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.

Causes of acute glomerulonephritis include postinfectious, renal, and systemic etiologies.

Each is described briefly.

• Postinfectious etiologies
 ○ 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.
○ Other specific agents include viruses and parasites, systemic and renal
disease, visceral abscesses, endocarditis, infected grafts or shunts, and
pneumonia.
○ 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.
○ 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
○ 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 causes
○ Vasculitis (ie, Wegener granulomatosis causes glomerulonephritis that
combines upper and lower granulomatous nephritides).
○ Collagen vascular diseases (ie, systemic lupus erythematosus causes
glomerulonephritis through renal deposition of immune complexes).
○ Hypersensitivity vasculitis encompasses a heterogeneous group of
disorders featuring small vessel and skin disease.
○ Cryoglobulinemia causes abnormal quantities of cryoglobulin in plasma
that result in repeated episodes of widespread purpura and cutaneous
ulcerations upon crystallization.
○ Polyarteritis nodosa causes nephritis from a vasculitis involving the renal
arteries.
2
○ Henoch-Schönlein purpura causes a generalized vasculitis resulting in
glomerulonephritis.
 ○ Goodpasture syndrome causes circulating antibodies to type IV collagen
and often results in a rapidly progressive oliguric renal failure (weeks to
months).
○ Drug-induced (ie, gold, penicillamine)

• Renal diseases
○ Membranoproliferative glomerulonephritis is due to the expansion and
proliferation of mesangial cells as a consequence of the deposition of
complements.
○ Type I refers to the granular deposition of C3; type II refers to an irregular
process.
○ Berger disease (IgG-immunoglobulin A [IgA] nephropathy)
glomerulonephritis results from a diffuse mesangial deposition of IgA and
IgG.
○ 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.

Patients Profile
Name: Avila, Sonny Sarmiento
Age: 39 years old
Address: Sta, Ana Bulacan, Bulacan
Birthdate: May 22,1970
Religion: Roman Catholic
Race: Filipino
Place of admission: Gregorio del Pilar District Hospital
Date of admission: Dec. 03,2009
Chief Complaint: Fever and frequent urination for 2 weeks
Admitting 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.

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
.

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.

6
• 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.

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

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

10

DRUG STUDY

Medication Class Action Indication Contra- Adverse Drug to Drug to Nursing

indica- Effects drug lab-test Considera-
tion interaction interaction tions

Generic Anti- Anti- • Analgesic- •Contrain • CNS: Increased Inter- • Assess for
name: pyretic pyretic: Antipyretic dicated Headache toxicity ference allergy to
Acetamino- Reduces in patients with with long with acetami-
phen/Para- Anal- fever by with aspirin allergy to • CV: term, Dextrostix nophen/para
cetamol gesic acting allergy, acetami- Chest pain, excessive cetamol,
directly hemostatic nophen/ dyspnea, ethanol pregnancy,
Brand on the distur- parace- myocardial ingestion lactation,
 name: hypothal bances. tamol damage chronic
Biogesic amic Possible alcoholism
heat- • arthritis •Use • GI: decreased
regula- and cau- Hepatic effec- • Do not
ting rheumatic tiously toxicity and tiveness exceed the
center to disorders with failure, of zidovu- recom-
cause involving impaired jaundice dine mended
vasodi- musculo- hepatic dosage
lation skeletal function, • Hyper-
and pain. chronic sensitivity: • Consult
sweating alcoho- Rash, fever physician if
which • Common lism, needed for
helps cold, flu, preg- children <3
dissipate other viral nancy, yrs.
heat. and lactation
bactericidal •Disconti-
Analge- infections nue if
sic: with pain hypersen-
Site and and fever. sitivity
mecha- occurs
nism of
action
unclear.

11
DRUG STUDY

Medication Class Action Indication Contra- Adverse Drug to Drug to Nursing

indicatio Effects drug lab-test Considera-
n interaction interaction tions

Generic Anti- Bacteric Oral •Contrain • CNS: Increased Possibility • Arrange

name: biotic idal: (cefuroxime dicated Headache, nephroto- of false for
Inhibits axetil) with Dizziness, xicity results on sensitivity
synthe- allergy to Lethargy with tests of test before
sis of •Pharyn- cephalos- Paresthesia aminogly- urine and during
Brand bacterial gitis, porins cosides, glucose therapy if
name: cell tonsillitis or peni- • GI: using expected
wall, caused by cillins. Nausea Increased Benedict’s response is
Ceftin; causing strepto- Vomiting bleeding sol’n, not seen.
Zinacef cell coccus • Use Diarrhea effects Fehling’s
death. pyogens cautious- Anorexia with oral solution, • Give oral
ly with Abdominal anticoa- Direct drug with
• Otitis renal pain gulant Coomb’s food
media failure, Flatulence test to decrease
caused by lactation, Liver to- GI upset
S. pneumo- preg-- xicity and enhance
niae, nancy. absorption
Haemo- • GU:
philus Nephro- • Have Vit.
influenzae, toxicity K available
S. pyogens hypopro-
•Hemato- thrombinem
• UTIs logic: ia occurs.
caused by Bone
E. coli, marrow •Disconti-
Klebsiella depression nue if
pneumoniae hypersen-
•Hyper-sensi sitivity
• Treatment tivity: occurs.
of early Ranging
Lyme dse. from rash to Teaching
fever to points
Parenteral anaphylaxis
(cefuroxime • Take full
sodium) • Local: course of
Pain, therapy
• Lower abscess at even
respiratory infection if you are
infections site, feeling
caused by phlebitis, better.
S. pneumo- inflam-
niae, S. mation at IV • You may
aureus, E. site experience
coli, these side
Klebsiella, • Other: effects:
S. pyogens Superinfec- stomach
tions upset or
•Septice- diarrhea
mia caused
by S. • Report
pneumo- severe
niae, E. diarrhea
coli, S. with blood,
influenzae, pus or
Klebsiella mucus,
rash,
•Meningitis difficulty
caused by breathing,
 S. aureus, bruising,
N. meningi- unusual
tidis, S. itching or
pneumoniae irritation.

• Periopera- Parenteral
tive Drug
prophylaxis
• 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.

19

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