I.

INTRODUCTION

Acute glomerulonephritis 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.
Acute nephritic syndrome is a group of disorders that cause inflammation of the internal
kidney structures (specifically, the glomeruli). In acute glomerulonephritis, the kidneys
are normal in size or enlarged and edematous, and the surface of the kidney may show
punctate hemorrhages. With the development of the microscope, Langhans was later
able to describe these pathophysiologic glomerular changes.

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. As will be discussed, acute
glomerulonephritis can be due to a primary renal or systemic disease.

Symptoms of acute glomerulonephritis include the following:Hematuria is a

universal finding, even if it is microscopic. Gross hematuria is reported in 30% of
pediatric patients. Edema (peripheral or periorbital) is reported in approximately 85% of
pediatric patients; edema may be mild (involving only the face) to severe, bordering on
a nephrotic appearance.Headache may occur secondary to hypertension; confusion
secondary to malignant hypertension may be seen in as many as 5% of
patients.Shortness of breath or dyspnea on exertion secondary toheart failure or
pulmonary edema; usually uncommon, particularly in children.Possible flank pain
secondary to stretching of the renal capsule. Hypertension is seen in as many as 80%
of affected patients. Hematuria, either macroscopic (gross) or microscopic, may be
noted. Skin rashes (ie, malar rash frequently seen with lupus nephritis) may be
observed. Abnormal neurologic examination or altered level of consciousness occurring
because of malignant hypertension or hypertensive encephalopathy. Arthritis may be
noted.

The most common cause is postinfectious Streptococcus species (ie, group A,

beta-hemolytic). Two types have been described as (1) attributed to serotype 12,
poststreptococcal nephritis due to an upper respiratory infection occurring primarily in
the winter months, and (2) attributed to serotype 49, poststreptococcal nephritis due to a
skin infection usually observed in the summer and fall and more prevalent in southern
regions of the United States.

With some exceptions, a reduction in the incidence of poststreptococcal

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. In Port Harcourt, Nigeria, the incidence of acute
glomerulonephritis in children aged 3-16 years was 15.5 cases per year, with a male-to-
female ratio of 1.1:1; the current incidence has not changed much over the past 14
years.(http://emedicine.medscape.com/article/777272-overview; http://www.total-health-
care.com/illness/acute-glomerulonephritis.htm)

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 affected age
group, pediatric patients, has been reported at 0-7%. A male-to-female ratio of 2:1 has
been reported. 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.
 On the other hand, a urinary tract infection (UTI) is a bacterial infection that
affects any part of the urinary tract. The main etiologic agent is Escherichia coli.
Although urine contains a variety of fluids, salts, and waste products, it does not usually
have bacteria in it.[1] When bacteria gets into the bladder or kidney and multiply in the
urine, they may cause a UTI.

Infections of the urinary tract are the second most common type of infection in
the body. Urinary tract infections (UTIs) account for about 8.3 million doctor visits each
year. Women are especially prone to UTIs for reasons that are not yet well understood.
One woman in five develops a UTI during her lifetime. UTIs in men are not as common
as in women but can be very serious when they do occur.

The most common type of UTI is acute cystitis often referred to as a bladder
infection. An infection of the upper urinary tract or kidney is known aspyelonephritis, and
is potentially more serious. Although they cause discomfort, urinary tract infections can
usually be easily treated with a short course of antibiotics. Symptoms include frequent
feeling and/or need to urinate, pain during urination, and cloudy urine.

UTIs in men are often a result of an obstruction—for example, a urinary stone or

enlarged prostate—or from a medical procedure involving a catheter. The first step is to
identify the infecting organism and the drugs to which it is sensitive. Usually, doctors
recommend lengthier therapy in men than in women, in part to prevent infections of the
prostate gland.

As a group, we decided to study this kind of disease for us to know more about
the complications. As a nursing students, we must not only focus to one corner or
merely by just taking care of our patients but to know their underlying condition as well
for the better and good nursing intervention done to promote maximum living ability.

Furthermore, we have chosen this case study in order to identify and determine
the general health problems and needs of the patient with an admitting diagnosis of
acute glomerulonephritis. This study also intends to help patient as well as its significant
others to promote health and medical understanding of such condition through the
application of the nursing theories and nursing skills.
II. Clients Profile

A. Socio-demographic data

Patient X is a 13 year old male, Roman Catholic; a resident of Esperanza

Agusan del Sur. Patient X was admitted for the first time at Northern Mindanao Medical
Center on July 31, 2010 at 5:30 pm. due to facial edema. He arrived at the hospital
awake, conscious and coherent with a chief complaint of facial edema.

B. Vital Signs

The patient’s vital signs are essential because it provides a baseline data in
determining alteration in the patient’s body that may suggest underlying disease. Any
changes from the normal are considered to be an indication of the person’s state of
health and provide cues to the physiological functioning of the client.
The patient had the following vital signs: blood pressure: 100/70 mmHg, pulse
rate: 104 bpm, respiratory rate: 32 cpm, temperature: 36.9ºC. He currently weighs 35
kilograms from the previous weight of 32 kilograms and he is 4’6 tall.

C. Health Patterns Assessment

1. History of Present Illness

The client was brought to the hospital due to anemia anasarca. Six
months prior to admission, onset of edema with no other associated
symptoms noted.

Three months prior to admission, persistence of facial edema

associated with pallor.

A month prior to admission, enlarging abdomen and pallor and

decreased urine output (1 time per day) was noted which prompted patient
to seek medical consultation.

Patient has no previous hospitalization and surgeries. Client has no

family history of kidney-related diseases. Patient X was not taking any
medication. He’s a non tobacco user and a non alcoholic drinker. He has
no known food and drug allergies. Patient X has an abdominal girth 77cm
and weighs 35 kg.

2. Nutrition
 During pre-hospitalization, the client used to eat junk foods which
are high sodium and almost always eat “guinamos” as their viand.

During hospitalization, Patient X was on a low salt, low fat diet. He

consumed whole share with good appetite. The client seldom drinks water
and was not taking in any vitamins. The client is not hooked in any
intravenous fluid.

3. Elimination Pattern

Pre-hospitalization, Patient X defecates once to twice daily with

formed, brownish stool and soft in consistency. No discomfort felt during
defecation but during hospitalization, the client has difficulty in defecating,
thus, making him at risk to have constipation. While confined, the client
defecates after 2-3 days.

Pre-hospitalization, a month before the admission to the hospital,

client has difficulty urinating thus, decreasing the urinary frequency from 6-
8 times to 1 time per day. It’s yellowish in color and clear.

4. Activity -Exercise Pattern (pre – hospitalization)

Patient X is incorporating his exercise when walking going to school

every morning and he’s going home from the school. Playing is his leisure
activity together with few of his friends but mostly, he loves to play with his
other siblings.

A. Activity-Exercise Pattern (while confined)

Describe the patient’s functional abilities

a. Feeding: independent

b. Bathing: independent

c. Toileting: independent

d. Bed mobility: independent

e. Dressing: independent

f. Grooming: dependent
 g. General mobility: independent

h. ROM: independent

i. Ambulation: independent

The patient can do independently all activity- exercise but then, it is

limited and controlled due to disease condition and client prefer to stay in
the bed than ambulating. Toileting was done in the bedside only like
urinating except defecating and don’t take a bath during hospitalization
rather, his mother cleans wipe out dirt in the body which made him
dependent in Grooming.

5. Cognitive-Perceptual Pattern

Patient X understands and speaks Visayan language and he didn’t

have any speech deficit. Patient is an elementary student without any
learning difficulties. There is pain felt in the right costovertebral angle and
patient usually guards the location of pain.

6. Sleep -Rest Pattern

Pre-hospitalization, Patient X usually sleeps for 11 hours. He

doesn’t have any sleep disturbances but while confine, he verbalized
problem of sleeping disturbances at night. Imagery is one of the effective
tool for him in order to sleep at night.

7. Self-perception and Self-concept Pattern

Patient X says that he is handsome and he is a good as well as

responsible student because he usually gets an award after each school
year. He feels that he was weak and fear to be behind in their classroom
lessons and scared not to get an award this school year due to the series
of absences because of his hospitalization.
 8. Role-Relationship Pattern

His family specifically his mother and grandmother who helped him
during hospitalization. His father and other members in the family ar not
around because they can’t visit for they are very far from the city thus, it
requires money in order for them to visit at the hospital. Other than that,
Philhealth is also their financial support system.

9. Coping -stress Tolerance Pattern

Patient X seldom experience any stress, but whenever he has, he

subject his self in sleeping.

10. Value -Belief Pattern

Patient X is a Roman Catholic. To him it is important as it had

helped him when he has a problem. He goes to church 3 times a month
because the church is far away from their home and they nees to spent a
lot of time walking because they have financial constraints as well. The
client also prays frequently as part of his religious practices.

D. Physical Assessment

1. Neurologic Assessment

Level of consciousness Conscious

Orientation Oriented
Emotional state Worried/anxious (sometimes); restless
(sometimes)

2. Head

Head Normocephalic
Facial movement Symmetrical
Fontanels Closed
Hair Fine
Scalp Clean

3. Eyes

Lids Symmetrical
Periorbital region Edema
Conjunctiva Pale
Cornea & lens Opacity R/L
Sclera Anicteric
Pupils Equal in size
Reaction to l ight Brisk R/L
Reaction to accommodation Uinform to constriction
Visual acuity Grossly normal
Peripheral vision Intact/full

4. Ears

External pinnae Normoset

External canal No discharge
Tympanic membrane Intact
Gross hearing normal

5. Nose

Mucosa Pinkish
Patency Both patent
Gross smell Normal/symmetrical
Sinuses No tenderness presence

6. Mouth
Lips Pallor
Mucosa Pinkish
Tongue Midline
Teeth Complete
Gums pinkish

7. Pharynx

Uvula Midline
Tonsils Not inflamed
Posterior pharynx No inflame presence

8. Neck

Trachea Midline
Thyroids non-palpable

9. Skin

General color Pallor

Texture Rough
Turgor Firm
Tempareture warm

10. Abdomen

Configuration Globular
Bowel sound Hypoactive (3 counts)
Percussion Tympanitic

11. Cardiovascular Status

Precordial area Flat
Point of maximal impulse(PMI) 5th intercostal
Apical & rhythm normal(108bpm)
Heart sound Regular
Peripheral pulse Symmetrical & regular but weak
Calillary refill 2 second

12. Respiratory Status

Breathing pattern Irregular (tachypneic)

Shape of chest AP2:L1
Lung expasion Symmetrical
Percussion Resonant
Breath sound Vesicular
Cough non-productive
III. ANATOMY AND PHYSIOLOGY

The Kidney

The main functional unit of the kidney is the nephron. There are approximately one
million nephrons per kidney. The role of nephrons is to make urine by:

• Filtering blood of small molecules and ions such as water, salt, glucose and other
solutes including urea. Large “macromolecules” like proteins are untouched.
 • Recycling the required quantities of useful solutes which then re-enter the
bloodstream. (A process called reabsorption)
• Allowing surplus or waste molecules/ions to flow from the tubules/ureter as urine.

Nephrons are the basic structural and functional units of the kidney. They consist
of a network of tubules and canals specialized in filtration.

The kidney is responsible for maintaining fluid balance within the body. The basic
structural and functional units of the kidneys are the nephrons. Each nephron is made of
intricately interwoven capillaries and drainage canals to filter wastes, macromolecules,
and ions from the blood to urine. The approximately 1 million nephrons in each human
kidney form 10-20 cone-shaped tissue units called renal pyramids that span both the
inner and outer portions of the kidney, the renal medulla and renal cortex.

A. Renal Vein

This has a large diameter and a thin wall. It carries blood away from the kidney
and back to the right hand side of the heart. Blood in the kidney has had all its urea
removed. Urea is produced by your liver to get rid of excess amino-acids. Blood in the
renal vein also has exactly the right amount of water and salts. This is because the
kidney gets rid of excess water and salts. The kidney is controlled by the brain. A
hormone in our blood called Anti-Diuretic Hormone (ADH for short) is used to control
exactly how much water is excreted. This blood vessel supplies blood to the kidney from
the left hand side of the heart. This blood must contain glucose and oxygen because the
kidney has to work hard producing urine. Blood in the renal artery must have sufficient
pressure or the kidney will not be able to filter the blood. Blood supplied to the kidney
contains a toxic product called urea which must be removed from the blood. It may have
too much salt and too much water. The kidney removes these excess materials; that is
its function.

B. Renal Artery
This blood vessel supplies blood to the kidney from the left hand side of the
heart. This blood must contain glucose and oxygen because the kidney has to work
hard producing urine. Blood in the renal artery must have sufficient pressure or the
kidney will not be able to filter the blood. Blood supplied to the kidney contains a toxic
product called urea which must be removed from the blood. It may have too much salt
and too much water. The kidney removes these excess materials; that are its function.

C. Pelvis
This is the region of the kidney where urine collects. If you are very unlucky, you
may develop kidney stones. Sometimes the salts in the urine crystallise in the pelvis
and form a solid mass which prevents urine from draining out of the medulla of the
kidney. You will need treatment: see your doctor.

D. Ureter
This one is easy peasy: the ureter carries the urine down to the bladder. It does
this 24 hours per day, but fortunately the urine can be stored in a bladder so that it is not
necessary to wear a nappy!

E. Medulla
The medulla is the inside part of the kidney. It is shown in green in the diagram,
but in real life it is a very dark red colour. This is where the amount of salt and water in
your urine is controlled. It consists of billions of loops of Henlé. These work very hard
pumping sodium ions. ADH makes the loops work harder to pump more sodium ions.
The result of this is that very concentrated urine is produced.The opposite of an anti-
diuretic is a "diuretic". Alcohol and tea are diuretics.
F. Cortex
The cortex is the outer part of the kidney. This is where blood is filtered. We call
this process "ultra-filtration" or "high pressure filtration" because it only works if the
blood entering the kidney in the renal artery is at high pressure. Billions of glomeruli are
found in the cortex. A glomerulus is a tiny ball of capillaries. Each glomerulus is
surrounded by a "Bowman's Capsule". Glomeruli leak. Things like red blood cells, white
blood cells, platelets and fibrinogen stay in the blood vessels. Most of the plasma leaks
out into the Bowman's capsules. This is about 160 litres of liquid every 24 hours.Most of
this liquid, which we call "ultra-filtrate" is re-absorbed in the medulla and put back into
the blood.

G. Glomerulus and Bowman's Capsule

This is where ultra-filtration takes place. Blood from the renal artery is forced into
the glomerulus under high pressure. Most of the liquid is forced out of the glomerulus
into the Bowman's capsule which surrounds it. This does not work properly in people
who have very low blood pressure. Proximal Convoluted Tubules Proximal means "near
to" and convoluted means "coiled up" so this is the coiled up tube near to the Bowman's
capsule.
This is the place where all that useful glucose is re-absorbed from the ultra-
filtrate and put back into the blood. If the glucose was not absorbed it would end up in
your urine. This happens in people who are suffering from diabetes.

H. Loop of Henlé
This part of the nephron is where water is reabsorbed. Kidney cells in this region
spend all their time pumping sodium ions. This makes the medulla very salty; you could
say that this is a region of very low water concentration. If you remember the definition
of osmosis, you will realise that water will pass from a region of high water
concentration (the ultra-filtrate and urine) into a region of low water concentration (the
medulla) through cell membranes which are semi-permeable.

I. Distal Convoluted Tubules

Distal means "distant" so it is at the other end of the nephron from the Bowman's
capsule. This is where most of the salts in the ultra-filtrate are re-absorbed.

J. Collecting Duct
Collecting ducts run through the medulla and are surrounded by loops of Henlé.
The liquid in the collecting ducts (ultra-filtrate) is turned into urine as water and salts are
removed from it. Although our kidneys make about 160 litres of urine every 24 hours,
we only produce about ½ litre of urine.It is called a collecting duct because it collects the
liquid produced by lots of nephrons.

Nephron Function

The blood is filtered and urine formed by the actions of the nephrons. In each
nephron, high pressure in the glomerulus pushes water and small dissolved materials
into the extravascular space of the Bowman’s capsule and into the tubule. The proximal
tubule reabsorbs water, salts, glucose, and amino acids to maintain electrolyte levels in
the body. The interstitium of, that is the tissue space surrounding, the loop of Henle
concentrates salts that will be excreted in the urine, creating a concentration gradient in
the medulla. The limbs of Henle’s loop are permeable to particular ions (descending,
water and some urea; thin ascending, general ions; medullary thick ascending –
sodium, potassium, chloride), with the cortical thick ascending limb draining into the
distal convoluted tubule. The distal tubule contains cells specialized in active transport
and maintains urine and blood pH levels, particularly through the regulation of sodium
and potassium.

Fluid then passes from the distal tubule to the collecting ducts, a tubule system that can
become permeable or impermeable to water depending on the body’s needs.
Ultrafiltration also occurs in the cortex in the cortical collecting ducts, which is regarded
by some anatomy references as not being a portion of the nephron, and by others as
being the final portion of the nephron. The urine then passes from the collecting ducts
through the drainage system of the kidney to the ureters and bladder for urination.

Tubular Secretion in the Kidneys

Another, less familiar, mechanism for urine production in the kidneys is tubular
secretion. Specialised cells move solutes directly from the blood into the tubular fluid.
For example, hydrogen and potassium ions are secreted directly into the tubular fluid.
This process is “coupled” or balanced by the re-uptake of sodium ions back into the
blood.

Tubular secretion of hydrogen ions, augmented by control of bicarbonate levels,

is important in maintaining correct blood pH. When the blood is too acidic (acidosis)
more hydrogen ions are secreted. If the blood becomes too alkaline (alkalosis),
hydrogen secretion is reduced. In maintaining blood pH within normal limits (about
7.35–7.45) the kidney can produce urine with pH as low as that of acid rain or as
alkaline as baking soda!
 The Kidney as an Endocrine Gland

In addition to its excretory and homeostatic roles, the kidneys also release two
important hormones into the blood. These are:

• Erythropoietin which acts on bone marrow to increase the production of red blood
cells
• Calcitriol which promotes the absorption of calcium from food in the intestine and
acts directly on bones to shift calcium into the bloodstream.

Finally the kidney produces the enzyme renin, an important regulator of blood
pressure.

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 which maintains normal

blood levels of sodium and potassium and contributes to the maintenance of normal
blood pH, blood volume, and blood pressure.
VIII. DISCHARGE PLANNING/ HEALTH TEACHINGS

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 of
the drugs.

• Encourage to follow the dosages and proper timing of his meds. Such as the
Furosemide 1 ampule every 12hours x3doses, Omeprazole 20mg 1capsule
once a day, Captopril25mg 1tablet twice a day, & Spironolactone 50mg 1
tabletthrice a day. As prescribed by his physician

Economic status

• Explain to significant others that the rehabilitation may be prolonged to be able

for the family to prepare financial needs

• Have occupational therapist to help re- learn everyday activities or ADL

• Inform the patient to avail to some government programs such as Philhealth.

Treatment

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

• . 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.

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 could
get some benefits.

• He will also be able to avail the services offered by the barangay health center
and and at the “Botika ng barangay”.

• Instruct patient to seek regular medical check-up

DIET

• Eat five or more servings of vegetables and fruit daily.

• Intake of fluids 8-10 glasses a day to avoid constipation and to maintain skin
turgor.

• Instruct patient to eat low fat and low sodium foods that will help not worsen her
condition that is ordered by the physician.
IX. RELATED LEARNING EXPERIENCE

We were assigned in the Reverse Isolation Ward for almost 4 weeks. We have
encountered several restraints with regards to the implementation. It was not easy that
we are dealing with our patients lives. But we did not loose hope because it’s our
responsibility to care and to address the patient’s needs.

We spent three nights of multi-tasking and time management even though we are
busy in our major subject, we tried our best to do this case study correctly and to avoid
corrections about this work but then again caring patient in reverse isolation ward is
challenging task for us because this is our first time to be exposed in this ward with
different kind of diseases that some are not easy to handle and should be closely
monitored. Moreover, some of the significant others are uncooperative but as student
nurses we are responsible in understanding their situation. Hence, it is imperative that
we should establish rapport towards them. However, it was a wonderful experience
since we have handled different patients with different disease condition which enable
us to apply our knowledge and performed some procedures in the care of our client. We
are fortunate enough, that we have our clinical instructor and our PCI who persistently
supervised us and assisted us to avoid errors.

Although, this is our 4th time to manage group case study in different setting, we are
still up for improvement especially in assessing our patient thoroughly. Also we have
acquired ourselves with regards to establish rapport with our patient to have trusting
relationship. But enjoy with other people helps you identify your strength and weakness,
and it aids in modifying what is somehow negative in our attitude. Most and for all we
thank to god for the guidance always and for giving wisdom and knowledge to do this
case study successful.
X. SOURCES:

WEB:

http://generalmedicine.suite101.com/article.cfm/the_human_kidney_structure_and_func
tion#ixzz0wIXUzTtr

http://cellstissuesmembranes.suite101.com/article.cfm/nephron_structure_and_fu
nction

http://emedicine.medscape.com/article/777272-overview;

http://www.total-health-care.com/illness/acute-glomerulonephritis.htm)

BOOKS:

Nurse’s Pocket Guide 11th edition (Diagnoses, Prioritized interventions, and

Rationales)

By:

Marilyn E. Doenges

Mary Frances Moorhouse

Alice C. Murr

Nursing 2003 Drug Handbook 23rd edition

By: Springhouse Lippincott Williams and Wilkins