ANGELES UNIVERSITY FOUNDATION COLLEGE OF NURSING ANGELES CITY

Nursing Care Management Of A Pediatric Patient Diagnosed with AGN

SUBMITTED TO Mr. Arnold Esguerra, RN

PREPARED BY De Vera ,Jerome Indiongco, Cristine Libres, Mary Angelica Teoffy Meneses, Maria Cristina

BSN III-4 GROUP # 15

I. Introduction

Acute Glomerulonephritis Acute glomerulonephritis (AGN) refers to a specific set of renal diseases in which an immunologic mechanism triggers inflammation and proliferation of glomerular tissue that can result in damage to the basement membrane, mesangium, or capillary endothelium. Hippocrates originally described the manifestation of back pain and hematuria, which lead to oliguria or anuria. With the development of the microscope, Langhans was later able to describe these pathophysiologic glomerular changes. Most research focuses on the post streptococcal patient. Acute

glomerulonephritis is defined as the sudden onset of hematuria, proteinuria, and red blood cell casts. This clinical picture is often accompanied by hypertension, edema, and impaired renal function. AGN can be due to a primary renal or systemic disease. Studies by two leading hospitals in Metro Manila indicate that the most common underlying diseases for ESRD (end-stage renal disease) are chronic glomerulonephritis, chronic pyelonephritis, diabetes mellitus and hypertensive nephrosclerosis. In short, deaths from renal causes are the consequences of prolonged or uncontrolled assault of infectious or metabolic agents on the kidneys and are regarded as degenerative. Studies indicate that around 9,500 Filipinos develop fatal diseases of the kidneys annually. It is expected to increase proportionately with the incidence of degenerative or lifestyle-related diseases like poor hygiene practices. In the United States, 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 populations. Despite sporadic outbreaks, incidence of poststreptococcal glomerulonephritis has fallen over the last few decades. In the international view it has been found that with some exceptions, a reduction in the incident of post streptococcal 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 South America.

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%. A male-to-female ratio of 2:1 has been reported which means that males tend to become more affected by the condition rather than the females. 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. No More Dialysis Immunologists Develop Method to Decrease Rejections of Kidney Transplants October 1, 2007 A nephrologist has found that a specialized type of anti-rejection therapy using intravenous immunoglobulin can make kidney transplants possible for patients with high 'anti-donor' antibodies. 25 to 30 percent of patients on the kidney transplant list could benefit from this therapy. Tissue compatibility issues exist with any organ transplant, but the risk is greatly increased for those with high exposure to antigens received through blood transfusions, previous transplantation, or even pregnancy. Seventy-thousand Americans are waiting for a kidney transplant. A third of them are parked on dialysis because their antibody levels are too high for a transplant. But that's no longer a barrier for some people. Dialysis is something Kohanzadeh would rather forget, but if telling her story saves lives, it's worth it. Kohanzadeh -- like many kidney failure patients -- developed high levels of "antidonor" antibodies through blood transfusions. Her highly sensitized immune system would likely reject any donated kidney. But Kohanzadeh is no longer here, thanks to intravenous immunoglobulin therapy or IVIG. Here's how it works: during dialysis, patients are given blood containing a mix of immunoglobulins, which "turn-off" the anti-donor antibodies' attack response without suppressing the patient's immune system. Through their website, this mother-daughter team works to spread the word of a little known therapy that could save thousands in need of a kidney. IVIG is

covered by Medicare and can be used in both living and cadaver-donor transplants. Nearly 30 percent of patients on the kidney transplant list might benefit from this therapy. BACKGROUND: About one-third of kidney patients are often told they cannot have a transplant even if they have a donor with an otherwise perfectly matched tissue and blood type. Their anti-donor antibody levels are so high that any transplanted organ would be rejected by their highly sensitized immune system. Now there is a specialized type of anti-rejection therapy using intravenous immunoglobin (IVIG), which injects antibodies from healthy people into the blood supply, to modulate the immune system without suppressing it. This makes kidney transplant possible for as much as 25-30% of this group of patients, who would otherwise not be eligible for a transplant because of their high antibody levels. DEALING WITH REJECTION: Tissue compatibility is an issue for all patients receiving organ transplants, but rejection risks are much higher for those with high exposure to human leukocyte antigens (HLAs) that are not produced by their own bodies. Exposure may be the result of blood transfusions, previous transplantation, or even pregnancy if the mother is exposed to the father's antigens, which are then expressed in the cells of the developing fetus. The immune system is then 'sensitized' to those antigens -- primed with antibodies that attack any foreign tissue, even if the antigens arrive in the form of a life-saving donated organ. Reasons why the group chose acute glomerulonephritis are to have an overview and to know the factors which primarily may cause the disease. Knowledge regarding the disease is very important to aid in the prevention and possible treatment of its occurrence. This case study leads to a broader knowledge regarding the disease and to understand the factors that lead in the occurrence of the disease. This may be useful for future nurses to be equipped with adequate knowledge in the care of patients with the disease and may apply certain preventive measures.

Objectives: After the completion of the study, the student nurses shall have: Able to know the risk factors about the disease condition Knowledge about the disease condition Determine the degree of impairment Assess level of progress Assess causative/contributing factors about the underlying disease condition Correct/minimize growth deviations and associated complications. Determine degree of deviation from growth/developmental norms

After the completion of the study, the patient/SO shall have: Patient/SO is able to express feelings and concerns appropriately. Patient/SO be able to identify precipitating factors contributed to the patient disease Patient/SO be able to verbalized ability to cope adequately with existing situation, provide support/monitoring Patient/SO be able to adopt lifestyle changes necessary for the patients wellness and recovery as well as to prevent further complication of the disease. Patient/SO will verbalize desire to seek higher level of wellness Patient/SO will be able to set their own progress short-term goals that could had to the patient recovery, wellness and prevention of further complications. Patient/SO will able to identify long-range needs of the client and who will be responsible for actions to be taken Patient/SO is able to verbalize understanding of illness, treatment regimen and prognosis.

II. Nursing Assessment 1. Personal Data Our patient is Baby AGN, female, five years of age and currently residing at Baliti, Arayat Pampanga. A Filipino and naturally born Kapampangan on August 05, 2002 at Magalang Pampanga. Her parents are Mr. AGN and Mrs. AGN. She was admitted last June 20, 2008 (Friday) 7:15 pm at a secondary type of government hospital. The patient was discharged last June 26, 2008. The group had their assessment, patient, interaction & interview for 2 days in the Pedia Ward of the said hospital. 2. Pertinent Family History After establishing rapport with the patient and her significant others, we interviewed the SO and asked some question about their family history. The family of Baby AGN is a nuclear type of family. Mr. & Mrs. AGN are blessed for having five children, two girls & three boys. Baby AGN is the fourth child of her parents. She is a preparatory student at the Baliti, Arayat Elementary School. Mrs. AGN gave birth to her five children by a Normal Spontaneous Delivery (NSD) in a hospital at Arayat Pampanga. All of her children were delivered through a NSD in the said hospital. Mrs. AGN still believes in the possible complications of pregnancy thats why she doesnt want to have a home delivery. Mr. AGN is a farmer in Baliti, Arayat. He was also diagnosed to have a kidney disease together with his brother (uncle of Baby AGN) but had been treated, the informant doesnt know the specific kidney disease, according to him he manifested malaise, nausea and abdominal cramps) last 1998. Mrs. AGN is a housewife. The family lives in a 200 square meter house with an adequate ventilation due to the presence of five windows. The house is concrete built surrounded by some farm land. Total number of members in the family is seven with five children, the eldest is a thirteen year old male, next is a eleven year old male, nine year old female, five year old female and four year old male. Mr. AGN earns around Php 2,000 a month. The familys religion is Catholic. Mrs. AGN included that they attend the mass. About their cultural beliefs and practices, they do not consult herbularios/ albularios but

rather choose to seek for medical advice from the physician when someone in the family experiences some illness.

SCHEMATIC DIAGRAM OF THE FAMILY HEALTH-ILLNESS HISTORY

Father side Grandfather Grandmother Mother side Grandfather Grandmother

Uncle

Uncle

Father (Mr. AGN)

Aunt

Aunt

Mother

(Mrs. AGN)

Legend: Male Female

No health problem With kidney disease

Died With AGN

Looking at the legend of the family history of Baby AGN, her grandfather in mother side died because of old age and her grandparents in her father side doesnt have any health problem and are still living. Her parents are still alive, and her father was diagnosed with a kidney disease. Among the five children, only baby AGN have been diagnosed with acute glomerulonephritis.

3.

Personal History According to Mrs. AGN, her menarche started at the age of twelve years old

during sixth grade. During the pregnancy of Mrs. AGN, she didnt experience any problem in giving birth to her five children. She gave birth to her children with no specific birth gap. Her eldest was born in the year 1994, next child was born in the year 1996, the third child was born in year 1998, the fourth child was born in 2002 and the youngest was born in the year 2003. As said in the family history, she gave birth through Normal Spontaneous Delivery (NSD) in the hospital. She doesnt consult a hilot or kamadrona. Mrs. AGN had a full age of gestation (the informant has forgotten her LMP). Mrs. AGN breastfed her five children. According to Baby AGNs mother, she had a complete immunization during her infancy stage at their Health center in Baliti, Arayat. Frueds Personal Development: Preschooler: Phallic stage Childs personality development appears to be non-reactive or dormant. Help the child to have positive experiences as his/her self-esteem continues to grow and child prepares for the conflict of adolescence.

In this stage, child learns sexual identity through awareness of genital area. Baby AGN is assisted by Mrs. AGN on the meticulous guidance on what to know and expect about her sexual identity to prevent confusion and establish understanding. In addition, Mrs. AGN practices Baby AGN on the proper care towards the childs genital area.

Ericksons Personality Development: Initiative vs. Guilt

Preschooler child development task is to form a sense of initiative versus

guilt. Child is introduced to the teachers. Mrs. AGN accompanies her daughter for several days in school since in this stage the child fears to be left out.

Baby AGN enjoys playing games when she gets home from school. She is a

talkative child but seems silent when she feels sick or ill. On the days of hospitalization of Baby AGN, she was silent primarily because she was weak and the condition that she had was making her feel uncomfortable.

Piagets Stage of Cognitive Development: Preconventional Thought(2-7 y)

Preconventional thought has not yet developed the sense of time. It also

includes that the child must be presented of a specific activity to be able to know what will happen by that time. Baby AGN achieve this development by telling her other family members that her father is about to leave for work whenever she sees him gathering his things for work. Baby AGN is capable of drawing a straight line, circle, square and triangle or diamond. She can drive a three wheel bike.

Baby AGN takes a bath and brushes her teeth before she goes to school

and takes a half bath before going to sleep but she does not brushes her teeth anymore. Kohlbergs Stage of Moral Development: Preconventional (Level 1) (4-7)

Preconventional includes individualism. Starts to develop sense of

instrumental purpose and exchange.

Baby AGN shows a characteristic of being possessive. Whenever she

arranges her things for school she wanted to elaborate her own things not to be used by her other siblings . 4. History of Past Illness Based on our interviews, Mrs. AGN told us that Baby AGN had no minor hospitalization prior to admission and claims (she wasnt diagnose and didnt take any medications) to have asthma when she was 3 years old. They used to not allow Baby AGN become exhausted and kept her from allergic causing objects. Baby AGN had some minor illnesses such as fever, colds and chicken pox. The family consults the Health Care Provider for medical assistance.

5.

History of Present Illness

Days before Baby AGNs hospitalization, she had acquired a streptococcal infection which resulted to an Upper Respiratory Tract Infection. Due to a bad hygienic practices which includes a once a day routine of brushing of teeth that lead to streptococcal infection. Few hours prior to admission, Baby AGN had an undocumented fever and edema. This prompted the family to consult a clinic in Arayat, Pampanga. The assessment in the clinic revealed an elevated blood pressure and diagnosed that the patient have an Acute Glumerulonephritis. The hospital didnt do any treatment because they can no longer handle the condition of Baby AGN (we dont know the specific medications but according to our informant, they gave some medications. But our informant was not there so she cant tell the specific medications that Baby AGN had taken) so Baby AGN was referred to the secondary type of government hospital. Upon admission, Baby AGN still manifested fever accompanied by facial edema, hematuria and elevated BP 140/80. She was admitted last June 20, 2008 with a diagnosed of an Acute Glumerulonephritis versus Nephrotic Syndrome.

6. Physical Examination:

June 20, 2008 (Upon Admission) LIFTED FROM THE CHART: Vital signs: T- 38.40C PR- 84bpm RR- 22cpm BP- 140/80

Skin: (-) pallor, (+) edema, warm to touch Head EENT: pinkish palpebral conjunctiva, (-) icteric sclera, (+) periorbital edema Lymph nodes: (-) swelling/ enlargement Chest: symmetrical, no retractions Lungs: normal breathing pattern and clear breath sounds

June 24, 2008 ACTUAL NURSE-PATIENT INTERACTION: Vital signs: T- 36.70C Appearance and Behavior Mental state: patient is conscious and coherent Language: patient is able to speak Posture: with good posture Built: normal built Integumentary: patient has a fair complexion, good skin turgor. Head: normal contour; (+) periorbital edema. Eyes: no discoloration, (+)periorbital edema, pinkish palpebral conjunctiva, (-) icteric sclera, pupils equally reactive to light, eye movement synchronous in all directions, eye brows are symmetrical. PR- 68 bpm RR- 60 cpm BP- 110/80

Ears: symmetrical, no discharged noted. Nose: symmetrical, no discharges note. Mouth: no dentures, able to move tongue. Neck: able to move neck and no engorgement of veins. Chest and lungs: clear breathe sounds. Heart: normal rate and rhythm. Abdomen: no rebound tenderness, no abdominal distention, normal bowel sounds. Extremities: able to move hands and feet, no fractures and deformities, with dry nails, and edema noted. Bowel and Bladder: no difficulty during urination and defecation. Genitalia: no lesions and no pubic hair noted.

June 25, 2008 Vital signs: T-36.10C Appearance and Behavior Mental state: patient is conscious and coherent Language: patient is able to speak Posture: with good posture Built: normal built Integumentary: patient has a fair complexion, good skin turgor. PR- 97bpm RR-18cpm BP- 90/60

Head: normal contour, (+) periorbital edema. Eyes: no discoloration, (+) periorbital edema, pinkish palpebral conjunctiva, (-) icteric sclera, pupils equally reactive to light, eye movement synchronous in all directions, eye brows are symmetrical. Ears: symmetrical, no discharged noted. Nose: symmetrical, no discharges note. Mouth: no dentures, able to move tongue. Neck: able to move neck and no engorgement of veins. Chest and lungs: clear breath sounds. Heart: normal rate and rhythm. Abdomen: (-) rebound tenderness, (-) abdominal distention, normal bowel sounds. Extremities: able to move hands and feet, no fractures and deformities, with dry nails and edema noted. Bowel and Bladder: doesnt have difficulty in urination and defecation. Genitalia: no lesions and no pubic hair noted. 7. Diagnostic and Laboratory Procedure Diagnostic/ Date Indications Laboratory Ordered or Purpose Procedure Date Result Results Normal Values Analysis and Interpretati on

1.)CBC
A. D.O: 06-20The amount 118.9 125-155 g/L Indication of

Diagnostic/ Date Indications Laboratory Ordered or Purpose Procedure Date Result

Results

Normal Values

Analysis and Interpretati on anemia due to hematuria because of decrease erythropoieti n leads to damage in the kidney.

Hemoglobin (hgb)

08 D.R: 06-2008

of hgb determines how much oxygen the RBC's are capable of carrying to other cells. The hct shows the oxygencarrying capacity of the blood. This value also tells whether the blood is too thick or too thin. WBC count is the count of the so-called leukocytes. WBC's defend the body against infection and make up part of the immune system. 0.35 M: 0.40-0.52 F: 0.38-0.48

B. Hematocrit (hct)

D.O: 06-2008 D.R: 06-2008

Indication of anemia due to hematuria because of decrease erythropoieti n leads to damage in the kidney.

C. White Blood Cells (WBC)

D.O: 06-2008 D.R: 06-2008

10.20

6-10 g/L

More than required WBC count. Indicates infection.

Diagnostic/ Date Indications Laboratory Ordered or Purpose Procedure Date Result

Results

Normal Values

Analysis and Interpretati on Range is within normal range. Indicative of antibody production.

D. Lymphocytes

D.O: 06-2008 D.R: 06-2008

The second most type, are cells that produce antibodies, regulate the immune system and fight viruses.

0.41

0.20-0.60

E. Platelet

D.O: 06-2008 D.R: 06-2008

Responsible for blood coagulation and determines bleeding tendencies.

358

150-400 x 108L

Range is within normal range. Indicative of coagulation.

F. Segmenters

D.O: 06-2008 D.R: 06-2008 D.O: 06-2008 D.R: 06-2008 Eosinophils become active when you have certain allergic diseases, infections, and other medical conditions.

0.57

.55-.70

Range is within normal range.

Range is within normal range. Fights parasitic and allergic reaction.

G. Eosinophils

0.02

0 0.02

Diagnostic/ Date Indications Laboratory Ordered or Purpose Procedure Date Result

Results

Normal Values

Analysis and Interpretati on

CBC
A. Hemoglobin (hgb) D.O: 06-2408 D.R: 06-2408 The amount of hgb determines how much oxygen the RBC's are capable of carrying to other cells. The hct shows the oxygencarrying capacity of the blood. This value also tells whether the blood is too thick or too thin. WBC count is the count of the so-called leukocytes. WBC's defend the body against infection and make up part of the immune system. 10.0 12-16 Indication of anemia due to hematuria because of decrease erythropoieti n leads to damage in the kidney. Indication of anemia due to hematuria because of decrease erythropoieti n leads to damage in the kidney.

B. Hematocrit (hct)

D.O: 06-2408 D.R: 06-2408

0.32

M: 0.40-0.52 F: 0.38-0.48

C. White Blood Cells (WBC)

D.O: 06-2408 D.R: 06-2408

4,000

5-10x 10 to the 3rd power

Indicates infection.

Diagnostic/ Date Indications Laboratory Ordered or Purpose Procedure Date Result

Results

Normal Values

Analysis and Interpretati on Body have adequate amt. of lymphocytes to produce antibodies, regulate the immune system and fight viruses. Range is within normal range. Indicative of coagulation.

D. Lymphocytes

D.O: 06-2408 D.R: 06-2408

The second most type, are cells that produce antibodies, regulate the immune system and fight viruses.

54

25-40

E. Platelet

D.O: 06-2408 D.R: 06-2408

Responsible for blood coagulation and determines bleeding tendencies.

218

150-450 x 108L

F. Segmenters

D.O: 06-2408 D.R: 06-2408 D.O: 06-2408 D.R: 06-2408 Eosinophils become active when you have certain allergic diseases, infections, and other medical conditions.

40

50-70

G. Eosinophils

1-4

Active. Indicative of certain allergic diseases, infections, and other medical conditions.

Nursing Responsibilities:

Explain the procedure to the patient's significant others that these test

assess response to treatment.

Tell the patient's significant others that blood sample or specimen will be taken. Plan to obtain the specimen when the patient is calm and physically still. Ensure the specimen/blood sample is not taken from the hand or arm that has an intravenous line in the vein because of the dilution effect on the red blood cells concentration.

Diagnostic/ Laboratory Procedure

Date Ordered Date Result

Indications or Purpose

Results

Normal Values

Analysis and Interpretati on

2) Serum Creatinin
D.O: 06-2008 D.R: 06-2008 To evaluate any type of renal dysfunctions . .86 .3-.7 g/dl Result is within normal values. Indicative of (+)renal dysfunction.

A. Creatinine

Nursing Responsibilities:

Explain the procedure to the patient's significant others that these test assess response to treatment. Tell the patient's significant others that blood sample or specimen will be taken. Plan to obtain the specimen when the patient is calm and physically still. Ensure the specimen/blood sample is not taken from the hand or arm that has an intravenous line in the vein because of the dilution effect on the red

blood cells concentration.

Diagnostic/ Laboratory Procedure

Date Ordered Date Result

Indications or Purpose

Results

Normal Values

Analysis and Interpretati on

3) Blood Chemistry
A. Total Protein D.O:06-2108 D.R: 06-2108 To determine nutritional status or to screen for certain liver and kidney disorders as well as other diseases. To determine the extent of protein loss. Albumin maintains the amount of blood in the veins and arteries. When albumin levels become very low, fluid can leak out from the blood vessels into nearby tissues, causing swelling in the feet and 69.0 64-83 gm/L Range is within normal range.

B. Albumin

D.O:06-2108 D.R: 06-2108

34.0

3550 g/L

Range is below the normal range. Indicative of proteinuria and edema.

C. Globulin

D.O:06-2108 D.R: 06-2108

ankles. Very low levels of albumin may indicate liver damage. Globulin is carrier of some hormones, lipids, metal & antibodies.

35.0

20-35 g/L

Range is within normal range.

D. A/G Ratio

D.O:06-2108 D.R: 06-2108

1.5-1

0.8-2.0

Result is within normal values.

Nursing Responsibilities:

Explain the procedure to the patient's significant others that these test assess response to treatment. Tell the patient's significant others that blood sample or specimen will be taken. Plan to obtain the specimen when the patient is calm and physically still. Ensure the specimen/blood sample is not taken from the hand or arm that has an intravenous line in the vein because of the dilution effect on the red blood cells concentration.

Diagnostic/ Laboratory Procedure

Date Ordered Date Result

Indications or Purpose

Results

Normal Values

Analysis and Interpretati on

4) Serum Electrolyte
A. Na D.O:06-2108 D.R: 06-21Sodium is both an electrolyte 162.0 136145

Solutes milliequivale absorbed by

08

B. K

D.O:06-2108 D.R: 06-2108

and mineral. It helps keep the water (the amount of fluid inside and outside the body's cells) and electrolyte balance of the body. Sodium is also important in how nerves and muscles work. It helps keep the water (the amount of fluid inside and outside the body's cells) and electrolyte balance of the body.

nts per liter (mEq/L) or 136145 millimoles per liter (mmol/L)

the kidney results to damage and decrease reabsorptio n

4.0

3.44.7 mEq/L or 3.44.7 mmol/L (in children)

Result is within normal values.

Nursing Responsibilities:

Explain the procedure to the patient's significant others that these test assess response to treatment. Tell the patient's significant others that blood sample or specimen will be taken. Plan to obtain the specimen when the patient is calm and physically still. Ensure the specimen/blood sample is not taken from the hand or arm that has an intravenous line in the vein because of the dilution effect on the red blood cells concentration.

Diagnostic/ Date Indications Laboratory Ordered or Purpose Procedure Date Result

Results

Normal Values

Analysis and Interpretati on Color: Normal Transparanc y:Normal

5) Routine Urinalysis

D.O: 06-2308 D.R: 06-2308

Urinalysis was ordered for Baby AGN to determine whether the urine contains substances indicative or normally absent from urine and detected by urinalysis are proteins, glucose, acetone, blood, pus and casts.

Color: yellow Transparenc y: sl. Tubid Sugar: negative Albumin: +1 Reaction: acidic

Color: light yellow to dark amber

Sugar: negative Albumin: negative

Sugar: Normal

Microalbimin uria. It Reaction: indicates acidic spillage of Specific Specific protein from gravity: the damaged 1.000 gravity: glumerulus. 1.001-1.035 Normal. Reaction Pus cells:4-6 Normal. Pus cells: 0-3 Bacteria: Gravity negative Bacteria: slightly lower none than normal. Pus cells increased value indicates infection. Bacteria: Normal

Nursing Responsibilities:

Explain the procedure to the patient's significant others that these test assess response to treatment. Tell the patient's significant others that blood sample or specimen will be taken.

Plan to obtain the specimen when the patient is calm and physically still. Ensure the specimen/blood sample is not taken from the hand or arm that has an intravenous line in the vein because of the dilution effect on the red blood cells concentration.

For urinalysis, instruct the SO to collect urine specimen. Collect urine by clean catching. If there is a necessary urine collection, instruct SO to collect the urine in every urination and put it in the bedside.

III. Anatomy and Physiology The Urinary System The urinary tract is composed of four structures:

Kidney Ureters Bladder Urethra

The kidneys balance the urinary excretion of substances against the accumulation within the body through ingestion or production. Consequently, they are a major controller of fluid and electrolytes homeostasis. The kidneys also have several no excretory metabolic and endocrine functions, including blood pressure regulations, erythropoietin regulation and vitamin D metabolism. Filtration at the renal glumerulus is the first steps in urine formation. Normally, a volume equal to plasma volume is filtered every 24 minutes and a volume equal to total body water is filtered every 6 hours. This glomerular filtrate is similar to plasma, but it lack cells and large-molecular-weight proteins. The glomerular filtrate is modified by active transport, diffusion and osmosis as it passes through the renal tubules. Reabsorption of filtrate components enhances elimination of organic acids and bases (and some drugs). The remnants of the glomerular filtrate exit the kidney through the uterus.

The ureters conduct urine from the kidney to the bladder by peristaltic contraction. The bladder is distensible chamber that stores urine until it is excreted. The urethra is the exit passageway from the bladder that carries urine for elimination from the body.

Structures of the Urinary System The kidneys are located retro peritoneal, in the posterior aspects of the abdomen, on either side of the vertebral column. They lie between the 12th thoracic and the third lumbar vertebrae. The left kidney is usually positioned slightly higher than the right. Adult kidney average approximately 11 cm in length, 5 to 7.5 cm in width and 2.5 cm in thickness. Affixing the kidneys in position behind the parietal peritoneum is a mass of perirenal fat (adipose capsule) and connective tissue called Gerota's (subserosa) fascia. A fibrous capsule (renal capsule) forms the external covering of the kidney except for the hilum. The kidney is further protected by layers of muscles of the back. Flank abdomen as well as by layer of fat, subcutaneous tissues and the skin. The kidney has a characteristics curve shape, with a convex distal edge and a concave medial boundary. In the innermost part of the concave section is hilus, through which pass the renal artery, renal vein, lymphatic, nerves and renal pelvis (the natural upper extension of the ureter). A fibrous capsule surrounds each kidney and adheres the renal parenchyma. Each kidney is divided in to three major areas: (1) cortex, (2) medulla and (3) pelvis. The cortex of the kidney lies just under the fibrous capsule, and portions of the extend down into the medulla layer to form the renal columns (columns of Bertin) or cortical tissue that separates the pyramids. The medulla is divided into eight to 18 cone shaped masses of collecting ducts called the renal pyramids. The bases of the pyramids are positioned on the corticomedullary boundary. Their apices extend toward the renal pelvis, forming papillae. The papillae have 10-25 openings each on the surface, through which the urine empties into the renal pelvis. Eight or more groups of papillae are present in each pyramid; each empties into a

minor calix and several minor calices join to form a major calix. The two or three major calices are outpouching of the renal pelvis (inner area of the kidney). They channel urine from the pyramids to the renal pelvis. The renal pelvis is a cavity lined with transitional epithelium. The combined volume of the pelvis and calices is approximately 8 ml. Volumes in excess of this amount damage the renal parenchyma tissue. The renal pelvis narrows and reaches the hilus and becomes the proximal end of the ureter. Within the cortex lies the nephron, the functional unit of the kidney, consisting both vascular and tubular elements. Filtration begins at the glumerulus. The glomerular tuft (glumerulus) contains capillaries and the beginning of the tubule system, Bowman's capsule. Filtrate from the glumerulus enters the Bowman's capsule and the passes through a series of tubule segments that modify the filtrate as it passes through the renal cortex and medulla and finally, flows into the renal calices. A second capillary bed, the peritubular capillaries, carries the reabsorbed water and solutes back towards the vena cava..

Renal Blood Flow, Glomerular Filtration The kidneys receive 20% to 25% of the cardiac output under resting conditions, averaging more that 1 L of the arterial blood per minute. The renal arteries branch from the abdominal aorta at the level of the second lumbar of vertebra, enter the kidney, and progressively branch into lobar arteries, inner lobar arteries, accurate arteries and interlobular arteries. Blood flows from the inerlobular arteries through the afferent arteriole and the peritubular capillaries carry a small amount of blood (5% of renal blood flow) to the renal medulla in the vasa recta (long, straight blood vessels) before entering the venous drainage. The blood leaves the kidney in a venous system closely corresponding to the arterial system: interlobular veins, accurate veins, interlobular veins, and the renal vein. The renal circulation then empties the inferior vena cava.

Ureters

The ureters from the medial tapering of the renal pelvis at the hilus of the kidney. Usually 25-35 cm long in the adult, the ureters lie in the extraperitoneal connective tissue and descend vertically along the psoas muscle towards the pelvic cavity. After dipping into the pelvic cavity, the ureters course anteriorly to join the bladder in its posterolateral aspect. At each ureterovesical junction, the ureter runs obliquely through the bladder wall for about 1.5 to 2 cm before opening into the lumen of the bladder.

Each ureter has elastic characteristics and is made of three tissues layers; (1) an inner mucosa (transitional epithelial membrane) lining the lumen, (2) a muscular layer and (3) a fibrous outer layer. The musculature is generally designed as inner longitudinal and outer circular. Along most of the ureter, however, the muscle fiber actually run obliquely and blends with one another to form a mesh-like tissue. The muscle arrangement allows urine to propel down by the ureter by peristaltic action. Peristalsis is regulated by a myogenic pacemaker located near the renal calices. Blood is supplied to ureters by one or more vessels that run longitudinal along the tube. The number and assortment of articles anastomosing with the ureteric vessels vary with each individual. Because the ureters travel through several anatomic areas, the urethral vessels are fed several of the following arteries: (1) renal (frequently), (2) testicular or ovarian, (3) aorta and common iliac, (4) internal iliac (frequently), (5) vesical, (6) umbilical and (7) uterine.

Bladder The urinary bladder is a hallow organ located in the anterior half of the pelvis behind the symphisis pubis. The space between the bladder and symphisis pubis is filled with a loose connective tissue that allows the bladder to stretch cranially as it fills. The peritoneum covers the top border of the bladder, and the base is held loosely in place by the true ligaments. The bladder is also enveloped by a loose fascia.

Urethra The urethra differs greatly in females and males. The urethra is a muscular tube that connects the bladder with the outside of the body. The function of the urethra is to remove urine from the body. It measures about 1.5 inches (3.8 cm) in a woman but up to 8 inches (20 cm) in a man. Because the urethra is so much shorter in a woman it makes it much easier for a woman to get harmful bacteria in her bladder this is commonly called a bladder infection or a UTI. The most common bacteria of a UTI is E-coli from the large intestines that have been excreted in fecal matter. Female urethra. In the human female, the urethra is about 1-2 inches long and opens in the vulva between the clitoris and the vaginal opening. Men have a longer urethra than women. This means that women tend to be more susceptible to infections of the bladder (cystitis) and the urinary tract.

Pathophysiology (client-centered) A. Schematic Diagram Non Modifiable Factors 1.) Female 2.) Age (5 years old) 3.) Familial history of kidney disease Modifiable Factors 1.) Streptococcal infections (URTI) 2.) Skin infections (presence of lesions) 3.) Poor personal hygiene 4.) Lack of Financial Support 5.) Compromise Defense Mechanism

Antigen Anti-body reaction Insoluble immune complexes develop and become entrapped in glomerular tissue Renal function is depressed. S.O; admission) Decreased in circulating plasma triggered stimulation pus is of renin presence of lysosomes released during the inflammatory response damage top glomerular basement membrane Presence of may be due to Streptococcus Angiotensin I Angiotensin Converting Enzyme destruction and inflammation of kidneys inflammatory Response of the body. (hyperthermia) (Date: reported by occurred prior

Angiotensin II

Increased aldosterone secretion promoted renal retention of Na and H2O ` & increased Sumptoms of circulating fluid Anemia

increase permeability leaking RBC in urine

of protein in urine

Hematuria Volume

Signs

serum albumin is decreased and released (UA dated:06-23-08) ( + 1 albumin)(UA Dated:06-23-08)

Hemoglobin & hematocrit count decreased (CBC dated:06-20-08) (CBC dated:06-24-08) increased cardiac workload
08)

fluid shifted from intravascular into interstitial spaces decrease osmotic pressure Elevated Blood pressure (Date: upon admission) edema (+ facial edema)
23-08)

transient in uremic & +3 RBC in urine (UA Dated:06-23-

Tea-colored urine (UA Dated:06-

(Date: apparent upon admission June 20& still slight apparent until discharge June 26,2008)

IV. Patients Illness Synthesis of the Disease a. Definition of the disease Acute glomerulonephritis is the term generally reserved for the variety of renal disease in which inflammation of the glomerulus. Manifested by proliferation of the cellular elements, is secondary to an immunologic mechanism. Most incidence of AGN appears to be associated with a post infection state. Several bacterial and viral infections have been incriminated in its causation. It follows streptococcal infections of the respiratory tract or less commonly, skin infections such as impetigo. AGN is most common in males ages 6-10 but can occur at any age. Up to 95% of children and up to 10% of adults with AGN recover fully; the remainder of patients may progress to chronic renal failure within months. Acute glomerulonephritis results from the entrapment and collection of antigen-body complexes produced as an immunologic mechanism in response to streptococci in the glomerular capillary membranes, including the inflammatory damage and impending glomerular function. Sometimes the immune complement further damages the glomerular membrane. The damage and inflamed glomerulus loses the ability to be selectively permeable and allow RBC and CHONs to filter through as the glomerular filtration rate falls.

b. Modifiable:
Patient ages 5 years old has familial history of kidney disease. During this age she acquired streptococcal infection. According to Black, streptococcal infection is one of the factors that may cause acute glomerulonephritis. According to the informant, she acquired sore throat and also skin infection, due to this factors these may contribute to the disease condition of the patient. Although she

is suffering infection, the patient did not seek medical attention instead just neglect it and continue her poor personal hygiene. c. Signs and Symptoms and its Rationale: 1.) Shortness of breath and cough- due to extra fluid in the lungs. (Date: June 20, 2008) 2.) Elevated Blood Pressure- due to impaired renal function results to decrease circulating plasma that triggered the stimulation of renin, to angiotensin I converted by Angiotensin Converting Enzyme to Angiotensin II that acts on adrenal cortex causing secretion of aldosterone. Increased in aldosterone promoted renal retention of Na and H2O which means that there would be increased in circulating fluid that would increase the heart's workload resulting to increased Blood Pressure. (Date: June 20, 2008) 3.) Hematuria due to increased permeability that lead to leaking RBC in urine. (CBC dated: June 20, 2008) (CBC Dated: June 24, 2008) 4.) Fever due to the inflammatory response, swelling and death of some tissues. (Date: June 20, 2008) 5. ) Edema- due to the leakage of proteins in the urine that resulted in decreased serum osmotic pressure that leads to retention of fluid in interstitial spaces. Also due to the increase in aldosterone that promoted the retention of Na and H 2O resulted to edema. (Date: apparent upon admission June 20 & still slight apparent until discharge June 26,2008)

6.) Abnormal Neurological examination or altered level of consciousness-because of malignant hypertension or hypertensive encephalopathy. (Date: June 20, 2008)

d. Health promotion And Preventive Aspects When glomerulonephritis is caused by an infection, the first step in treatment is to eliminate the infection. If bacteria caused the infection, antibiotics may be given. However, children who develop the disease following a streptococcal infection often recover without any specific treatment. When glomerulonephritis has slowed the amount of urine a person is producing, he or she may be given medications called diuretics, which help the body to rid itself of excess water and salt by producing more urine. More severe forms of the disease are treated with medications to control high blood pressure, as well as changes in diet to reduce the work of the kidneys. A small percentage of people with severe glomerulonephritis may be treated with medications called immunosuppressive drugs, which decrease the activity of the immune system, such as corticosteroids and/or cyclophosphamide (Cytoxan). To prevent glomerulonephritis following an infection, the infection must be treated promptly. Most forms of glomerulonephritis cannot be prevented.

V. PATIENT AND HIS CARE A. Medical Management Medical Date General Management ordered Description Date Performe d Date Changed Hypertonic solution DO: 06-20- which causes cell D5 0.3 NaCl 08 shrinkage 500 cc x KVO DP: 06-2008 DC: 06-2608 Indication(s) Or Purposes Clients initial rxn to treatment Clients response to the treatment

To replace fluid loss and serve as a vehicle for administration of drugs.

Patient cried when IV insertion is done.

Patient was able to maintain hydration status. KVO: To not aggravate fluid retention.

Nursing Responsibilities in IVF insertion: Wash hands before preparing the equipment. Check the health practitioners order for the type and amount of solution. Check integrity of the IV solution and equipment. Prepare IV solution label with clients name, date, time, additives, and initial of the administering nurse. Explain to the client what you are doing before taking the equipment into the clients room.

Instruct the patient to limit his movement of puncture site and notify for any problems or discomfort. Assess patient for any signs of edema and swelling. Nursing Responsibilities on the patient with IVF: Explain the procedures to the patient. Assist patient with care since mobility is limited. Check solution for clarity and correct IV type. Regulate flow. Monitor intake

B. Drugs Name of drug Date ordered/Date taken Route of administration/dos age and frequency of administration General action/Function al classification/ Mechanism of Action To treat moderate to severe systemic infections caused by penicillinsensitive microorganisms Antipyretic Initial reaction Clients response to the medication

GN: Penicillin G. Sodium

DO: 06-20-08 DP: 06-20-08 D/ C: 06-26-08

IV 375,000 U every 6 hours

Patient dislikes the feeling of IV administration of drugs

Patients WBC count decreased

GN: Paracetamol

DO: 06-20-08 DP: 06-20-08 D/C: 06-24-08 DO: 06-20-08 DP: 06-20-08 D/C: 06-21-08

IV 200 mg every 4 hours

GN: Metoclopramide

IV amp now

Increases sensitivity to acetylcholine; results in increased motility of the upper GI tract and relaxation of the pyloric sphincter and duodenal bulb.

Patient dislikes the feeling of IV administration of drugs Patient dislikes the feeling of IV administration of drugs

Patients temperature decreased Patient did not vomit.

Nursing Responsibilities: Check name of patient before administering any medications Check right dosage and route before administration Check expiration date of medications Prepare medications aseptically Administer medications at the right time Observe patient for any manifestation of adverse effect

C. Diet Type of Diet

Date ordered Date Performed Date Changed DO: 06-20-08 (Patient was advised to maintain this type of diet even after discharge)

General Description

Indication(s) Or Purposes To prevent fluid retention, decrease metabolic demand and help decrease blood pressure

Specific foods taken

Low salt, Low fat

A type of diet wherein foods provided to the patient are low in fat and sodium content.

Rice, fish

Clients response and/or rxn to the diet Development of further edema was prevented.

Low Protein

DO: 06-26-08 (Patient was advised to maintain this type of diet after discharge) DO: 06-26-08 (Patient was advised to maintain this type of diet after discharge)

A type of diet wherein foods provided to the patient are low in protein content.

To allow kidney function to rest.

Bread, chocolate

Development of further edema kidney disfunction will be prevented.

High Protein

A type of diet wherein foods provided to the patient are high in protein content.

To allow tissue repair.

Fish, cheese

Stronger and healthier body will be achieved.

D. Activity/Exercise Date ordered Date Type of Performed exercise Date Changed Bed rest DO: 06-20-08 (Patient was advised to maintain this type of exercise even after discharge) C. Nursing Management

Nursing Responsibilities: Explain the reason for suggested diet and exercise Monitor foods taken by the patient

General Description

Indication(s) Or Purposes

Clients response to the activity/exercise Patient shows gradual increase in strength.

A type of activity wherein the patient is kept on bed with limitations to activity

To reduce oxygen demand and prevent fatigue

Nursing Responsibilities: Explain the reason for suggested exercise

1. Nursing Care Plan Assessme Nursing nt S= O= patient manifests: diagnosis Hyperthermia

Scientific explanation People suffer heatrelated illness when the body's temperature control system is overloaded. The body normally cools itself by sweating. But under some conditions, sweating just isn't enough. In such cases, a person's body temperature rises rapidly. Very high body temperatures can damage the brain or other vital organs.

Objectives SHORT TERM: After 4 of NI, patients boby temp. will decrease rom 38.4 C to 37 C.
0 0

Interventi on - Monitor VS and note level of consciousn ess

Rationale - To have a baseline data and to reveal alteration

Expected Outcome SHORT TERM: Patients body temperature shall have decreased from 38.40C to 370C

-body malaise -pale palpebral conjunctiva -pale skin -activity intoleran ce VS as follows: T - 38.40C PR 84bpm, RR 22 bpm

- performed TSB (tepid LONG TERM: After 8 days of NI, patients SO verbalize understanding o the underlying cause factors and importance of treatment -Instruct patient to avoid strenuous -instructed patient increase fluid intake sponge bath)

- to promote wellness LONG TERM: patients SO shall have - to promote wellness verbalized understanding o the underlying cause factors and -To conserve importance of treatment

activity -Provide foods rich in Iron and Vitamin C -Encourage use of relaxation techniques

energy

- To promote wellness

-To avoid fatigue

Assessme nt S= O= patient manifests:

Nursing diagnosis Activity intolerance

Scientific explanation The kidneys are remarkable in their ability to compensate for problems in their function. That is why chronic kidney disease may progress without symptoms for a long time until only very minimal kidney function is left. Because the kidneys perform so many functions for the body, kidney disease can affect the body in a large number of different ways. Symptoms vary greatly. Several different body systems may be

Objectives SHORT TERM: Ater 4 o NI the pts SO will use identified techniques to enhance activity tolerance

Interventi on - adjust activities

Rationale - to prevent overexertio n

Expected Outcome SHORT TERM: the pts SO shall have used identified techniques to enhance activity tolerance

- encourage rest periods -promote comfort measures - to enhance ability to participate in activities -assist client in learning safety measures -Encourage use of relaxation -To avoid fatigue - to prevent injuries - to reduce fatigue

-appears weak -body malaise -pale palpebral conjunctiva -pale skin -activity intoleran ce

LONG TERM: After 5 days of NI the pt. will actively or willingly participate in necessary activities

LONG TERM: pt. shall have actively or willingly participated in necessary activities

techniques affected. -plan maximal activity within the clients ability - to promote wellness

Assessme nt S= O= patient manifests:

Nursing diagnosis Poor personal hygiene

Scientific explanation It is generally known that unclean conditions and poor hygiene are the main promoters of bacterial growth.

Objectives SHORT TERM: After 4 the pt.s SO will verbalize understanding of proper hygiene

Interventi on - instruct proper bathing -implement proper bowel/ bladder training

Rationale - to promote wellness -to assist in correcting situations

Expected Outcome SHORT TERM: the pts SO shall have verbalized understanding of proper hygiene LONG TERM:

-appears weak -body malaise -pale palpebral conjunctiva -pale skin -with facial edema

LONG TERM: After 3-4 days of NI the pt. will perform selfcare activities within level of own ability

pt. shall have - instruct proper handwashin g - encourage food and fluids choices that -to assist in correcting meets nutritional situations - to promote wellness performed selfcare activities within level of own ability

needs -make home visit - to assess environmen tal needs

Assessme nt S= O= patient manifests:

Nursing diagnosis Fluid volume excess r/t disruption of regulatory mechanism

Scientific explanation The inflammation disrupts the functioning of the glomerulus, which is the part of the kidney that controls filtering and excretion. This disruption results in blood and protein appearing in the urine, and the build up of excess fluid in the body.

Objectives SHORT TERM: After 4 the pt.s SO will verbalize understanding of individual fluid restrictions

Interventi on - Establish rapport

Rationale - To gain the trust of the client - To have a baseline data and to reveal alteration

Expected Outcome SHORT TERM: the pts SO shall have verbalized understanding of individual fluid restrictions

-body malaise -pale palpebral conjunctiva -pale skin -with facial edema

- Monitor VS and note level of

LONG TERM: After 3-4 days of NI the pt. will stabilized fluid volume as evidenced by balance I&O

consciousn ess

-Monitor I & O

- To reveal alteration in fluid status LONG TERM: pt. shall have stabilized fluid volume as -To reduce further edema evidenced by balance I&O

- Restrict fluid/sodiu m intake as indicated

-Administer diuretics as ordered

-To promote fluid excretion

Assessmen t S= O= patient manifested:

Nursing diagnosis Altered tissue perfusion related to decreased hemoglobin level/concentration in the blood

Scientific explanation Patients with kidney problems manifest anemia due to the interruption in the release of erythropoietin, an enzyme responsible for RBC production and presence of hematuria.

Objectives SHORT TERM: After 6 of NI, patients SO will be able to verbalize understanding of condition and therapy regimen

Interventio n -Establish rapport - Monitor VS and note level of consciousnes s

Rationale -To gain trust of the client - To have a baseline data and to reveal alteration

Expected Outcome SHORT TERM: Patients SO was able to verbalize understanding of condition and therapy regimen

-body malaise -pale skin -activity intolerance -decreased performanc e -with periorbital edema -vital signs taken as follows: T:36.10C PR:97 RR:18 BP: 90/60

-Elevate HOB -To increase LONG TERM: After 8 days of NI, patient will be able to demonstrate increased perfusion as individually appropriate -Provide quiet, restful environment -Instruct -To promote relaxation -Check for calf tenderness gravitationa l blood flow - May indicate thrombus formation LONG TERM: Patient was able to demonstrate increased perfusion as individually appropriate

-To

patient to The patient may manifest: dehydration -inappropriate urine output for intake -Encourage use of relaxation techniques avoid strenuous activity -Provide foods rich in Iron and Vitamin C

conserve energy

- To promote RBC production -To avoid fatigue

Assessme nt S= O= patient manifest: -body malaise -pale skin -activity intolerance -decreased performanc e -with periorbital edema -vital signs taken as follows: T:36.1 C PR:97 RR:18 BP: 90/60 The patient
0

Nursing diagnosis Fatigue related to increased metabolic demands and anemia

Scientific explanation Patients with anemia experience fatigue which is due to increased oxygen demand caused by decreased ability of the blood to provide adequate tissue perfusion. Moreover, presence of edema may increase level of fatigue due to hematuria which decreases oxygen and leads to a decrease in cerebral tissue perfusion.

Objectives SHORT TERM: After 6 of NI, patient will be able to report an improved sense of energy

Interventio n - Establish rapport

Rationale - To gain the trust of the client - To have a baseline data and to reveal alteration

Expected Outcome SHORT TERM: Patient was able to report an improved sense of energy

- Monitor VS and note level of consciousnes s

LONG TERM: LONG TERM: After 8 days of NI, patient will be able to report improved sense of energy - Provide supplementa l oxygen as indicated -Provide -To support oxygen demand -Accept reality of patients report of fatigue - For proper assessmen t Patient was able to report improved sense of energy

may manifest: dehydratio n -inappropriate urine output for intake

environment conducive to relief of fatigue -Assist patient with activity -For safety -Assist patient to identify appropriate coping behaviors - To promote sense of control measures -To reduce exhaustion And to promote comfort

Assessme

Nursing

Scientific explanation

Objectives

Interventio

Rationale

Expected

nt S= O= patient manifested:

diagnosis Decreased cardiac output related to altered blood pressure The excessive urine output of the patient is due to failure of regulatory mechanism resulted to altered circulation/ increased in blood pressure due to albuminuria which causes edema and leads to an increase in blood volume that triggered the stimulation of renin, to angiotensin I converted by Angiotensin Converting Enzyme to Angiotensin II that acts on adrenal cortex causing secretion of aldosterone. Increased in aldosterone promoted renal retention of Na and H2O which means that there would be increased in circulating fluid that would increase the heart's workload resulting to increased blood pressure. LONG TERM: After 3-4 days of NI, patient will be to demonstrate an increase in activity tolerance SHORT TERM: After 6 of NI, patient will be able to display hemodynamic stability

n - Establish rapport - Monitor VS - To gain the trust of the client - To have a baseline data and to reveal alteration - To maximize sleep periods

Outcome SHORT TERM: After 6 of NI, patient was able to display hemodynamic stability

-with history of hematuria -with history of frequent urination but small amount of urine in yellow color -appears weak -with good skin turgor -decreased food intake -VS taken as follows:

-Promote adequate rest by decreasing stimuli, providing quiet environment . Schedule activities and assessments

LONG TERM: After 3-4 days of NI, patient was able to demonstrate an increase in activity tolerance

- Provide supplementa

-To increase oxygen

T:36.80C PR:72 RR: 19 BP: 80/72 The patient may manifest: dehydratio n inappropria te urine output for intake

l oxygen as indicated -Encourage relaxation techniques -Provide for diet restrictions (e.g. low sodium, bland, soft, low calorie/ residue/ fat diet, with frequent small feedings as indicated

available to the tissues -To reduce anxiety

-To maintain adequate nutrition and fluid valance

Assessm ent S=

Nursing diagnosis Risk for

Scientific explanation The presence of

Objectives SHORT TERM:

Interventio n - Establish

Rationale - To gain the

Expected Outcome SHORT TERM:

O= patient impaired manifeste d: Skin Integrity related to --with history of hematuria -with history of frequent urination but small amount of urine in yellow color -appears weak -with good skin turgor decreased food intake -VS taken edema

edema interferes with cellular nutrition, which makes the patient more susceptible to skin breakdown.

After 6 of NI, patient will demonstrate behaviors to prevent skin breakdown

rapport

trust of the client

Patient was able to demonstrate behaviors to prevent skin breakdown

- Monitor VS and note level of consciousne ss

- To have a baseline data and to reveal alteration

-Assess skin LONG TERM: After 6 days of NI, patients edema will decrease/subside - Monitor weight daily condition

- To reveal abnormality/skin disruption

LONG TERM: Patients edema was able to decrease/subsid e

-To monitor presence of edema

-Provide meticulous skin care -Keep bed

-To prevent skin breakdown

-To prevent

as follows: T:36.80C PR:72 RR: 19 BP: 80/72 The patient may manifest: dehydratio n inappropriate urine output for intake

linens dry

moisture which may promote skin breakdown -To promote proper circulation and prevent excessive pressure on skin

-Frequently change patients position

Assessme nt S= O= patient manifests:

Nursing diagnosis Risk for spread of infection

Scientific explanation Viruses and bacteria both enter your body through your mouth or nose either because you breathe in particles that are released into the air when someone coughs or sneezes, or because you have hand-to-hand contact with an infected person or use shared objects such as utensils, towels, toys, doorknobs or a telephone.

Objectives SHORT TERM: After 4 the pt.s SO will identify interventions to reduce spread of infection

Interventi on - instruct proper hygiene

Rationale - to reduce existing risk factors

Expected Outcome SHORT TERM: the pts SO shall have identified interventions to reduce spread of infection

-appears weak -body malaise -pale palpebral conjunctiva -pale skin -with facial edema

- instruct proper handwashin g

- to reduce existing risk factors

LONG TERM: After 3-4 days of NI the pt.s SO will demonstrate techniques, lifestyles changes to promote safe environment - change linens an dressings as needed - to - promote clean environmen t - to correct existing risk factors - to prevent inection LONG TERM: pt. shall have demonstrated techniques, lifestyles changes to promote safe environment

-emphasize necessity of taking antibiotics as directed -encourage proper nutrition, appropriate exercise program and need for rest

promote wellness

- to promote wellness

C. Nursing Management (Actual SOAPIERS)

June 24, 2008 (Tuesday)

A.1)

S> O > received patient sitting in bed with ongoing IVF of D5.3 NaCl 500 cc x 10-11 ugtts/min at 100 cc level, appears weak with periorbital edema good skin turgor moist mucous membrane decreased food intake, vital signs taken as follows: T36.80C PR-72bpm RR-19cpm A > Excess fluid volume related to albuminuria secondary to acute glomerulonephritis P > After 6 hours of nursing interventions, the patient will be able to stabilize fluid volume as evidenced by absence of edema I> Established rapport.

Monitored and recorded vital signs. Checked patency of IVF.

Regulated IVF x 10-11 ugtts/min at 9:24am.

Noted amount or rate of fluid intake from sources.

Noted presence of edema (puffy eyelids dependent swelling ankles/feet if

ambulatory or up in chair; sacrum and posterior thighs when recumbent), anasarca Set an appropriate rate of fluid intake infusion 24 hour period.

 Discussed the importance of fluid restrictions ad :hidden sources of intake (such as foods high in water content). Provided adequate rest periods. Due meds given. Attended needs. Endorsed. E > Goal met after 6 hours of NI, as evidenced by stabilized fluid volume of the patient which is evident by absence of edema

June 24, 2008 (Tuesday)

A.2)

S> O > received patient sitting in bed with ongoing IVF of D5.3 NaCl 500 cc x 10-11 ugtts/min at 100 cc level, appears weak with periorbital edema good skin turgor moist mucous membrane decreased food intake, vital signs taken as follows: T36.80C PR-72bpm RR-19cpm A > Activity intolerance due to prolonged bedrest P > After 6 hours of nursing interventions, the patient will be able to identify negative factors affecting activity tolerance and eliminate or reduce their effects when possible I> Established rapport.

Monitored and recorded vital signs.

 Encourage expression of feelings contributing to condition. Increase exercise or activity levels gradually; teach methods to conserve energy, such as stopping to rest for three minutes during a 10-minute walk. Encourage participation in recreation or social activities hobbies appropriate for situation.

Due meds given.

Attended needs. Endorsed. E > Goal met after 6 hours of NI, as evidenced by patients capability to identify negative factors affecting activity tolerance and eliminate or reduce their effects when possible

June 25, 2008 (Wednesday)

B.1)

S> O > received patient sitting in bed with ongoing IVF of D5.3 NaCl 500 cc x 10-11 ugtts/min at 100 cc level, appears weak with periorbital edema with reduced interaction with people and environment with polyuria, vital signs taken as follows: T-36.10C PR-97bpm RR-18cpm A > Risk for deficient fluid volume AEB frequent urination related to disease condition P > After 6 hours of nursing interventions, the patient will not be able to manifest signs and symptoms of dehydration I>

Established rapport.

Monitored vital signs. Provided adequate rest periods. Seen on rounds by Dra. Aguillar with new order made and recorded (Order: KVO) IVF to KVO Due meds given. Attended needs. Endorsed. E > Goal met after 6 hours of NI, as evidenced by patient was not able to manifest the signs and symptoms of dehydration

June 25, 2008 (Wednesday)

B.2)

S> O > received patient sitting in bed with ongoing IVF of D5.3 NaCl 500 cc x 10-11 ugtts/min at 100 cc level, appears weak with periorbital edema with reduced interaction with people and environment with polyuria, vital signs taken as follows: T-36.10C PR-97bpm RR-18cpm A > Social isolation related to altered state of wellness P > After 6 hours of nursing interventions, the patient will be able to verbalize willingness to interact with others I>

Established rapport.

Monitored vital signs. Provided adequate rest periods. Introduce client to those with similar or shared interests and other supportive people. Provide environmental stimuli (open curtains, TV, radio and pictures). Due meds given. Attended needs. Endorsed. E > Goal met after 6 hours of NI, as evidenced by patient was able to verbalize willingness to interact with others

VI. Clients Daily Progress in the Hospital 1. Clients Daily Progress Chart
Clients daily Progress 06-21-08 06-22-08 06-2308

Nursing Problems Hyperthermia Activity intolerance Poor personal hygiene Fluid volume excess r/t disruption of regulatory mechanism Altered Tissue Perfusion Fatigue Decreased cardiac output

Admission (06-20-08)

06-24-08

06-25-08

Discharge

Risk for impaired Skin Integrity related to edema

Risk for spread of infection

Vital Signs Temperature

38.4C

37.3

37

36.8C

36.1C

Pulse rate Respiratory rate Blood Pressure *Temp, PR, RR and BP were not available in the chart for some dates Diagnostic Procedure CBC Serum Creatinine Blood Chemistry Serum Electrolyte Routine Urinalysis Medical Management

84 22 90/60 80/60 70/60

72 19 80/72

97 18 90/60

A. IVF
D5 0.3 NaCl B. Drugs Pen G Sodium Metoclopramide Paracetamol C. Diet Low salt, Low fat

Low Protein

High Protein D. Activity

Bed rest

2. Discharge Planning a. General condition of the client upon discharge Baby AGN was discharged last June 26, 2008 (Thursday). She still has slight facial edema, normal body temperature, (-) hematuria and stable vital signs. She has still lesions on her scalp and minimal lesions on her extremities. b. Method S> O > Received patient sitting on bed; pt. still has slight facial edema; (-) hematuria, pt. still has lesions on her scalp and minimal lesions on her extremities; appears slightly weak; with stable vital signs. A > For home maintenance and health management. P > After 1 hour of nursing interventions, the patient and SO will verbalize understanding of health teachings. I> M > Instructed patient to take the following home medications E > Instruct the patient to do some activities of daily living. T > Instruct the patient to take the medications religiously. H > Instructs patients to eat nutritious foods such as fruits and vegetables that are not contraindicated. > Instructs patient to have proper personal hygiene. O > Instructed patient to come back for follow-up check D > Instructed patients SO to provide foods that are low in salt and fat. E > Goal met as evidenced by patients SO verbalized understanding of health teachings.

VII. Conclusions

Acute Glomerulonephritis is relatively common bilateral inflammation of the glomeruli. It follows a streptococcal infection of the respiratory tract or less commonly, a skin infection. It is a must that we shouldgive enough attention to those suffering of such disease so as to prevent aggravation and further complications that could possibly occur.To help patient to cope up with his/her condition we are to perform proper monitoring and treatment. As a student nurse, the student should be competetive enough, equipt with enough and accurate knowledge of the disease. Not just with learning through lectures and theories is the way to understand these diseases. Through interaction, knowledge acquired from theories was much appreciated by the students since he/she can actually assess the patients condition. Equipt with enough and accurate information and enhance skills, she/he may be able to be competetive enough to handle future situations and patients suffering from the mentioned condition.

Bibliography:

www.yahoo.com www.emedicine.com Medical Surgical Nursing PDR Nurses Drug Handbook 2005 Nurses Pocket Guide http://en.wikibooks.org/wiki/Human_Physiology/The_Urinary_ System#Urethra