Epidemiology: Glomerulonephritis Represents 10-15% of Glomerular Diseases.

Epidemiology:

Glomerulonephritis represents 10-15% of glomerular diseases. Variable incidence has been reported due in part to the subclinical nature of the disease in more than one half the affected population. Despite sporadic outbreaks, incidence of poststreptococcal glomerulonephritis has fallen over the last few decades. Factors responsible for this decline may include better health care delivery and improved socioeconomic conditions.

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 So uth 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.

Immunoglobulin A (IgA) nephropathy glomerulonephritis (ie, Berger disease) is the most common cause of glomerulonephritis worldwide.

Mortality/Morbidity

Most epidemic cases follow a course ending in complete patient recovery (as many as 100%).

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%.

Sex

A male-to-female ratio of 2:1 has been reported.

Age

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.

Etiology:

Immunoglobulin A (IgA) nephropathy glomerulonephritis (ie, Burger disease) is the most common cause of glomerulonephritis worldwide.

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Causes of acute glomerulonephritis include postinfectious, renal, and systemic etiologies. Each is described briefly.

Postinfectious etiologieso 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.

o Other specific agents include viruses and parasites, systemic and renal disease, visceral abscesses, endocarditis, infected grafts or shunts, and pneumonia.

o Bacterial causes other than group A streptococci may be diplococcal, streptococcal, staphylococcal, or mycobacterial. Salmonella typhosa, Brucella suis, Treponema pallidum, Corynebacterium bovis, and actinobacilli have also been identified.

o Cytomegalovirus, coxsackievirus, Epstein-Barr virus, hepatitis B rubella, rickettsial scrub typhus, and mumps are accepted as viral causes only if it can be documented that a recent group A beta-hemolytic streptococcal infection did not occur. Acute glomerulonephritis has been documented as a rare complication of hepatitis A.3

o Fungal and parasitic: Attributing glomerulonephritis to a parasitic or fungal etiology requires the exclusion of a streptococcal infection. Identified organisms include Coccidioides immitis and the following parasites: Plasmodium malariae, Plasmodium falciparum, Schistosoma mansoni, Toxoplasma gondii, filariasis, trichinosis, and trypanosomes.

Systemic causeso Vasculitis (ie, Wegener granulomatosis causes glomerulonephritis that

combines upper and lower granulomatous nephritides).o Collagen vascular diseases (ie, systemic lupus erythematosus causes

glomerulonephritis through renal deposition of immune complexes).o Hypersensitivity vasculitis encompasses a heterogeneous group of

disorders featuring small vessel and skin disease.o Cryoglobulinemia causes abnormal quantities of cryoglobulin in plasma

that result in repeated episodes of widespread purpura and cutaneous ulcerations upon crystallization.

o Polyarteritis nodosa causes nephritis from a vasculitis involving the renal arteries.

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o Henoch-Schönlein purpura causes a generalized vasculitis resulting in glomerulonephritis.

o Goodpasture syndrome causes circulating antibodies to type IV collagen and often results in a rapidly progressive oliguric renal failure (weeks to months).

o Drug-induced (ie, gold, penicillamine)

Renal diseaseso Membranoproliferative glomerulonephritis is due to the expansion and

proliferation of mesangial cells as a consequence of the deposition of complements.

o Type I refers to the granular deposition of C3; type II refers to an irregular process.

o Berger disease (IgG-immunoglobulin A [IgA] nephropathy) glomerulonephritis results from a diffuse mesangial deposition of IgA and IgG.

o Idiopathic rapidly progressive glomerulonephritis is a form of glomerulonephritis characterized by the presence of glomerular crescents. Three types have been distinguished. Type I is an antiglomerular basement membrane disease, type II is mediated by immune complexes, and type III is identified by antineutrophil cytoplasmic antibody.

Definition:

Acute Glomerulonephritis is a disease of the kidney in which there is an inflammation of the glomerular capillaries. In most cases, the simulus of the reaction is group A streptococcal infection, which ordinarily precedes the onset of glomerulonephritis by 2 to 3 weeks.

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Patients Profile

Name: Avila, Sonny SarmientoAge: 39 years oldAddress: Sta, Ana Bulacan, BulacanBirthdate: May 22,1970Religion: Roman CatholicRace: FilipinoPlace of admission: Gregorio del Pilar District HospitalDate of admission: Dec. 03,2009Chief Complaint: Fever and frequent urination for 2 weeksAdmitting Diagnosis: Acute Glumerulonephritis

Activity of Daily Living

Sonny S. Avila is 39 years old, single and a service driver. He lives at Sta. Ana Bulacan, Bulacan. He used to smoke a pack of cigarette a day and used to drink 2 to 3 bottles at least twice a week.

Family Medical History

On his father side there was a history of having Hypertension and Diabetes.

Present Illness

Sonny S. Avila came to the hospital with the chief complaint of fever and frequent urination for 2 weeks. He under gone some specific medical diagnostic test such as CBC and Urinalysis.

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Physical Assessment

1.Hematuria

May be microscopic and not identified by the patient. May be macroscopic and lead to dark brown or smoky or tea colored

urine.

2.Oliguria

Urine output is less than 400 ml/day May be not observed by the patient

3.Edema

Pitting edeme Starts in the eyelids and face then the lower and upper limbs then

generalized. It may be migratory ; appear in eyelid in tne morning , disappear in the

afternoon and reappear around the ankle in the ambulant patients by the end of the day.

4.Hypertension

It usually mild to moderate Pulmonary congestion and congested neck veins may be present, but

usually due to salt and water retention.

5. General Pallor due to edema and/or anemi

.

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Anatomy and Physiology of the Kidney

The kidneys are the primary organs of the urinary system in vertebrates. The kidneys filter the blood, remove the wastes, and excrete the wastes in the urine. About 1,300 milliliters of blood flow through the kidneys each minute (about 400 gallons a day). From this blood the Malphigian corpuscles (see below) extract about 170 liters of filtrate a day. As this fluid passes down the uriniferous tubules it is almost all reabsorbed. Only about 1.5 liters are left in the tubules to carry away the waste products.

The whole blood supply passes through the kidneys every 5 minutes, ensuring that waste materials don't build up. The renal artery carries blood to the kidney, while the renal vein carries blood, now with much lower concentrations of urea and mineral ions, away from the kidney. The urine formed passes down the ureter to the bladder.

The work of the kidneys is much more than just the removal of waste, however. Other functions of the kidneys include:

Helping control the amount of water lost to the outside world – most important in land animals.

Helping regulate the pH (i.e., level of acidity or alkalinity) of the blood and the general balance of ions in the blood, and hence in the body fluid as a whole.

Conserving essential substances such as glucose and amino acids.

Location, shape, and size of the kidneys

The kidneys are paired, bean-shaped organs. Adult human kidneys, are approximately 12 cm long, 6 cm wide, and 3 cm thick. They are situated in the abdominal cavity, just below the rib-cage, one on either side of the spine. More specifically, they lie between the twelfth thoracic vertebra and third lumbar vertebra.

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The right kidney usually is slightly lower than the left because the liver displaces it downward.

The kidneys, protected by the lower ribs, lie in shallow depressions against the posterior abdominal wall and behind the parietal peritoneum. This means they are retroperitoneal.

Each kidney is held in place by connective tissue, called renal fascia, and is surrounded by a thick layer of adipose tissue, called perirenal fat, which helps to protect it. A tough, fibrous, connective tissue known as the renal capsule closely envelopes each kidney and provides support for the soft tissue that is inside.

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Urinalysis

Color – reddish yellow PUS cells – 2-5/HPF

Transparency – turbid RBC – TNTC/HPF

Reaction – 6.0 Epithelial cells – few

Specific Gravity – 1.020 Mucous Threads – some

Sugar – negative Amorphous urates/Phospates – few

Albumin - +2

Bile

Pregnancy Test

Others

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HEMATOLOGY

Test Result Normal Values

RBC 5.38 4.5-5.8x10 12/L

WBC 4.90 5.0-10.0x10 9/L

HGB 170 140.0-180.0 6/L

HCT 0.50 0.42-0.52

Differential Count

Segmenters 0.60 0.50-0.66

Lymphocytes 0.40 0.20-0.40

Platelet Count 162 150-450x109/L

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DRUG STUDY

Medication Class Action Indication Contra-indica-tion

AdverseEffects

Drug to drug interaction

Drug to lab-testinteraction

Nursing Considera-tions

Generic name:Acetamino-phen/Para-cetamol

Brand name:Biogesic

Anti-pyretic

Anal-gesic

Anti-pyretic:Reduces fever by acting directly on the hypothalamic heat-regula-ting center to cause vasodi-lation and sweating which helps dissipate heat.

Analge-sic:Site and mecha-nism of action unclear.

• Analgesic-Antipyretic in patients with aspirin allergy, hemostatic distur-bances.

• arthritis and rheumatic disorders involving musculo-skeletal pain.

• Common cold, flu, other viral and bactericidal infections with pain and fever.

•Contraindicated with allergy to acetami-nophen/ parace-tamol

•Use cau-tiously with impaired hepatic function, chronic alcoho-lism, preg-nancy, lactation

• CNS:Headache

• CV:Chest pain, dyspnea, myocardial damage

• GI:Hepatic toxicity and failure, jaundice

• Hyper-sensitivity:Rash, fever

Increased toxicity with long term, excessive ethanol ingestion

Possible decreased effec-tiveness of zidovu-dine

Inter-ference with Dextrostix

• Assess for allergy to acetami-nophen/paracetamol, pregnancy, lactation, chronic alcoholism

• Do not exceed the recom-mended dosage

• Consult physician if needed for children <3 yrs.

•Disconti-nue if hypersen-sitivity occurs

11DRUG STUDY

Medication Class Action Indication Contra-indication

AdverseEffects

Drug to drug interaction

Drug to lab-testinteraction

Nursing Considera-tions

Generic name:

Anti-biotic

Bactericidal:Inhibits synthe-sis

Oral(cefuroxime axetil)

•Contraindicated with allergy to

• CNS:Headache,Dizziness,Lethargy

Increased nephroto-xicity with aminogly-

Possibility of false results on tests of

• Arrange for sensitivity test before and during therapy

Brand name:

Ceftin; Zinacef

of bacterial cell wall, causing cell death.

•Pharyn-gitis, tonsillitis caused by strepto-coccus pyogens

• Otitis media caused by S. pneumo-niae, Haemo-philus influenzae, S. pyogens

• UTIs caused by E. coli, Klebsiella pneumoniae

• Treatment of early Lyme dse.

Parenteral(cefuroxime sodium)

• Lower respiratory infections caused by S. pneumo-niae, S. aureus, E. coli, Klebsiella, S. pyogens

•Septice-mia caused by S. pneumo-niae, E. coli, S. influenzae, Klebsiella

•Meningitis caused by S. aureus, N. meningi-tidis, S. pneumoniae

• Periopera-tive prophylaxis

cephalos-porinsor peni-cillins.

• Use cautious-ly with renal failure, lactation, preg--nancy.

Paresthesia

• GI:Nausea VomitingDiarrheaAnorexiaAbdominal painFlatulenceLiver to-xicity

• GU:Nephro-toxicity

•Hemato-logic:Bone marrow depression

•Hyper-sensitivity:Ranging from rash to fever to anaphylaxis

• Local: Pain, abscess at infection site, phlebitis, inflam-mation at IV site

• Other:Superinfec-tions

cosides,

Increased bleeding effects with oral anticoa-gulant

urine glucose using Benedict’s sol’n, Fehling’s solution, Direct Coomb’s test

if expected response is not seen.

• Give oral drug with food to decrease GI upset and enhance absorption

• Have Vit. K available hypopro- thrombinemia occurs.

•Disconti-nue if hypersen-sitivity occurs.

Teaching points

• Take full course of therapy even if you are feeling better.

• You may experience these side effects: stomach upset or diarrhea

• Report severe diarrhea with blood, pus or mucus, rash, difficulty breathing, bruising, unusual itching or irritation.

Parenteral Drug

• Avoid alcohol while taking this

drug and for 3 days later bec. Severe reactions often occur.

• You may experience these side effects: stomach upset or diarrhea

Coarse in the Ward

Day 1

Last December 3.2009 at around 5:30pm, the patient consulted at Gregorio del Pilar District Hospital because of 5 days fever. Consent for admission and management was secured and the patient was hence admitted to patient`s room of choice under the supervision of Dr. Maria Rhina R. Uy. Then, assessment for Temperature, Blood Pressure, and Respiratory every shift. Administration of D5LR 1L to run for 8 hours. Dr. Maria Rhina R. Uy prescribed Cefuroxime 100mg and Ranitidine 1 ampule to be given Intravenously to run for 8 hours and Paracetamol 500mg tab. Round the clock every 6 hours. And also ordered to monitor Vital signs every 6 hours and record all the assessment findings. An order for Complete Blood Count, Platelet Count and urinalysis was also given for Kidney, Ureter, Bladder – Ultrasound. Repeat Complete Blood count and Platelet Count tomorrow as ordered.

Day 2

The next day, December 4,2009, Complete Blood Count/kidney, Ureter, Bladder – Ultrsound repeated. Then, the following drugs were given at 1:00pm and mnonitoring the Vital signs.

Day 3

The following day, December 5,2009, Dr. Maria Rhina R. Uy, ordered to repeat Urinalysis prior to discharge. Dr, Maria Rhina R. Uy prescribed Lefuroxime 50mg, Rowatinex 1 tab and relief forte 1 tablet two times a day for Home Medication. The Patient will come back on Friday 1pm referred to Dr.Acob.

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Discharge Planning

D – iscipline regarding the diet

I – nstruct to avoid excessive use of salt

S – eek for medical assistance for further complications

C- ontinue to take medication for maintenance

H – ealth teaching regarding the importance of restricting diet

A – ssess for any adverse effect of the medication

R – egular check-up

G – ive the importance in taking the medication

E – ncourage to follow the prescribed medication at home

20 OUR LADY OF FATIMA UNIVERSITY

A CASE PRESENTATION

PRESENTED

BY

BSN 4D2-3/GROUP 131

MEMBERS:

Mendenilla, Dyan Gracile

Molina, Jose Antonio

Mondragon, Hairiya Rahima

Pasamba, Mark Carlo

Pasubilio, Crispino

Perez, Joanna Marie

Punzal, Michael Mon

Puyat, Ma. Razelyn

Ramos, Arilles Clair

San Antonio, Madeline

San Antonio, Mary Joyce

Sario, Jefherson

DECEMBER 2009

TABLE OF CONTENTS

INTRODUCTION ----------------------------------------------------------------------- 1-3

PATIENT’S PROFILE ----------------------------------------------------------------- 4

PHYSICAL ASSESSMENT ----------------------------------------------------------- 5

ANATOMY AND PHYSIOLOGY -------------------------------------------------- 6-7

PATHOPHYSIOLOGY ---------------------------------------------------------------- 8

DIAGNOSTICS EXAMINATION --------------------------------------------------- 9-10

MEDICAL MANAGEMENT --------------------------------------------------------- 11-15

NURSING CARE PLAN --------------------------------------------------------------- 16-18

COURSE IN THE WARD -------------------------------------------------------------- 19

DISCHARGE PLANNING ------------------------------------------------------------- 20