Case Study: Acute Glomerulonephritis

BSN 3-A Group 2B

Rosario, Meljun Gerald V.

Rendora, Jelly Ann
Soriano, Maricar A.

College of Nursing

Our Lady of Fatima University

Regalado Quezon City

Mrs. Marie Anne Lapitan MAN, RN

Clinical Instructor

Mrs. Cecile Guevarra MAN, RN

Level Coordinator

Mrs. NeliaCapulong MAN, RN

Dean College of Nursing
 TABLE OF CONTENTS

Title Page i

Table of Contents ii

Abstract iii

I. Introduction 1
II. Biographical Data 2
A. Personal Profile 2
B. History of Present Illness 2
C. Past Medical History of Illness 2
D. Family History 3
E. Social History 3
F. Developmental Stage ( Erik Erikson) 3
III. Anatomy and Physiology 4
IV. Physical Assessment 8
V. Pathophysiology 18

VI. Medical Management 19

a. Doctor’s Order 19
b. Laboratory and Diagnostic Procedures 20
c. Drug Study 28
VII. Nursing Management 33
a. Course in the Ward 33
b. Nursing Care Plan 35
VIII. Discharge Plan 38
IX. References 39

Abstract
 This case study focused on patient M.B., 26 years old, male, single, Filipino, Roman Catholic, born
on May 28, 1993 in La Union, residing in Bagulin La Union. He was admitted last July 31, 2019
with chief complaint of bilateral leg swelling. His condition was not associated with fever, sore
throat, dysuria nor gross hematuria. One month prior to his admission, patient sought consultation
and on his laboratory examination, her creatinine was elevated at 378. On his KUB, it was noted
unremarkable. His C3 and ANH levels were within normal limits. Patient was given Ciprofloxacin
and Febuxostat. The consideration that time was Nephritic-Nephrotic syndrome hence patient was
advised to undergo kidney biopsy.

I. Introduction
Objective:

To be able to provide student nurses & other health care professional with the overview of the condition
process and the nursing implication of acute glomerulonephritis.

Specific Objectives:

 By the end of the study, we will be able to:

 Identify Acute Glomerulonephritis and its pre disposing factors

 Identify the history and manifestations of the disease through research.

 Identify the laboratory results undergone by the patient.

 Discuss the pathophysiology of Acute Glomerulonephritis

 Identify means of preventing acute glomerunephritis

Background of the Study:

Acute glomerulonephritis requires prompt diagnosis, as it can rapidly progress to permanent kidney
disease if left undiagnosed. Glomerulonephritis is the third most common cause of end-stage renal
disease, following diabetes mellitus and hypertension and is responsible for about 15% of cases of end-
stage renal disease.

The emergency physician must consider acute glomerulonephritis in the differential diagnosis for patients
that present with hypertension, hematuria, proteinuria, peripheral edema, and/or acute pulmonary edema.
Acute glomerulonephritis is defined as inflammation and subsequent damage of the glomeruli leading to
hematuria, proteinuria, and azotemia; it may be caused by primary renal disease or systemic conditions
I. Biographical Data

a. Personal Profile
 Name: M.B
 Age: 26 years old
 Birthday: May 28, 1993
 Gender: Male
 Civil Status: Single
 Spouse: Not applicable
 Occupation: Enlisted Personnel of AFP
 Nationality: Filipino
 Religion: Roman Catholic
 Place of Birth: La Union
 Present Residence: La Union
 Date of Admission: July 31, 2019
 Chief Complaint: Bilateral leg swelling
 Diagnosis: Acute Glomerulonephritis
 Admitting Physician: C.M.M
 Attending Physician: Dr. J.A

b. History of Present Illness

One month prior to admission, patient had sudden onset of bilateral leg swelling
not associated with fever, sore throat, dysuria, gross hematuria. Patient sought consult to
a private hospital and upon evaluation, patient’s Creatine revealed to be elevated at 378.
KUB ultrasound was unremarkable; C3 and ANH levels were within normal limits. Urine
was noted to be frothy. Patient was given Ciprofloxacin and Febuxostat. Consideration
upon that time was Nephrotic nephritic syndrome, hence patient was advised to undergo
Kidney biopsy.

Patient was brought to AFP Medical Service for further evaluation and
management and hence admission.

c. Past Medical History

Patient was never hospitalized since he was a child. In 2016, he was diagnosed
with hypertension with blood pressure of 180/100 and no remarkable diseases.
 d. Family History
Patient has no history of hypertension, diabetes mellitus and asthma.

e. Social History

Patient M.B. is a college graduate. He is an enlisted personnel of AFP. He is a

non-smoker, not alcoholic and no history of substance abuse.

f. Developmental Stage (Erik Erikson)

Patient M.B. falls under the developmental stage of “Intimacy vs. Isolation” People in early
adulthood (20s through early 40s) are concerned with intimacy vs. isolation. After we have developed a
sense of self in adolescence, we are ready to share our life with others. However, if other stages have not
been successfully resolved, young adults may have trouble developing and maintaining successful
relationships with others. Erikson said that we must have a strong sense of self before we can develop
successful intimate relationships. Adults who do not develop a positive self-concept in adolescence may
experience feelings of loneliness and emotional isolation.

Patient is isolated in such a way that he is single at the age of 26 years old and has no intimate
relationship with opposite sex. He keeps on being alone and no other person is with him.
 III. Anatomy and Physiology

The glomerulus (plural glomeruli), is a network of small blood vessels (capillaries) known as a tuft,
located at the beginning of a nephron in the kidney. The tuft is structurally supported by the mesangium -
the space between the blood vessels - made up of intraglomerular mesangial cells. The blood is filtered
across the capillary walls of this tuft through the glomerular filtration barrier, which yields its filtrate of
water and soluble substances to a cup-like sac known as Bowman's capsule. The filtrate then enters the
renal tubule, of the nephron.

The glomerulus receives its blood supply from an afferent arteriole of the renal arterial circulation. Unlike
most capillary beds, the glomerular capillaries exit into efferent arterioles rather than venules. The
resistance of the efferent arterioles causes sufficient hydrostatic pressure within the glomerulus to provide
the force for ultrafiltration.

The glomerulus and its surrounding Bowman's capsule constitute a renal corpuscle, the basic filtration
unit of the kidney.[2] The rate at which blood is filtered through all of the glomeruli, and thus the measure
of the overall kidney function, is the glomerular filtration rate (GFR).
 IV. Physical Assessment

General Appearance: Client was conscious and coherent. He was not in cardiorespiratory
distress and no problem on ambulating. His cognitive perceptual was alert, cooperative, oriented
to place, time, person and events. Patient was aloft and has no interest on any conversation.

Date: September 18, 2019

Vital Signs:
Temperature: 36.3 °C
Pulse Rate: 60 bpm
Respiratory Rate: 20 cpm
Blood Pressure: 130/190mmHg
O2 stat: 98%
Pain Scale: N/A

BODY PARTS NORMAL ACTUAL INTERPRETATION ANALYSIS

FINDINGS FINDINGS
HEAD
Inspection and Generally round Head is round, NORMAL
Palpation symmetric, size
is appropriate to
body
No tenderness Head is NORMAL
on palpation normally hard
and smooth, no
lesion and no
tenderness
during
palpation.
HAIR
Inspection Can be black or Naturally black NORMAL
brown hair color
Depending on
the race
Evenly No hair loss NORMAL
distributed.
Covers the
whole scalp
Maybe thick or Smooth and thin NORMAL
thin, coarse or in
smooth Neither characteristics
brittle nor dry
SCALP
Inspection and Lighter in The color is NORMAL
palpation color than the lighter than in
complexion the complexion.
Can be moist Slightly moist
or oily
No scars No scars noted NORMAL
Free from lice, Scalp is clean, NORMAL
nits, and no lice and
dandruff dandruff
No lesions No lesions and NORMAL
should be parasites
noted
EYES
Inspection Symmetrical No double NORMAL
and in line vision,
with each other symmetrical and
in line to each
other.
Pupils are NORMAL
equally rounded
Pupils are and reactive to
equally rounded light.
CORNEA
Inspection Anicteric NORMAL
Transparent, schlera, pink
shiny and palpebral
smooth conjunctivae
NOSE
Inspection and No lesion The nasal NORMAL
palpation noted structure is
smooth and
symmetric and
no lesions
No discharge, NORMAL
No nasal turbinate not
discharges congestive
No tenderness The client report NORMAL
or masses on no tenderness
palpation and no masses
during palpation
MOUTH
Inspection Symmetrical, Moist buccal NORMAL
pink, smooth mucosa, no oral
and moist ulcers
LIPS
Inspection No No lumps but NORMAL
growth/lumps or pale in
discoloration of appearance
the tissue
TEETH
Inspection Clean with no No dentures, NORMAL
decay Appears clean entire
white and shiny teeth
enamel with
smooth surfaces
and edges
GUMS
Inspection Symmetrical, Pink gums, (-) NORMAL
moist, swelling and
pink/coral with moist
tight well-
defined margins
TONGUE
Inspection Should be pink, Moderate in NORMAL
moist, moderate size, pink in
size with appearance
papillae present.
Patient report NORMAL
No lesions with no lesions
EARS
Inspection Symmetry Symmetrical NORMAL
No nodules or No nodules or NORMAL
masses on masses during
palpation and palpation, no
ear discharges aural discharge
NECK
Inspection and Supple neck, NORMAL
Palpation symmetrical , no
Symmetry, no distended neck
lesions vein
No palpable Free from NORMAL
lymph nodes nodules or no
lymph nodes
when palpated

SKIN
No lesions No cyanosis, no NORMAL
Inspection jaundice,
No No masses or NORMAL
masses/nodules nodules during
palpation
When skin is Skin is goes back NORMAL
pinched, skin immediately
goes back when pinched.
immediately.
Skin is intact and Intact skin, no NORMAL
there are no rashes or any
redness abnormalities
during inspection
NAILS
Capillary refill < Capillary refill < NORMAL
3 seconds 3 Seconds when
Inspection palpated.

No presence of Clean nails with NORMAL

lesion and other no abnormalities
abnormalities
CHEST,
LUNGS and
HEART
Inspection, No lumps and A dynamic NORMAL
Palpation and masses No precordium,
Auscultation tenderness normal rate,
regular rhythm,
no murmur
 No discharge No discharge
from the nipples from nipples
Apical pulse is High blood ABNORMAL Cause of reduce
normal and pressure kidney function
regular by rate and can influence
how kidney
handle sodium

UPPER
EXTREMITIES
Inspection and No swelling and No swelling and NORMAL
Palpation tenderness tenderness noted
ABDOMEN
Inspection and Surgical scar (-) scar NORMAL
Palpation from incision
Umbilicus Umbilicus at the NORMAL
located at the center, clean, no
middle redness and no
inflammation
No presence of (-) pain during NORMAL
pain upon palpation, non
palpation tender abdomen,
normo active
bowel sound
LOWER
EXTREMITIES
Inspection Full range of (+) edema at ABNORMAL Due to fluid
motion resistance bipedal retention

V. Pathophysiology

Acute GLomerulonephritis

ETIOLOGY: UNKNOWN

RISK FACTORS: HYPERTENTION

GENETICS

IRREVERSIBLE LOSS OF NEPHRONS

GLOMERULAR HYPERFILTRATION
 GLOMERULAR PERMEABILITY ↑ RENIN PRODUCTION
ACTIVATION OF RAAS

↑FILTRTION OF PROTIENS AND MACROMOLECULES ↑HR

HYPERTENTIO
PROTERNURIA N

NEPHROTOXIC INFLAMATION

DYSLIPIDEMIA

↓GFR ↓URINE UREMIA

OUTPUT

VI. Medical Management

a. Doctor’s Order

Sept. 18, 2019

The doctor ordered ivf to follow plain LR to run at 80cc/hr.

Sept. 22, 2019

The doctor ordered ivf to heplock. Then continue fluconazole up to day 3 and continue present meds.

Sept. 23, 2019

The doctor ordered to continue present medications.

Sept 24, 2019

The doctor ordered to continue present medications.

b. Drug Study
c. Laboratory Findings

SURGICAL PATHOLOGY / CYTOLOGY TEST REPORT

DATE SUBMITTED: 8/22/19 1:30:00 PM

DATE REPORTED: 8/30/19 4:04:29 PM

DIAGNOSIS:
Kidney (needle biopsy)
Clinically, IgA nephropathy

IgA NEPHROPATHY (OXFORD CLASSIFICATION SYSTEM (2009): MI, EO, S1, T1)
WITH 24% GLOBAL GLOMERULOSCLEROSIS (5 OF 21 GLOMERULI) AND 19%
SEGMENTAL GLOMERULOSCLEROSIS (4 OF 21)

ACUTE INTERSTITIAL NEPHRITIS WITH ACUTE TUBULAR INJURY

MODERATE INTERSTITIAL FIBROSIS AND TUBULAR ATROPHY

COMMENTS:
Suggest electron microscopy and clinicoserologic correlation

SPECIMEN:
Renal

CLINICSL DIAGNOSIS AND/OR HISTORY:

A 26 years old male presented 2 months ago with sudden onset of bilateral leg swelling and
frothy urine. Serum creatinine was 378 umol/L. serum C3 was within normal limits

GROSS AND MICROSCOPIC DESCRIPTION:

Received 3 tissue cores measuring 0.4 x 0.1 x 0.1 cm ( in formalin ), 0.3 x 0.1 x 0.1 cm,
( both corfes in unlabeled fixative ). Also received in unlabeled fixative is a fragmented tissue
core with an aggregate diameter of 0.2 cm. One end of the first core is cut and saved for
electron microscopy and the rest of the core submitted for the light microscopy. The 2 nd and
3rd core, together with the fragmented tissue core, are submitted for immunofluorescense
microscopy

Histologic preparations (H&E, PAS, PAAg) of 1 core of cortical tissue include 7 glomeruli, 2
of which are globally sclerosed. Four glomeruli are segmentally sclerosed with adhesions.
Two glomeruli have periglomerular fibrosis. Some glomeruli have mild to moderate
segmental increase in mesangial cells and matrix. There are mononuclear for cells, plasma
cells, few neutrophils, and occasional macrophages and eosinophils in theinterstitium (40%) .
 VII. Nursing Management

a. Course in the Ward

Sept. 18, 2019

Patient received on bed, lying and awake. On prednisone treatment. Advised the patient to wear mask at
all times.

Sept 23, 2019

Patient received on bed, lykng and awake. On prednisone treatment. Advised the patient to weat mask at
all times. Patient was monitored for any signs and symptoms.

Sept. 24, 2019

Patient still on prrdnisone treatment. Advised the patient to wear mask at all times.

Sept 25, 2019

Patient on prednisone treatment. Monitored for signs and symptoms. Emphasized proper hygiene..
 Nursing Care Plan

Assessment Diagnosis Planning Implementation Evaluation

 Subjective: Excess Fluid LTG: Rationale:
“Namamaga ang After 8 hrs, LTG:
Volume
mga binti ko” as Client will have 1. Monitor vital signs - An assessment
verbalized by the related to normal fluid every 4 hours; notify provides baseline After 8 hrs,
client balance as any significant information for Client had normal
decrease in
evidenced by changes. monitoring changes fluid balance as
regulatory absence of edem and evaluating the evidenced by
and balanced fluid effectiveness of absence of edem
mechanisms
Objective: intake and output therapy. and still with
- Puffiness in the with the imbalanced fluid
face 2. Auscultate breath -Crackles upon intake and output.
potential of
-leg edema STG: sounds for the auscultation Goal partially met.
water After 30 mins of presence of crackles.
Nursing
indicate a fluid STG:
Observe for increased accumulation
intervention, the
patient work of breathing, resulting in After 30 mins of
vital signs within cough, and nasal pulmonary nursing
the client normal flaring. congestion. intervention, the
limit. patient
3. Weigh the child on vital signs within
- Weight gain results
the same scale at the the client normal
from fluid retention;
same time daily. limit. Goal met.
Accurate
Monitor intake and
measurement of intake
output accurately.
and output helps
4. Measure and assess fluid balance.
record abdominal
-Edema normally
girth daily.
observed in the
abdomen which may
increase as the
5. Administer condition progresses.
diuretics as
prescribed. -Decreases plasma
volume and edema by
causing diuresis.

VIII. Discharge Plan

Medication

 Penicillin- to prevent recurrence of streptococcal infection

 Zinc sulphate syrup 5ml PO OD-for maintenance of normal growth and skin hydration, and
senses of taste and smell.

 Furosemide ( Lasix) –diuretic that is used to treat excessive accumulation of fluid and swelling
(edema) of the body. It is sometimes used alone or in conjunction with other blood pressure pills
to treat high blood pressure.
Exercise/Environment

 Advised caregiver to encourage the child to have non-strenuous and nom jarring exercise such as
walking. They can attend and engage in normal activities after 1 to 2 weeks.
 Advised client and his family to try to have or maintain safe, clean, comfortable and calm
environment.

Treatment
 Ensure follow up and self care.
 Advice client or significant others to take in time the prescribed medicine for high blood
 Enaure dietary restrictions on salt and protein.
 Tell significant others to closely watched and monitor for signs of developing kidney failure.

Health Teaching

 Describe to the client the sign and symptoms to be reported immediately.

 Explain the nature of disease.
 Clearly outline as follow up plan and discuss the plan with the family.
 Advise significant others to immediately consult physician if signs and symptoms of the disease
occurs or persist.

Diet

 Assure a low sodium, low protein diet.

 Limitation of fluid and salt intake to minimize vascular overload and hypertension.
 The diet should contain sufficient amount of carbohydrates to prevent protein from being used for
energy which will result from muscle wasting and nitrogen imbalance.

Spiritual

 Counseling: Tell the client that neither she or GOD is to blame for her condition, everything
happens for a reason.

 Advise relatives or significant others to provide moral support and widen their understanding
References:

https://int.search.tb.ask.com/search/GGmain.jhtml

https://en.wikipedia.org/wiki/Glomerulus_(kidney)#/media/File:Renal_corpuscle-en.svg