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, Michaela Bugayong, John lorence Casingal, Mary Joy De Francia, Sheryllyne Anne Ellamil, Arlene Remegio, Rhea BSN-III Block-I October 17, 2012

ACUTE GLOMERULARNEPHRITIS
BY: III BSN/ Block 1

Table of Contents

I. II. III. IV. V. VI. VII. VIII. IX. X. XI. XII. XIII. XIV. XV. XVI.

Statement of Objectives Clients Profile Chief complaint Present History of Illness Past History of Illness Family Health History Developmental History Social & Environmental History Lifestyle and Health Practices Health Assessment Diagnostics Anatomy and Physiology Comprehensive Pathophysiology Treatment/ Management Nursing Care Plan ( NCP) List of References

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. Define Acute glomerularnephrtisand its effects to the body as a whole;

2. Illustrate the pathophysiology of acute glomerularnephrtisand in relation to the signs and symptoms specifically observed in the client; 3. Describe and identify the common signs and symptoms of acute glomerularnephrtis 4. Discuss the medical and surgical interventions for the management of acute 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.

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 WardandRoom: PediaWard Admitting Diagnosis: Acute Glomerulonephritis Attending Physician: Dr..MVG

III. Chief Complaint

Chief Complaint: Preorbital edema on both right and left eye

IV. Present History of Illness

Present Health History Chief complaint: The patient had complaint ofFatigue, less urine outputand Coughing even Edema.

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.

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.

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.

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.

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.

X. Health Assessment Head- to- Toe Assessment Eye Swelling of eyelinds: Swollen Discharge: No Color of sclera/conjunctiva: White/Pink Corneal/lens/reaction to light: Yes Eye movement: Both eyes move together while following the object Vision problem: No Ear Appearance: Top of the pinna meets the eye occiput line Discharge/Pain: No discharge or pain Wax/redness of external auditory canals Hearing problems: No Nose Discharge: No Blockage: No Bleeding: No Septal defect: No septal defect, located centrally Problem with smelling: No Mouth Color 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 Enlargement of tonsils: Small tonsils Oral hygiene: Good Inspect neck for Mobility: Full and smooth range of movement, no stiffness or tenderness Palpate neck for Enlarged lymph nodes: No Enlarged thyroid gland: No Enlarged neck veins: No

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 regular Chest percussion: Deep resonant sound over the lungs Auscultate the chest for Breathing sounds (front and black): Breath sounds are heard in all areas of thelungs Heart sounds (4 areas): Clear and regular heart beats, no heart murmur Examination of Abdomen Inspect abdomen for Shape: Rounded or uniform shape, scar was present 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: No Tenderness: 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 Back Inspect back for Position of spine/movement: Spine is in the midline Condition of skin/prone to bedsore: No

Diagnostics

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 hematuria Transparency: Turbid due to the increased sediments. Specific Gravity: 1.031 Due to decrease urine output. Glucose: +1 Protein: +2 Glycosuria and proteinuria due to increased glomerular permeability. RBC: + NTC Hematuria due to damage of glomerulus.

Hematology test

Concerned with the study of blood, the bloodforming organs, and blood

Blood is the transport medium in the body so any toxin or antibodies

July 11, 2012 RBC: 3.62x106/ul Possibly due to hematuria. Hgb: 9.20g/dL Due to decrease of RBC production.

diseases.

will be found in it.

Hct: 26.7% Due to decrease of RBC production. Serum Blood Glucose: 60 mg/dL Due to glycosuria Serum 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 to filter this waste product out of blood and pass into the urine. So, if the kidneys are not working properly, this blood test will be high.

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 through 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.

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, bladder and urethra. The kidneys are 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 body o The kidneys also produce renin and erythropoietin The bladder is a pyramid-shaped organ. o The main function of the bladder is to store urine o 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

Glomerulus The glomerulus is a capillary tuft that receives its blood supply from an afferent arteriole of the renal circulation. Glomerular Capsule or Bowman's capsule Bowman's capsule (also called the glomerular capsule) surrounds the glomerulus and is composed of visceral and parietal layers. o Measuring the glomerular filtration rate (GFR) is a diagnostic test of kidney function. A decreased 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.

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 lung tissue and vascular endothelium. secreted by the

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.

XIII. Comprehensive Pathophysiology

Predisposing Factors: Age: 9 yrs. Old Poor Hygiene Streptococci Infection B- hemolytic Streptococci

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 Leukocytes infiltration of the glomerulus Thickening of the glomerular filtrationmembraneHct Renal Blood Flow Glumerular GFR Permeability Glycosuria
to release renin

Hematuria RBC Hgb

Proteinuria
USG

Oliguria Activation of BUN, RAAS s. CreatineStimulation of JGC

Renin stimulate liver Angiotensine I

Hypoalbuminuria
angiotensine

Bld. Glucose Hypoglycemia Weakness BP Vasoconstriction

Colloidal oncotic Pressure Fluid shift

Angiotensine II

ACE

Edema
Edema Na & H2O retention aldosterone secretion stimulation of adrenal cortex

Treatment / Management

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 of the 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.

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 center and and at the Botikang barangay. Instruct patient to seek regular medical check-up

Fluid Volume Excess

Assessment Subjective: Angsakitnghitako as manifested by the patient. Diagnosis Planning Intervention Independent: Assess Vital signs: BP, PR, RR and T. manifested by guarding Objective: -Swelling -Pain appropriate nursing interventions, the Note Complaints associated with normal levels, no scale of 7/10. 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. pain and edema more longer edema. complaints of pain Assist and edema.
client and family to cope with the situation.

Rationale

Evaluation After performing

Acute pain related Short Term: to inflammation and edema as : After 2-4 hours of providing

Obtain Baseline for comparison that help to identify the underlying cause & monitor progress.

intervention for 3 days for client:

Had Vital signs near

behavior and pain patient

Provide and Encourage frequent skin hygiene. Dependent:

Administer IV fluids and meds.as prescribed.

To Keep skin dry and clean to avoid irritation.

Medication to decrease pain and IV fluids for maintaining good nutrition of the patient.

Long Term: Af t e r 6 8 d a ys of p ro vi di n g a pp ro p ri at e nu rsi n g i nt er v ent i on s, t h e pa t i ent s i nflammation and edema will decrease.

Imbalanced Nutrition: Less than Body Requirement

Assessment Subjective:

Diagnosis Imbalanced Nutrition: less

Planning Short Term:

Intervention Assess nutritional status:

Rationale

Evaluation After performing interventions for 2

Masyadoatangk akauntiangmgapi napakainsaanakk

than body requirements related to

After 2 days of intervention, the

Assess body Weight, lab values (serum creatinine,

Obtain Baseline for comparison that help to identify the underlying cause & monitor progress.

days, the client: Have Observably increased energy levels.

client will: BUN and protein).

o as verbalized increased by the father. glomerular permeability as restrictions Objective: evidenced by proteinuria. UA: Protein = +2 Glucose = +1 Have Increased energy levels and appetite. edema. Advise Family members to Prevent Protein deficiency. remove water, food or drinks from bedside. Prevents Deviation from prescribed diet. Promote Low Sodium, low potassium, high calorie and protein restricted. To decrease Reported The kidney's workload and Increased appetite. to minimize or prevent retention of fluids that leads to swelling. Progression of Reported no signs of Comply With dietary

Assist client and family to cope with the discomfort caused by restrictions in the diet.

Understanding And comfort promotes compliance and increases appetite.

Monitor and clients progress:

 Weigh patient daily.

To Evaluate Progress or effectivenessof the diet.

Collaborative:

Coordinate with other health care personnel (nutritionist, physician)

XVII. List of References

1. Brunner &Suddarths Textbook of Medical surgical Nursing 12th e 2. Your kidneys and how they work. National Kidney and Urologic Diseases Information Clearinghouse.

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 Information Clearinghouse. 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-B978-1-4377-07922..50025-0--cesec6&isbn=978-1-4377-07922&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" at Dorland's Medical Dictionary 9. Dr. Zaid G. Nguyen MD. University of Melbourne, Dept of Medicine 10. http://www.nlm.nih.gov/medlineplus/ency/article/000472.htm 11. Robbin's Pathology 12. Couser WG (May 1999). "Glomerulonephritis". Lancet353 (9163): 150915. doi:10.1016/S0140-6736(98)06195-9. PMID 10232333.