Acute glomerulonephritis
Table of contents
I. a. b. c. Introduction Overview of the Case Objective of the Study Scope and Limitation of the Study
II. Health History a. Profile of patient b. Personal Health History c. History of Present Illness d. Chief Complaint III. Developmental Data
IV. Medical Management a. Medical Orders and rationale b. Drug study V. Pathophysiology with Anatomy and Physiology VI. Nursing Assessment (System Review & Nursing Assessment II) VII. Nursing Management a. Ideal Nursing Management (NCP) b. Actual Nursing Management (SOAPIE) VIII. IX. Referrals & Follow-up Evaluation and Implications
X. Bibliography
I. INTRODUCTION
A. Overview of the Case
Acute Glomerulonephritis is the disease of the kidney in which there is an inflammation of the glomerular capillaries. In most cases, the stimulus of the reaction is group A streptococcal infection, which ordinarily precedes the onset of glomerulonephritis by 2 to 3 weeks.
B. Objective of the Study
The study generally aims to investigate the condition of an adult man and further understand the extent of the case.
Specifically, the health care provider sought to; Perform Physical Assessment, Data Base and History taking that solidifies the present diagnosis of the client. Identify the development and changes encountered by the client. Identify the nursing problems which will be the basis of the care plan. Develop Plan of the Care and Implement nursing interventions relevant and suitable for the case.
As nursing students they will be able to improve their skills in accordance to patients needs and condition.
The purpose of the study is to gather significant data to broaden our knowledge with regards to the condition of the patient and to improve our abilities as future health care providers. Moreover, this case study will enable us to apply the acquired skills we obtained in the classroom set-up.
C. Scope and Limitation of the Study
The study focuses only on one of the many problems of the kidney, mainly the glomerulonephritis and its causes and effects on patients that are being diagnosed to it. Also, the study tackles on how this problem is being acquired.
II. HEALTH HISTORY
A. Clients Profile
Name Wife Address Civil Status Sex Age Religion Educational Status Income Nationality Date of Admission Time of Admission Informant Height Weight : : : : : : : : : : : : : : : Lisdan, Elpedio N. Lisdan, Jemma San Rafael, Talakag, Bukinon province Married Male 42 years old Roman Catholic Elementary level 2,000 php/month Filipino January 27, 2009 9:10 am Patient 158 centimetres 52 kg
Vital Signs during Assessment
Temperature Pulse Rate Respiratory rate Blood Pressure : : : : 36.7 C 55 bpm 20 cpm 150/110 mmHg Acute Glomerulonephritis related to nephritic syndrome; hypertension Dr. Joseph Borong
Admitting Diagnosis : Attending Physician :
B. Family and Personal Health
Patients History
Allergies: - No known allergies on foods and drugs. Injuries/ Accident in the past: - Patient had not experience injuries or accident in the past. Blood Transfusion: - Patient didnt receive blood in the past. Family health history: - Experienced Hypertension and Kidney disorder (2006)
Social History
Alcohol use: - Patient occasionally drinks alcoholic beverages, as seldom as once in 2 months. Tobacco use: - Patient often smokes. Home and Environment: - Resides at San Rafael, Talakag - Living status is just enough for their family needs
C. Chief Complaint and History of Present Illness
Noted to have edema; condition noted for a week prior to admission as onset of fever on and off associated with dysuria tea colored urine.
III. DEVELOPMENTAL DATA
The Developmental Stages of Erik Erickson
Middle Adulthood: 35 to 65: Generativity vs. Self absorption or Stagnation Now work is most crucial. Erickson observed that middle-age is when we tend to be occupied with creative and meaningful work and with issues surrounding our family. Also, middle adulthood is when we can expect to "be in charge," the role we've longer envied. The significant task is to perpetuate culture and transmit values of the culture through the family (taming the kids) and working to establish a stable environment. Strength comes through care of others and production of something that contributes to the betterment of society, which Erikson calls generativity, so when we're in this stage we often fear inactivity and meaninglessness.
Freud's Psychosexual Stages of Development
The Genital Stage In the genital stage, as the child's energy once again focuses on his genitals, interest turns to heterosexual relationships. The less energy the child has left
invested in unresolved psychosexual developments, the greater his capacity will be to develop normal relationships with the opposite sex. If, however, he remains fixated, particularly on the phallic stage, his development will be troubled as he struggles with further repression and defenses.
Robert Havighurst Developmental Task Theory
Middle Adulthood (30-60 years) Achieving adult social and civic responsibility; Reaching and maintaining satisfactory performance in ones occupational career; Developing adult leisure time activities; Relating oneself to ones spouse as a person; To accept and adjust to the physiological changes of middle age; Adjusting to aging parents. Assisting teenage children to become responsible and happy adults; achieving adult social and civic responsibility.
Piaget's Theory of Cognitive Development
Formal operational stage (Adolescence and adulthood) In this stage, intelligence is demonstrated through the logical use of symbols related to abstract concepts. Early in the period there is a return to egocentric thought. Many people do not think formally during adulthood.
IV. MEDICAL MANAGEMENT
A. Medical Orders and Rationale
Doctors Order 01/27/09 Please admit TPR q 4h Full low salt, low fat diet To monitor patients medical condition and proper management. To monitor any abnormal changes in vital signs For proper nourishment and for prevention of disease that may lead to severity of the condition To promote good nutritional status To monitor body fluids & prevent dehydration For treatment of hypertension, edema associated with CHF, cirrhosis and renal disease For treatment of lower respiratory infection, UTI & dermatologic infection First line treatment for heartburn and short term treatment of active duodenal ulcer Treatment for pulmonary tuberculosis that is not responsible to 1st line antituberculosis For proper hydration of the patient and carefully monitor the fluid losses Rationale
Give 1 egg white a day 0.9 NaCl @ KVO rate Furosemide i amp q 12h x 3doses
Cefuroxime 750 mg q 8h IVTT
Omeprazole 20mg icap OD P.O. Captopril 25mg itab BID P.O.
I & O q shift
01/28/09
IVF 0.9 NaCl @ KVO rate Spironolactone 50mg itab TID P.O. Continue meds. Weight patient daily pre-breakfast
To monitor body fluids & prevent dehydration To counteract potassium loss caused by other diuretics To treat the disease & remove the symptoms To monitor if the symptoms are relieved
01/29/09 Continue meds. IVF of D5nm iL @ KVO rate To treat the disease & remove the symptoms To monitor fluids
B. Drug Study
Generic Name of Ordered Drug Cefuroxime Date Ordered Classification Dose/ Frequency/ Route 750 mg q 8h IVTT Mechanism of Action Specific Indication Contraindication Side Effects/ Toxic Effects Hypersensitivity, nephrotox icity, pain at injection site Nursing Precaution
01/27/09
Antibiotic (Cephalos porin 2nd generatio n)
Inhibits synthesis of bacterial cell wall, causing cell death.
For lower respiratory infection, UTI & derma tologic infection
Contra indicated with allergy to cephalosporin or penicillins
Assess for hepatic or renal impairment Assess for skin status Check for sensitivity tests
Generic Name of Ordered Drug Furosemide
Date Ordered
Classification
Dose/ Frequency/ Route
Mechanism of Action
Specific Indication
Contraindication
Side Effects/ Toxic Effects Polyuna, Nocturia, Rash, Anemia, Muscle spasms, Cardiac arrythmia s
Nursing Precaution
01/27/09
Loop Diuretic
Amp of 12h x 3 doses
Inhibits reabsoption of Na and Cl from the proximal and distal tubules and ascending limb of the loop of Henle, leading to a Na-reach diuresis
Hypertension, Edema associated with CHF, cirrhosis and renal disease
Contraindicat es allergy to furosemide; anuria, hepatic coma
Assess for allergy to furosemide Assess for skin color, lesions and edema CBC, serium electrolytes
Generic Name of Ordered Drug Omeprazole
Date Ordered
Classification
Dose/ Frequency/ Route
Mechanism of Action
Specific Indication
Contraindication
Side Effects/ Toxic Effects Rash, alopecia, nausea, vomiting Epistasis, fever
Nursing Precaution
01/27/09
Antisec retory drug; Proton Pump Inhibito r
20mg icap OD P.O.
Gastric acid First line Contrapump treatment indicated with inhibitor: for hyperSupresses heartburn sensitivity to gastric acid and short omeprazole or secretion by term its specific treatment of component. inhibition of active Use hydrogenduodenal cautiously K ATPase ulcer pregnancy enzymes lactation system at secretory surface of the gastric parietal cells.
Assess for hypersensiti vity to omeprazole Assess for skin lesions Assess for urinary output
Generic Name of Ordered Drug Captropil
Date Ordered
Classification
Dose/ Frequency/ Route
Mechanism of Action
Specific Indication
Contraindication
Side Effects/ Toxic Effects Polyuria, Tachycardia, proteinuri acough dry mouth
Nursing Precaution
01/27/09
ACE inhibito r
25mg itab BID P.O.
Polypeptide Antibactic; against Mycobacter ium tuberculosis
Treatment hypertension
Contraindicated allergy to capreomycin; pre-existing auditory impairment
Assess for allergy to captropil Assess for skin color and lesions For CBC and differential
Generic Name of Ordered Drug Spironolactone
Date Ordered
Classification
Dose/ Frequency/ Route
Mechanism of Action
Specific Indication
Contraindication
Side Effects/ Toxic Effects Clumsy Headache Dyscrasia s
Nursing Precaution
01/28/09
Diuretic s
50mg itab TID P.O.
Cause loss of sodium bicarbonate and calcium while saving potassium and hydrogen ions
To counteract potassium loss caused by other diuretics
Hypersensitivity; Hyperkalemia
Monitor intake & output Daily weight during therapy Monitor BP before administering
V. PATHOPHYSIOLOGY
VI. ASSESSMENT
EENT:
[ ] impaired vision
[ ] blind GENITO URINARY and GYNE: [x] pain [x] urine color [ ] vaginal bleeding [ ] hermaturia [ ] discharge [ ] nocturia [ ] no problem
[ ] pain [ ] reddened [ ] drainage [ ] gums [ ] hard of hearing
[ ] deaf [ ] burning [x] edema [ ] lesion [ ] teeth [ ] no problem
RESPIRATORY: [ ] asymmetric [ ] tachypnea [ ] apnea [ ] rales [x] cough [ ] barrel chest [ ] bradypnea [ ] shallow [ ] rhonchi [x] sputum [ ] diminished [ ] dyspnea [ ] orthopnea [ ] labored [ ] wheezing [ ] pain [ ] cyanotic [ ] no problem
NEUROLOGICAL: [ ] paralysis [ ] stuporous [ ] unsteady [ ] seizures [ ] vertigo [ ] vision [ ] lethargic [ ] tremors [ ] grip [ ] comatose [ ] confused [x] no problem
MUSCULOSKELETAL: [ ] appliance [ ] stiffness [ ] petechiae [ ] hot [ ] swelling [ ] itching [ ] drainage [ ] lesion [ ] deformity [ ] skin color [x] pain
CARDIO VASCULAR: [ ] arrhythmia [ ] tachycardia [ ] numbness [ ] diminished pulses [ ] edema [ ] fatigue [ ] irregular [ ] bradycardia [ ] murmur [ ] tingling [ ] absent pulses [x] pain [ ] no problem
[ ] prosthesis
[ ] poor turgor [ ] cool [ ] wound [ ] flushed [ ] rash [ ] atrophy
[ ] ecchymosis [ ] diaphoretic [ ] moist [ ] no problem
GASTRO INTESTINAL TRACT: [ ] obese [ ] distension [ ] mass [ ] dysphagia [ ] rigidly [ ] pain [x] no problem
NURSING ASSESSMENT II
SUBJECTIVE
COMMUNICATION: [ ] Hearing Loss [ ] Visual Changes [x] Denied Comments: wala man wala gihapon As verbalized by the husband [ ] Glasses [ ] Contact lens R L Pupil Size: 3-5 mm Reaction: PERRLA
OBJECTIVE
[ ] Language [ ] Hearing Aide [ ] Speech difficulties
OXYGENATION:
[ ] dyspnea [ ] smoking history Oftentimes [x] cough [x] sputum [ ] denied Comments: Nah! gapanigarilyo mana siya -giubo pd siya karon oh. As verbalized by the wife Comments: Sakit! bug-at nanghubag na man gni ako mga tiil As verbalized by the patient
Respiratory: [x] regular [ ] irregular Describe: regular breathing but associated with pain Right: Right lung is symmetrical to left lung. Left: Left lung is symmetrical to right lung. Heart Rhythm [x]regular [ ] irregular Ankle Edema: present in lower extremities Pulse Carotid Radial DP Femoral Right: 62 65 60 not assessed Left: 62 65 60 not assessed Comments: Pulse sites are palpable and its rate are within normal range. [ ] dentures Upper Full [] Partial [ ] [ ] [x] none With Patient [ ] [ ]
CIRCULATION:
[ ] chest pain [x] leg pain [x] numbness of extremities [ ] denied
NUTRITION: Diet: DAT but decreased fluid intake
[ ]N [ ]V Character [ ] recent charge in weight, appetite [ ] swallowing Difficulty [x] denied Comments: Wala manpermanente nay gana As verbalized by the patient
Lower []
ELIMINATION:
Usual bowel pattern Once a day [ ] constipation Remedy January 27, 2009 Date of last BM [ ] diarrhea character [ ] urinary frequency once daily [ ] urgency [x] dysuria [ ] hematuria [ ] incontinence [ ] polyuria [ ] foly in place [ ] denied Comments: urinate once daily due to pain and excrete small amount. Bowel Sounds: Audible sounds Abdominal Distention: Present [ ] Yes [x] No Urine (color, consistency, odor) tea color of urine, inconsistent
MANAGEMENT OF HEALTH & ILLNESS:
[x] alcohol [ ] denied (amount, frequency) Occasionally once in 2 months [ ] SBE Last Pap Smear: N/A LMP:
Briefly describe the patients ability to follow treatments (diet, meds, etc.) for chronic health problems (if present):
The patient is properly following her medications
SUBJECTIVE
SKIN INTEGRITY: [ ] dry [ ] itching [x] other - edematous [ ] denied Comments: wala man - nanghupong lang ko as verbalized by the Patient.
ACTIVITY/SAFETY: [ ] convulsions Comments: dili man [ ] dizziness hinuon, bug-at lang [ ] limited motion of joints gyud ako tiil Kay nanghupong Naman kaya Limitation in man hinuon nako. ability to as verbalized by the [ ] ambulate patient [ ] bathe self [ ] other [x] denied COMFORT/SLEEP/AWAKE: [ ] pain Comments: ok (location, raman hinuon Frequency, As verbalized Remedies) by the patient. [ ] nocturia [ ] sleep difficulties [x] denied COPING: Occupation : Farmer Members of household: 6 Most supportive person: Wife
SPECIAL PATIENT INFORMAT ION
_____________ __ Daily weight _____________ __ PT/OT _____________ ____ _____________ __ BP q shift _____________ __ Irradiation
_____________ __ Neuro VS _____________ _ Urine test _____________ __ _____________ __ CVP/SG. Reading ________ _____________ _ 24 hour urine collection
Date Ordered 01/27/09 01/27/09
Diagnostic/laboratory exams CBC Urinalysis
Date done 01/27/09
Date ordered 01/27/09
I.V. Fluids/Blood 0.9 Nacl iL @ KVO rate
Date disc.
VII. NURSING MANAGEMENT
A. Ideal Nursing Management Nursing Diagnosis:
Excessive fluid volume related to glomerulonephritis INTERVENTIONS Monitor intake and output Observe for fever Elevate edematous extremities, change position frequently After elevating, place in semi-fowlers position Provide quiet environment Administer furosemide I amp of 12h as prescribed by the
RATIONAL
To check fluid balance and pre
To check for infection since the
To reduce tissue pressure and r
To facilitate movement of diap respiratory effort
To promote ventilation and lim For the treatment for edema
physician
Nursing Diagnosis:
Ineffective airway clearance related to productive cough INTERVENTIONS Assess the airway patency
RATIONAL To check the effectivity of the management
Elevate the head part of the bed/change position q 2h
To enhance drainage of/ventila segments
Encourage deep-breathing and coughing exercise Monitored the fluid intake Instruct to have proper clothing, not too tight and not too loose
To mobilize secretions To help liquefy secretions and
To provide warm body/environ
Nursing Diagnosis:
Acute pain related to edema INTERVENTIONS
RATIONAL Because vital signs are altered
Monitor vital signs Acknowledge patients verbalization of pain & allow him to describe it Perform pain assessment each time occurs
Pain is subjective experience o can felt about it
To rule out worsening of under complication
Elevate edematous extremities, change position frequently Provide quiet environment Administer Spironolactone 50mg itab TID P.O. as prescribed by the physician
To reduce tissue pressure and r
To promote ventilation and lim For the treatment for edema
B. Actual Nursing Management S
Bug-at lang akong tiil kay nanghupong naman ko. As verbalized by the patient
Edema Oliguria Restlessness
Fluid volume excess related to Glomerulonephritis
Long term: At the end of 2 days, pt. will be able to lessen or diminished the symptoms of glomerulonephritis that produces excessive fluid. Short term: At the end of 8 hours, the pt. will be able to reduce the excessive fluid volume.
1) 2) 3) 4)
Monitor vital signs especially temperature To check & assess for infection since the pt. has a higher risk Monitor intake & output To monitor & check fluid volume & prevent dehydration Elevate the edematous extremities To reduce tissue pressure & risk in skin breakdown Place in a semi-fowlers position, change position frequently To facilitate movement of diaphragm & improve respiratory effort 5) Administer furosemide 1 ampule every 12h as prescribed by the physician For the treatment of edema At the end of 8 hrs, the pt reduces the excess fluid in his body thru excretion of stored fluids.
HEALTH TEACHINGS
Name of Patient: Gloria Yabo
Encourage to follow the dosages and proper timing of his meds. Such as the Furosemide 1 ampule every 12hours x 3doses, Omeprazole 20mg 1capsule once a day, Captopril 25mg 1tablet twice a day, & Spironolactone 50mg 1 tablet thrice a day. As prescribed by his physician. Encourage bed rest and frequent changes of position, early ambulation, and deep breathing exercise.
MEDICATIONS
EXERCISE
TREATMENT
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.
OUT-PATIENT (Check-up)
Encourage pt. that when his discharged, he must have a regular check-up to his physician until its needed. To evaluate the progress of his condition. Instruct to limit intake of salty & fatty foodsand enrich/increase the intake of foods rich in potassium such as bananas
DIET
VIII. REFERRALS AND FOLLOW-UP
Since the patient is suffering from Acute Glomerulonephritis, it is advised for him to stay in the hospital for a better and thorough management regarding on her condition. Acute Glomerulonephritis are very critical in a mans condition that is why the patient needs an urgent hospital service for him to be monitored every now and then. If the doctor has already approved the release or discharge of the patient from the hospital, the patient is highly advised to have a regular check-up on her personal physician to take out the risk from the said ailment. If the patient will again suffer the Acute Glomerulonephritis, it is best for him to be admitted to a tertiary-leveled hospital for better monitoring of his critical condition, knowing that even a single mistake worsen his condition.
IX. EVALUATION AND IMPLICATIONS
After conducting this care study, I was able to appreciate more the essence of utilizing the nursing process in the care and management of my patient. It was indeed a tough job on conducting this study yet, it gave me a big impact regarding how useful it is in my chosen profession. Nursing really demands a tender loving care attitude. It demands patience and it is calling that cannot be merely taken for granted. Moreover, this care study taught us to stand on our own by not depending on others just to make this. This provides us, the students, a big learning regarding on how well we take care of or patients in the real clinical setting. Most of all, this study teaches the students to provide clients care more efficiently and competently to achieve an effective and quality nursing care.
X. BIBLIOGRAPHY Doenges, Marilyn E. et.al Nurses Pocket Guide: Diagnoses, Interventions and Rationale. 9th edition pages 278-279, 472-477, 576-578 F. A Davis Company Philadelphia, 2004.
Lippincott Williams & Wilkins, Manual of Nursing Practice, 8th edition, volume 1.
Deglin, et al. Daviss Drug Guide for nurses, 9th edition. Smeltzer, Suzanne C. et al. Textbook of MedicalSurgical Nursing, 11th edition, volume 2.
