with Acute glomerularnephrtis( AGN) effectively and efficiently.

B. Specific Objectives

Specifically, this case analysis aims to:

1. DefineAcute glomerularnephrtisand its effects to the body as a whole;2. Illustrate the pathophysiology ofacute glomerularnephrtisand in relation to the signs and symptoms specifically

observed in the client;

3. Describe and identify the common signs and symptoms ofacute glomerularnephrtis

4. Discuss the medical and surgical interventions for the management ofacute glomerularnephrtis

5. Formulate appropriate nursing care plans suited for the client based on the assessment findings;

6. Identify care measures to be given to the patient and family to promote continuity of care and

independence after discharge.


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II. Patient's Profile

Name: XXX

Address:San Carlos City, Pangasinan

Age:9 years old

Gender:Male

Religion:Roman Catholic

Civil Status: Single

Nationality:Filipino

Date of Birth: March 15, 2003

Date of Admission:July 10, 2012

Ward and Room: Pedia Ward

Admitting Diagnosis:Acute Glomerulonephritis

Attending Physician: Dr. . MVG


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III. Chief Complaint

Chief Complaint:Preorbital edema on both right and left

eye


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IV. Present History of Illness

Present Health History

Chief complaint:

The patient had complaint ofFatigue, less urine outputand

Coughing even Edema.


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V. Past History of Illness

Past History of Illness

The client had no history of accidents and or trauma, only minor illnesses, such as cough, and edema (

periorbital) The client however, was admitted inElguira Hospital, San Carlos, due to the same problem and it was

the first time he was diagnosed to have Acute Glomerularnephritis.

He also verbalized that he did not have known allergies for foods or medications.


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VI. Family Health History

Family Health History

Health problems such as Asthma, kidney diseases, diabetes, or mental illness were verbalized to be

absent. No present illness is currently experienced by any member of the family.


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VII. Developmental History

Cognitive/Mental Status

He is very responsive upon interaction. He is well oriented about the time, date and place where he is

right now.

Emotional Status

Pt. X has a good support by his family especially with his mother. His mother supervised all his need. He

states that he is very blessed and happy because he had his family.

State of Mobility

Pt. X stays mostly on bed, and could only walks when he is going to the bathroom.

Perception and Coordination Status

All of his senses were functioning. He is very responsive and coherent upon interaction.


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VIII. Social and Environmental History

Social Status

Pt. X is male, 9 y.o currently residing at San Carlos. She is Roman Catholic in faith.In the ward, his mother

accompanied him. He is approachable whenever he is called for attention.


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IX. Lifestyle and Health Practices

Nutritional Status

Before Hospitalization Pt. X usually prefers to eat meat especially process meats. He eats 3x a day but

sometimes skip meals. He also loves to eat junk foods and also spicy and sour foods. During Hospitalization

He was on soft diet due to his condition.

Rest and Sleep Patterns

Before Hospitalization he usually sleeps 6-8 hr around 10pm-6am and could have a naps and rest at

daytimes. During Hospitalization As of now she sleeps for only 4-6hrs with intervals and could still have naps

and rest at daytimes.

Elimination Pattern

Before Hospitalization he usually defecates once or twice a day and urinates 3-5 times a day.

During Hospitalization As of now he defecates once a day and urinates 2-3 times a day.


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X. Health Assessment

Head- to- Toe Assessment

EyeSwelling of eyelinds: SwollenDischarge: No

Color of sclera/conjunctiva: White/Pink

Corneal/lens/reaction to light: YesEye movement: Both eyes move togetherwhile following the object

Vision problem: No

EarAppearance: Top ofthe pinna meets the eye occiput line

Discharge/Pain: No discharge or pain

Wax/redness of external auditory canalsHearing problems: No

Nose

Discharge: No

Blockage: No

Bleeding: NoSeptal defect: No septal defect, located centrally

Problemwith smelling: No

MouthColor of lips/mucous membrane: Pink, moist mucous membrane

Sores/cracks/swelling/bleeding pain of gums, tongue: No

Dental carries/missing teeth, denture: White teeth, no carries and missing teeth.Cracks lips: No

Enlargementof tonsils: Small tonsils

Oral hygiene: Good

Inspect neck forMobility: Full and smooth range of movement, no stiffness or tenderness

Palpate neck forEnlarged lymph nodes: No

Enlarged thyroid gland: No

Enlarged neck veins: No


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Examination of Chest

Inspect chest for

Shape of the chest: Normal

Equal movement of chest during breathing: Yes

Difficulty in breathing: No any difficulty, respiration was normal and regularChest percussion: Deep resonant sound over the lungs

Auscultate the chest for

Breathing sounds (front and black): Breath sounds are heard in all areas ofthelungs

Heart sounds (4 areas): Clear and regular heart beats, no heart murmur

Examination of Abdomen

Inspect abdomen for

Shape: Rounded or uniform shape, scar waspresent

Enlarged veins: No

Auscultate for

Bowels sound: Bowel sound is present in all areas

Abdominal percussion: Tympanic and dullness

Palpate the abdominal for

Enlarged liver: No

Enlarged spleen: NoTenderness: No

Masses: No

Examination of Limbs

Inspect/Palpate limbs for

Joint mobility/tenderness/redness/swelling: Good joint mobility and edema of legs and of the hand

skin: Dryness

Color of nails: Pinkish

Palpate maxillae/groins for

Enlarged lymph nodes: Absent

Examination of BackInspect back for

Position of spine/movement: Spine is in the midlineCondition of skin/prone to bedsore: No


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Diagnostics


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XI. Diagnostics

Laboratory/Diagnostic Test

Diagnostic

Procedure

Description of the

Procedure

Significance/Purpose

of the Procedure

Date of

Procedure

Findings and Implication

Urinalysis It is used as a screening

and/or diagnostic tool

because it can help detect

substances or cellular

material in the urine

associated with different

metabolic and kidney

disorders.

It is used to determine

or detect glucose,

protein and occult

blood. Patient with

AGN have an active

urinary sediment so it

means that sign of

active kidney

inflammation can be

detected when the urine

is examined under the

microscope.

July 11, 2012 Color: coca- cola like

Due to hematuriaTransparency: Turbid

due to the increased sedimentsSpecific Gravity: 1.031

Due to decrease urine output.Glucose: +1

Protein: +2

Glycosuria and proteinuriadue to increased glomerular

permeability.

RBC: + NTC

Hematuria due to damage oglomerulus.

Hematology

test

Concerned with the study

of blood, the blood-

forming organs, and blood

Blood is the transport

medium in the body so

any toxin or antibodies

July 11, 2012 RBC: 3.62x10 /ul

Possibly due to hematuria.Hgb: 9.20g/dL

Due to decrease of RBCproduction.


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diseases. will be found in it. Hct: 26.7%

Due to decrease of RBCproduction.

Serum Blood Glucose: 60 mg/dL

Due to glycosuriaSerum Albumin: 2.1 g/dL

due to proteinuria

Blood Urea

Nitrogen

BUN test is primarily,

along with the creatinine

test, to evaluate kidney

function in a wide range of

circumstances, to help

diagnose kidney disease.

It is used to monitor

kidney function.

July 11, 2012 BUN: 28mg/dL

Increased BUN level suggests

impaired kidney function. Urea

Nitrogen is waste product that is

excreted by your cell when they break

down protein. The kidneys are design t

filter this waste product out of blood an

pass into the urine. So, if the kidneys ar

not working properly, this blood test

will be high.


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Serum

Creatinine

Serum creatinine test is

performed to measure the

level of the waste product

creatinine in a persons

blood.

It used to assess the

function of the kidneys.

July 11, 2012 Serum Creatinine: 1.4 mg/dL

The kidneys filter the blood and

throw creatinine out of the body throug

urine. If the kidneys fail to do so

effectively due to some kidney disease

(particularly AGN), the creatinine level

in the urine decreases and that in blood

increases.

Ultrasound Is a high- frequency sound

waves to look at organs

and structures inside the

body.

It used to view the

kidneys.

July 11, 2012 KUB

The right kidney measures 8.0x 3.4 x

2.7 3.9cm with cortical thickness of

10cm, both kidneys have increase

parenchymal ethonegenecity. There is

poor corticomedullary delineation, no

evident mass, lithiasis and

hydronephrosis.

The urinary bladder is distended

without wall thickening or intravesical

echoes.

Interpretation: Bilateral renal

Parenchymal Disease. Unremarkable

Urinary Bladder.


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XII. Anatomy and Physiology

The Urinary System

The urinary system consists of all the organs involved in the formation and release of

urine. It includes the kidneys, ureters, bladderand urethra.

Thekidneysare large, bean-shaped organs towards the back of the abdomen (belly).o They help us get rid of waste products by making urine and excreting it from the bodyo The kidneys also produce

reninand

erythropoietin

The bladder is a pyramid-shaped organ.o The main function of the bladder is to store urineo the bladder can hold up to 500 mL of urine

Urethra

The male urethra is 1820 cm long, running from the bladder to the tip of the penis.Nephrons

A nephron is the basic structural and functional unit of the kidney.o Its chief function is to regulate water and soluble substances by filtering the blood, reabsorbing

what is needed and excreting the rest as urine.

o
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Glomerulus

The glomerulus is a capillary tuft that receives its blood supply from an afferent arteriole of the renalcirculation.

Glomerular Capsule or Bowman's capsule

Bowman's capsule (also called the glomerular capsule) surrounds the glomerulus and is composed ofvisceral and parietal layers.

o Measuring the glomerular filtration rate (GFR) is a diagnostic test of kidney function. Adecreased GFR may be a sign of renal failure.

FUNCTION OF URINARY SYSTEM

is the process of excretion Regulating the concentrations of various electrolytes in the body fluids and maintaining

normal pH of the blood.

Six important roles of the kidneys are:

Regulation of plasma ionic composition. Regulation of plasma osmolarity. Regulation of plasma volume. Regulation of plasma hydrogen ion concentration (pH). Removal of metabolic waste products and foreign substances from the plasma.


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THE RENIN ANGIOTENSIN MECHANISM

Decreased blood pressure stimulates the kidney to stimulates the kidney to secrete renin. Renin splits the plasma protein angiotensinogen (synthesized by the liver) to angiotensin I. Angiotensin I is converted to angiotensin II by an enzyme (called converting enzyme secreted by the

lung tissue and vascular endothelium.

Angiotensin II : causes vasoconstriction, stimulates the adrenal cortex to secrete aldosterone whichmaintains normal blood, levels of sodium and potassium and contributes to the maintenance of normal

blood pH, blood volume, and blood pressure.


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XIII. Comprehensive Pathophysiology

Predisposing Factors:

Age: 9 yrs. Old B- hemolytic Streptococci

Poor Hygiene

Streptococci Infection

M .o circulate in the bloodstream

Deposition of antigen- antibody complex glomerulus

Acute inflammation & damage within the nephrons including glomerulus

Proliferation of the endothelial cell lining of the glomerular capillary Hematuria

Leukocytes infiltration of the glomerulus RBC

HgbThickening of the glomerular filtrationmembraneHct

Renal Blood FlowGlumerular GFR

Permeability Oliguria Activation of

BUN, RAAS

Proteinuria Glycosuria s. CreatineStimulation of JGCUSG to release reninHypoalbuminuria Bld. Glucose Renin stimulate liverangiotensine

Colloidal oncotic Pressure Hypoglycemia Angiotensine I

Fluid shift Weakness BP Vasoconstriction ACEAngiotensine II

Edema

Edema Na & H2O retention aldosterone secretion stimulation of adrenal cortex


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Treatment / Management


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XIV. Treatment / Management

MEDICATIONS

Explain to the patient and family members the importance of

taking medicines.

Discuss to the patient and family the dosage, frequency and adverse effects ofthe drugs.

Encourage to follow the dosages and proper timing of his meds. Such as the:

Furosemide 1 ampule every 12hours x3doses,

Pen G (Drug of Choice) 500mg once a day,

Captopril25mg 1tablet twice a day,

Spironolactone 50mg 1tabletthrice a day.

As prescribed by his physician.

Economic status

Inform the patient to avail to some government programs such as Phil health.

Treatment

Tell the patient that she should have self-monitoring by checking his vital signsand weighing regularly.

Encourage/instruct to keep the edematous extremities toelevate as often

Limit of water intake; monitor intake andoutput

Provide warm environment

Weight the pt. daily, at the same time.


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HEALTH TEACHINGS

Instruct the patient to take medications religiously

Improve nutritional status.

Importance of proper hygiene for comfort.

OUT-PATIENT

The patient could avail his medication from government hospitals that he couldget some benefits.

He will also be able to avail the services offered by the barangay health centerand and

at the Botikang barangay.

Instruct patient to seek regular medical check-up


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Fluid Volume Excess

Assessment Diagnosis Planning Intervention Rationale Evaluatio

ubjective:

Angsakitnghitako as

manifested by the

atient.

bjective:

Swelling

Pain

Acute pain related

to inflammation

and edema as

manifested by

guarding

behavior and pain

scale of 7/10.

Short Term:

: After 2-4 hours of

providing

appropriate nursing

interventions, the

patient

willexperience

decreased

perception of pain

as manifested by

decreased

restlessness, patient

will bemore relaxed,

decreased pain scale

will be assessed and

patient will verbalize

decreased perceptionof

pain.

Independent:

AssessVital signs: BP,

PR, RR and T.

NoteComplaints

associated with

pain and edema

edema.

Assistclient and family to

cope with the

situation.

Provideand

Encourage

frequent skin

hygiene.

Dependent:

AdministerIV fluids and

meds.as prescribed.

ObtainBaseline for comparison

that help to identify the

underlying cause &

monitor progress.

ToKeep skin dry and clean to

avoid irritation.

Medication todecrease pain and IV fluids

for maintaining good

nutrition of the patient.

After performi

intervention fo

days for client:

HadVital signs nea

normal levels,

more longer

complaints of p

and edema.


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Long Term:

After 6-

8 days of pro

viding approp

r iate nurs ing

intervent ions ,

the pat ient s i

nflammation and

edema will decrease.

Imbalanced Nutrition: Less than Body Requirement

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Imbalanced

Nutrition: less

Short Term: Assess nutritional

status:

After performing

interventions for


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Masyadoatangk

akauntiangmgapi

napakainsaanakk

o as verbalized

by the father.

Objective:

UA: Protein = +2

Glucose = +1

than body

requirements

related to

increased

glomerular

permeability as

evidenced by

proteinuria.

After 2 days of

intervention, the

client will:

ComplyWith dietary

restrictions

HaveIncreased energy

levels and

appetite.

PreventProtein

deficiency.

Assess bodyWeight, lab values

(serum creatinine,

BUN and protein).

PromoteLow Sodium, low

potassium, high calorie

and protein restricted.

AdviseFamily members to

remove water, food or

drinks from bedside.

Assist client and family to

cope with the discomfort

caused by restrictions in

the diet.

Monitor and clients

progress:

ObtainBaseline for comparison

that help to identify the

underlying cause &

monitor progress.

To decreaseThe kidney's workload and

to minimize or prevent

retention of fluids that leads

to swelling.

PreventsDeviation from prescribed

diet.

UnderstandingAnd comfort promotes

compliance and increases

appetite.

days, the client:

HaveObservably

increased energy

levels.

ReporteIncreased appetit

Reporteno signs of

Progression of

edema.


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Weighpatient daily.

Collaborative:

Coordinate with other

health care personnel

(nutritionist, physician)

To EvaluateProgress or

effectivenessof the diet.

XVII. List of References

1. Brunner &Suddarths Textbook of Medical surgical Nursing 12th e2. Your kidneys and how they work. National Kidney and Urologic Diseases

Information Clearinghouse.


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http://kidney.niddk.nih.gov/kudiseases/pubs/yourkidneys/index.htm#rate.

Accessed Feb. 3, 2011.3. Glomerulonephritis. National Kidney Foundation.

http://www.kidney.org/atoz/content/glomerul.cfm. Accessed Feb. 3, 2011.

4. Glomerular diseases. National Kidney and Urologic Diseases InformationClearinghouse. http://kidney.niddk.nih.gov/kudiseases/pubs/glomerular/.

Accessed Feb. 3, 2011.5. Glomerular diseases. In: Kumar V, et al. Robbins and Cotran Pathologic

Basis of Disease. 8th ed. Philadelphia, Pa.: Saunders Elsevier, 2010.http://www.mdconsult.com/books/page.do?eid=4-u1.0-B978-1-4377-0792-

2..50025-0--cesec6&isbn=978-1-4377-0792-

2&type=bookPage&sectionEid=4-u1.0-B978-1-4377-0792-2..50025-0--cesec6&uniqId=234806001-3. Accessed Feb. 3, 2011.

6. Rose BD, et al. Differential diagnosis of glomerular disease.http://www.uptodate.com/index. Accessed Feb. 3, 2011.

7. Lau KK, et al. Glomerulonephritis. Adolescent Medicine Clinics.2005;16:67.

8. "glomerulonephritis" atDorland's Medical Dictionary9. Dr. Zaid G. Nguyen MD. University of Melbourne, Dept of Medicine10.http://www.nlm.nih.gov/medlineplus/ency/article/000472.htm11.Robbin's Pathology12.Couser WG (May 1999). "Glomerulonephritis".Lancet353 (9163): 150915.

doi:10.1016/S0140-6736(98)06195-9. PMID10232333.
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