OLIVAREZ COLLEGE PARANAQUE Dr. A. Santos Ave., Sucat, Parañaque College of Health Related Sciences – Nursing Department Case Study of a Client with a diagnosis of Acute glomerulonephritis CASE PRESENTATION BS NURSING IV SECTION A, Group 2 1 ST SEM - CLASS 2010-2011
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OLIVAREZ COLLEGE PARANAQUEDr. A. Santos Ave., Sucat, Parañaque
College of Health Related Sciences – Nursing Department
Case Study of a Client with a diagnosis of
Acute glomerulonephritis
CASE PRESENTATION
BS NURSING IV SECTION A, Group 2
1ST SEM - CLASS 2010-2011
Submitted to:
Ms. Acosta, RN
Introduction
Background of the study
Acute glomerulonephritis (AGN) is active inflammation in the glomeruli. Each kidney is composed of about 1 million microscopic filtering
"screens" known as glomeruli that selectively remove uremic waste products. The inflammatory process usually begins with an infection or injury
(e.g., burn, trauma), then the protective immune system fights off the infection, scar tissue forms, and the process is complete.
There are many diseases that cause an active inflammation within the glomeruli. Some of these diseases are systemic (other parts of the body
are involved at the same time) and some occur solely in the glomeruli. When there is active inflammation within the kidney, scar tissue may replace
normal, functional kidney tissue and cause irreversible renal impairment.
The severity and extent of glomerular damage—focal (confined) or diffuse (widespread)—determines how the disease is manifested.
Glomerular damage can appear as subacute renal failure, progressive chronic renal failure (CRF); or simply a urinary abnormality such as hematuria
(blood in the urine) or proteinuria (excess protein in the urine).
Case Abstract
This was a case of E.D., 6 year old male born on November 8, 2003 residing at Muntinlupa City was admitted at Ospital ng Muntinlupa on
August 24, 2010 at 8:15am with a chief complaint of Tea Colored Urine. He arrived at the hospital awake, conscious and coherent with admitting
diagnosis of Acute Glomerulonephritis.
Patient had high fever, sore throat, tonsillitis and facial edema12 days prior to confinement.
Vital Signs taken and recorded upon admission; BP 135/85 mmHg, T: 37oC, RR: 30, PR 100 bpm and Laboratory test; Urinalysis, Hematology, Blood Chemistry and ASO titer was done. Catheter was inserted upon admission. Furosemide, Nipedipine and Penicillin was given.
OBJECTIVES:
A. General Objectives
This study aims to convey familiarity and provide effective nursing care to a patient with admitting diagnosis of Acute Glomerulonephritis ,
through understanding the patient history, disease process and management.
B. Specific Objectives
At the end of the session, the students will be able to:
1. Present a thorough assessment regarding Acute Glomerulonephritis, through Nursing Health History, Maternal History, Physical
Assessment, and the interpretation of the laboratory examinations done on the patient.
2. Discuss the anatomy and physiology of Urinary system, pathophysiology of the patient’s condition, usual clinical manifestations and
possible complications of the condition.
3. Enumerate the necessary medications needed and be familiar to its mode of action.
4. Formulate a workable nursing care plan on the subjective and objective cues gathered through nurse-patient interaction to be able to help
( )Oriented( ) Disoriented Time ____ Place ____Person_______
Normal
DevelopmentInspection
() Endomorph / Well developed( ) Mesomorph / Fairly developed( )Ectomorph / Poorly developed() Looks According to Age( ) Appears older/ younger than stated age
( ) Resonant at ______________( ) Dullness at _______________( ) Hyper-resonant at _________( ) Liver Dullness at __________( ) Spleen Dullness at ________
Normal
Breath Sounds ( ) Bronchial at ______________() Bronchovesicular at ________( ) Vesicular at ______________( ) Crackles at ______________( ) Wheezing at _____________( ) Pleural friction rub _________
Normal
XHEART TECHNIQUE USED ACTUAL FINDING SIGNIFICANCE
Precordial Auscultation
() Flat( ) Bulging( ) Tenderness
Normal
( ) Heavy( ) Thrill( ) Normo-dynamic pre cordium
Point of Maximum Impulse AuscultationAt _________________________Apical beat at ________________
Normal
Heart Sounds Auscultation
() Distinct( ) Regular( ) Faint( ) IrregularS1 __________ S2 at the baseS1 __________ S2 at the apexOthers: ( ) S3 ( ) S4 ( ) Murmurs best heard at ____________
Normal
XIIBREAST AND
AXILLAE TECHNIQUE USED ACTUAL FINDING SIGNIFICANCE
() 4 Spontaneous( ) 3 To verbal command( ) 2 To pain( ) 1 No response
Normal
Verbal Response
() 5 Oriented and Converses( ) 4 Disoriented and Converses( ) 3 Inappropriate word( ) 2 Incomprehensible sound( ) 1 No response
Normal
Motor Response (Pedia)
() 6 Normal spontaneous movement( ) 5 Withdrawal to touch( ) 4 Withdrawal to pain( ) 3 Flexion-abnormal( ) 2 Extension-abnormal( ) 1 No response
Normal
Eyes Open() 4 Spontaneous( ) 3 To verbal command( ) 2 To pain( ) 1 No response
Normal
Verbal Response
() 5 Coos Babbles( ) 4 Irritable Cry( ) 3 Cries to pain( ) 2 Moves to pain( ) 1 No response
Normal
REVIEW OF SYSTEMS
BRIEF ANATOMY AND PHYSIOLOGY of SYSTEMS and BODY MECHANISM INVOLVED IN THE CASE.
Human Kidney Anatomy
The kidneys are bean-shaped organs, each about the size of a fist. They are located near the middle of the back, just below the rib cage, one on each side of the spine. The kidneys are sophisticated reprocessing machines. Every day, a person’s kidneys process about 200 quarts of blood to sift out about 2 quarts of waste products and extra water. The wastes and extra water become urine, which flows to the bladder through tubes called ureters. The bladder stores urine until releasing it through urination.
The kidneys remove wastes and water from the blood to form urine. Urine flows from the kidneys to the bladder through the ureters.
Wastes in the blood come from the normal breakdown of active tissues, such as muscles, and from food. The body uses food for energy and self-repairs. After the body has taken what it needs from food, wastes are sent to the blood. If the kidneys did not remove them, these wastes would build up in the blood and damage the body.
The actual removal of wastes occurs in tiny units inside the kidneys called nephrons. Each kidney has about a million nephrons. In the nephron, a glomerulus—which is a tiny blood vessel, or capillary—intertwines with a tiny urine-collecting tube called a tubule. The glomerulus acts as a filtering unit, or sieve, and keeps normal proteins and cells in the bloodstream, allowing extra fluid and wastes to pass through. A complicated chemical exchange takes place, as waste materials and water leave the blood and enter the urinary system.
In the nephron (left), tiny blood vessels intertwine with urine-collecting tubes. Each kidney contains about 1 million nephrons.
At first, the tubules receive a combination of waste materials and chemicals the body can still use. The kidneys measure out chemicals like sodium, phosphorus, and potassium and release them back to the blood to return to the body. In this way, the kidneys regulate the body’s level of these substances. The right balance is necessary for life.
In addition to removing wastes, the kidneys release three important hormones:
erythropoietin, or EPO, which stimulates the bone marrow to make red blood cells renin, which regulates blood pressure calcitriol, the active form of vitamin D, which helps maintain calcium for bones and for normal chemical balance in the body
Nephron
Is the basic structural and functional unit of the kidney. Its chief function is to regulate the concentration of water and soluble substances like sodium salts by filtering the blood, reabsorbing what is needed and excreting the rest as urine. A nephron eliminates wastes from the body, regulates blood volume and blood pressure, controls levels of electrolytes and metabolites, and regulates blood pH. Its functions are vital to life and are regulated by the endocrine system by hormones such as antidiuretic hormone, aldosterone, and parathyroid hormone. In humans, a normal kidney contains 800,000 to one million nephrons. Types of nephrons Two general classes of nephrons are cortical nephrons and juxtamedullary nephrons, both of which are classified according to the location of their associated renal corpuscle. Cortical nephrons have their renal corpuscle in the superficial renal cortex, while the renal corpuscles of juxtamedullary nephrons are located near the renal medulla. The nomenclature for cortical nephrons varies, with some sources distinguishing between superficial cortical nephrons and midcortical nephrons.
The Glomerulus
The glomerulus is the main filter of the nephron and is located within the Bowman's capsule. The glomerulus resembles a twisted mass of tiny tubes through which the blood passes. The glomerulus is semipermeable, allowing water and soluble wastes to pass through and be excreted out of the Bowman's capsule as urine. The filtered blood passes out of the glomerulus into the efferent arteriole to be returned through the medullary plexus to the intralobular vein.
Bowman's Capsule
The Bowman's capsule contains the primary filtering device of the nephron, the glomerulus. Blood is transported into the Bowman's capsule from the afferent
arteriole (branching off of the interlobular artery). Within the capsule, the blood is filtered through the glomerulus and then passes out via the efferent arteriole.
Meanwhile, the filtered water and aqueous wastes are passed out of the Bowman's capsule into the proximal convoluted tubule.
Increase in aldosteroneRelease of protein and RBC to the urine Vasoconstriction
Signs and symptoms:
Proteinuria and Hematuria.
Chief Complaint:
Tea colored Urine
Losses oncotic pressure
Sodium retention
Water retention
Signs and symptoms:
Hypertension (Client’s Bp is 135/85 mmHg)
Signs and symptoms:
Edema
Diagnostic Procedure:
Urinalysis, Hematology, Blood Chemistry and ASO titer.
Hematology reveals decreased in level of hemoglobin (110 g/L), increase in both WBC count (15.6 x 109 L), and neutrophils (0.84%)
Urinalysis reveals increase in Ph is acidic (Ph 5), protein (+2), RBC (TNTC), and pus cells (TNTC).
ASO Titer is elevated (>400 IU/ML)
Blood chemistry reveals elevated BUN (14.6 mmol/L)
Diagnosis: Acute Glumerulonephritis
Disease and Treatment Definition
Glomerulonephritis, also known as glomerular nephritis, abbreviated GN, is a renal disease characterized by inflammation of the glomeruli, or small blood vessels in the kidneys.It may present with isolated hematuria and/or proteinuria (blood resp. protein in the urine); or as a nephrotic syndrome, a nephritic syndrome, acute renal failure, or chronic renal failure. They are categorised into several different pathological patterns, which are broadly grouped into non-proliferative or proliferative types. Diagnosing the pattern of GN is important because the outcome and treatment differs in different types. Primary causes are ones which are intrinsic to the kidney, whilst secondary causes are associated with certain infections (bacterial, viral or parasitic pathogens), drugs, systemic disorders (SLE, vasculitis) or diabetes.
Treatment
Treatment varies depending on the cause of the disorder, and the type and severity of symptoms. High blood pressure may be difficult to control, and it is generally the most important aspect of treatment.Medicines that may be prescribed include:
Blood pressure medications are often needed to control high blood pressure. Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers are most commonly prescribed.
Corticosteroids may relieve symptoms in some cases. Medications that suppress the immune system may also be prescribed, depending on the cause of the condition.
A procedure called plasmapheresis may be used for some cases of glomerulonephritis due to immune-related causes. The fluid part of the blood containing antibodies is removed and replaced with intravenous fluids or donated plasma (without antibodies). Removing antibodies may reduce inflammation in the kidney tissues.Dietary restrictions on salt, fluids, proteinprotein, and other substances may be recommended to Persons with this condition should be closely watched for signs that they are developing kidney failure. Dialysis or a kidney transplant may eventually be necessary.
SIGNIFICANCE OF THE RESULT IN RELATION TO THE DISEASE
PROCESSUrinalysis
Color
Appearance
PH
Specific gravity
Protein
Yellow
Clear
7.35 -7.45
1.002-1.030
negative-trace
Amber
Turbid
5
1.025
+2
may be caused by excessive cellular material or protein in the urine or may develop from crystallization or precipitation of salts upon standing at room temperature or in the refrigerator which is usually of no significance.
Respiratory acidosis is a medical condition in which decreased respiration (hypoventilation) causes increased blood carbon dioxide and decreased pH
Normal
If there is protein in urine, there is something wrong with the filtration process in the kidneys. Normally, proteins molecules that are too large to enter the filtrate in the nephron of the kidney. If protein were to make it into the filtrate, then the kidneys are taking too much out of the blood and that could be disasterous.
Increased RBC in urine is termed hematuria, which can be due to hemorrhage, inflammation, necrosis, trauma or neoplasia somewhere along the urinary tract
Normal
Mucus is a frequent finding of the urinary sediment. The exact function of mucus is unknown.
Its an insignificant finding. Many times amorphous urates form as a result of the refrigeration process of urine when it is being processed. It has no clinical significance
ASO titer
HEMATOLOGY
Hemoglobin
Hematocrit
WBC
Neutrophils
Eosinophils
Lymphocytes
<200 IU/ml
13.2-16.2 gm/dL (Male)
31-43% (Child)
4.1-10.9x103/µL
2.5-7.5 x 10 9 /L
0-7%
20-40
>400IU/ml
11.0
0.33
15.6
0.84
0.06
0.10
Normal
Decrease may be in indicator of dietary deficiency, hemorrhage, lymphoma, anemia or sickle cell anemia
Normal
Elevated WBC can be an indication of infection, inflammation, trauma, and stress or tissue necrosis
Neutropenic patients are more susceptible to infections and less successful in fighting them off.
Normal
A decreased lymphocyte count of less than 500 places a patient at very high risk of infection, particularly viral infections. It is important when the lymphocyte count is low to implement measures to protect the patient from infection.
ESR
RBC
Platelet count
Clinical Chemistry
BUN
0-15 mm/hr
4.3-6.2x106/µL (Male)
150,000-400,000 cumm
2.86-8.93
117
3.86
395,000 cumm
14.6
A very high ESR usually has an obvious cause, such as a marked increase in globulins that can be due to a severe infection.
Anemia is a decrease in normal number RBCs or less than the normal quantity of hemoglobin in the blood.
Normal
When the kidneys aren't functioning as well as they should urea can build up in the blood causing an elevated BUN level
DRUG STUDY
NAME OF DRUG
CLASSIFICATION DOSAGE FREQUENCY
ROUTE
INDICATION MECHANISM OF ACTION
ADVERSE REACTION NURSING RESPONSIBILITY
FUROSEMIDE
(LASIX)
Loop diuretic Decrease plasma volume and edema by causing diuresis.
dizziness, headache, hypotension. Bone marrow depression (rare), hepatic
dysfunction. Hyperglycaemia,
glycosuria, ototoxicity
Perform frequent serum electrolyte monitoring.
Monitor patients fluid intake and output
NAME OF DRUG
CLASSIFICATION DOSAGE FREQUENCY
ROUTE
INDICATION MECHANISM OF ACTION
ADVERSE REACTION NURSING RESPONSIBILITY
NIFEDIPINE Anti-hypertensive
Calcium-Channel
blocker
90 mg OD It decreases BP caused by fluid retention due to
infection of glomerulus.
It blocks the slow
calcium channels
thus preventing the
flow of calcium ions
into the cell. It
produces peripheral
and coronary
vasodilatation,
peripheral
resistance and BP,
increases coronary
blood flow and
causes reflex
tachycardia.
Peripheral edema, hypotension,
palpitations, tachycardia, flushing,
dizziness, headache, nausea,
increased micturition frequency,
mental depression, visual
disturbances, tremor, impotence,
fever, paradoxical increase in
ischaemic chest pain during
initiation of treatment
WOF hypotension and bradycardia.
NAME OF DRUG
CLASSIFICATION DOSAGE FREQUENCY
ROUTE
INDICATION MECHANISM OF ACTION
ADVERSE REACTION NURSING RESPONSIBILITY
PENICILLIN V Antibiotic 50 mg TID IV Used to control local symptoms and to prevent spread of infection to close contacts.
Penicillin V works by binding to specific penicillin-binding proteins in bacterial cell walls and blocking the final cross-linking step in the synthesis of bacterial cell walls. This induces autolysis of the bactertial cells by autolysins.
Nausea, vomiting, epigastric distress, diarrhea, and black hairy tongue.
The hypersensitivity reactions reported are skin eruptions (maculopapular to exfoliative dermatitis), urticaria and other serum sicknesslike reactions, laryngeal edema, and anaphylaxis.
Fever and eosinophilia may frequently be the only reaction