Acute Glomerulonephritis 42-m

8/4/2019 Acute Glomerulonephritis 42-m

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Acute glomerulonephritis

Table of contents

I. Introductiona. Overview of the Caseb. Objective of the Studyc. Scope and Limitation of the Study

II.Health Historya. Profile of patientb. Personal Health Historyc. History of Present Illnessd. Chief Complaint

III. Developmental Data

IV. Medical Managementa. Medical Orders and rationale

b. Drug study

V. Pathophysiology with Anatomy and Physiology

VI. Nursing Assessment (System Review &Nursing Assessment II)

VII. Nursing Managementa. Ideal Nursing Management (NCP)

b. Actual Nursing Management (SOAPIE)

VIII. Referrals & Follow-up

IX. Evaluation and Implications

X.Bibliography


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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.


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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 : Lisdan, Elpedio N.Wife : Lisdan, JemmaAddress : San Rafael, Talakag, Bukinon provinceCivil Status : MarriedSex : MaleAge : 42 years oldReligion : Roman Catholic

Educational Status : Elementary levelIncome : 2,000 php/monthNationality : FilipinoDate of Admission : January 27, 2009Time of Admission : 9:10 amInformant : PatientHeight : 158 centimetresWeight : 52 kg


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Vital Signs during AssessmentTemperature : 36.7 CPulse Rate : 55 bpmRespiratory rate : 20 cpmBlood Pressure : 150/110 mmHg

Admitting Diagnosis : Acute Glomerulonephritis related to nephriticsyndrome; hypertension

Attending Physician : Dr. Joseph Borong

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


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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 culturethrough 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


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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 phallicstage, 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


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A. Medical Orders and Rationale

Doctors Order Rationale

01/27/09

Please admit

TPR q 4h

Full low salt, low fat diet

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

To monitor patients medicalcondition and proper management.

To monitor any abnormal changesin vital signs

For proper nourishment and forprevention of disease that may leadto severity of the condition

To promote good nutritional status

To monitor body fluids & preventdehydration

For treatment of hypertension,edema associated with CHF,cirrhosis and renal disease

For treatment of lower respiratoryinfection, UTI & dermatologicinfection

First line treatment for heartburn

and short term treatment of activeduodenal ulcer

Treatment for pulmonarytuberculosis that is not responsibleto 1st line antituberculosis

For proper hydration of the patientand carefully monitor the fluidlosses


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IVF 0.9 NaCl @ KVO rate

Spironolactone 50mg itab TID P.O.

Continue meds.

Weight patient daily pre-breakfast

01/29/09

Continue meds.

IVF of D5nm iL @ KVO rate

To monitor body fluids & preventdehydration

To counteract potassium losscaused by other diuretics

To treat the disease & remove thesymptoms

To monitor if the symptoms arerelieved

To treat the disease & remove the

symptoms

To monitor fluids


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B. Drug StudyGeneric

Name of

Ordered

Drug

Date

Ordered

Classi-

fication

Dose/

Frequency/

Route

Mechanism

of Action

Specific

Indication

Contra-

indication

Side

Effects/

Toxic

Effects

Nursing

Precaution

Cefuroxime 01/27/09 Antibiotic

(Cephalosporin 2nd

generation)

750 mg q 8h

IVTT

Inhibits

synthesis ofbacterialcell wall,

causing celldeath.

For lower

respiratoryinfection,UTI &dermatologic

infection

Contra

indicated withallergy tocephalosporinor penicillins

Hypersen-

sitivity,nephrotoxicity, pain

atinjection

site

Assess for

hepatic orrenalimpairment

Assess forskin status

Check forsensitivity

tests


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Generic

Name of

Ordered

Drug

Date

Ordered

Classi-

fication

Dose/

Frequency/

Route

Mechanism

of Action

Specific

Indication

Contra-

indication

Side

Effects/

Toxic

Effects

Nursing

Precaution

Furosemide 01/27/09 LoopDiuretic

Amp of 12h x 3doses

Inhibitsreabsoption

of Na andCl from theproximaland distal

tubules andascendinglimb of the

loop ofHenle,

leading to aNa-reach

diuresis

Hyperten-sion, Edema

associatedwith CHF,cirrhosisand renaldisease

Contraindicates allergy to

furosemide;anuria,hepatic coma

Polyuna,Nocturia,

Rash,Anemia,Musclespasms,Cardiac

arrythmias

Assess forallergy to

furosemide

Assess forskin color,lesions andedemaCBC,seriumelectrolytes


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Generic

Name of

Ordered

Drug

Date

Ordered

Classi-

fication

Dose/

Frequency/

Route

Mechanism

of Action

Specific

Indication

Contra-

indication

Side

Effects/

Toxic

Effects

Nursing

Precaution

Omeprazole 01/27/09 Antisecretorydrug;

ProtonPump

Inhibitor

20mg icap ODP.O.

Gastric acidpump

inhibitor:Supresses

gastric acidsecretion by

specificinhibition ofhydrogen-K ATPaseenzymessystem atsecretorysurface of

the gastricparietal

cells.

First linetreatment

forheartburnand short

termtreatment of

activeduodenal

ulcer

Contra-indicated with

hyper-sensitivity to

omeprazole orits

component.Use

cautiouslypregnancylactation

Rash,alopecia,nausea,

vomitingEpistasis,

fever

Assess forhypersensiti

vity toomeprazole

Assess forskin lesionsAssess for

urinaryoutput


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Generic

Name ofOrdered

Drug

Date

Ordered

Classi-

fication

Dose/

Frequency/Route

Mechanism

of Action

Specific

Indication

Contra-

indication

Side

Effects/Toxic

Effects

Nursing

Precaution

Captropil 01/27/09 ACEinhibito

r

25mg itabBID P.O.

PolypeptideAntibactic;

againstMycobacter

iumtuberculosis

Treatmenthyper-tension

Contra-indicatedallergy to

capreomycin;pre-existing

auditoryimpairment

Polyuria,Tachy-cardia,

proteinuriacough

dry mouth

Assess forallergy tocaptropil

Assess forskin colorand lesions

For CBCand

differential


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Generic

Name of

Ordered

Drug

Date

Ordered

Classi-

fication

Dose/

Frequency/

Route

Mechanism

of Action

Specific

Indication

Contra-

indication

Side

Effects/

Toxic

Effects

Nursing

Precaution

Spirono-lactone

01/28/09 Diuretics

50mg itab TIDP.O.

Cause lossof sodium

bicarbonateand calciumwhilesaving

potassiumand

hydrogenions

Tocounteract

potassiumloss causedby otherdiuretics

Hyper-sensitivity;

Hyperkalemia

ClumsyHeadache

Dyscrasias

Monitorintake &

output

Dailyweightduringtherapy

Monitor BPbeforeadminis-

tering


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V. PATHOPHYSIOLOGY


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VI. ASSESSMENT EENT:


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[ ] impaired vision [ ] blind

[ ] 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

CARDIO VASCULAR:

[ ] arrhythmia [ ] tachycardia [ ] numbness

[ ] diminished pulses [ ] edema [ ] fatigue

[ ] irregular [ ] bradycardia [ ] murmur

[ ] tingling [ ] absent pulses [x] pain

[ ] no problem

GASTRO INTESTINAL TRACT:

[ ] obese [ ] distension [ ] mass

[ ] dysphagia [ ] rigidly [ ] pain

[x] no problem

GENITO URINARY and GYNE:

[x] pain [x] urine color [ ] vaginal bleeding

[ ] hermaturia [ ] discharge [ ] nocturia

[ ] no problem

NEUROLOGICAL:

[ ] paralysis [ ] stuporous [ ] unsteady

[ ] seizures [ ] lethargic [ ] comatose

[ ] vertigo [ ] tremors [ ] confused

[ ] vision [ ] grip [x] no problem

MUSCULOSKELETAL:

[ ] appliance [ ] stiffness [ ] itching

[ ] petechiae [ ] hot [ ] drainage

[ ] prosthesis [ ] swelling [ ] lesion

[ ] poor turgor [ ] cool [ ] deformity

[ ] wound [ ] rash [ ] skin color

[ ] flushed [ ] atrophy [x] pain

[ ] ecchymosis [ ] diaphoretic [ ] moist

[ ] no problem


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NURSING ASSESSMENT IISUBJECTIVE OBJECTIVE

COMMUNICATION:

[ ]Hearing Loss Comments: wala[ ]Visual Changes man wala[x] Denied gihapon

As verbalized bythe husband

[ ] Glasses [ ] Language[ ] Contact lens [ ] Hearing Aide

R LPupil Size: 3-5 mm [ ] Speech difficultiesReaction: PERRLA

OXYGENATION:[ ] dyspnea Comments: Nah![ ] smoking history gapanigarilyo

Oftentimes mana siya -giubo[x] cough pd siya karon oh.[x] sputum As verbalized by[ ] denied the wife

Respiratory: [x] regular [ ] irregularDescribe: regular breathing but associated with

pain

Right: Right lung is symmetrical to left lung.Left: Left lung is symmetrical to right lung.

CIRCULATION:[ ] chest pain Comments: Sakit![x] leg pain bug-at[x] numbness of extremities nanghubag na[ ] denied man gni ako

mga tiil Asverbalized bythe patient

Heart Rhythm [x]regular [ ] irregularAnkle Edema: present in lower extremitiesPulse Carotid Radial DP Femoral

Right: 62 65 60 not assessedLeft: 62 65 60 not assessed

Comments: Pulse sites are palpable and its rate arewithin normal range.

NUTRITION:

Diet: DAT but decreased fluid intake[ ] N [ ] V Comments: WalaCharacter manperma-[ ] recent charge nente nay gana

in weight, appetite As verbalized[ ] swallowing by the patient

Difficulty[x] denied

[ ] dentures [x] none

Full Partial With PatientUpper [] [ ] [ ]

Lower [] [ ] [ ]

ELIMINATION:Usual bowel pattern [ ] urinary frequency

Once a day once daily[ ] constipation [ ] urgency

Remedy [x] dysuria[ ] hematuria

January 27, 2009 [ ] incontinenceDate of last BM [ ] polyuria

[ ] diarrhea character [ ] foly in place[ ] denied

Comments: urinate once Bowel Sounds:daily due to pain Audible soundsand excrete small Abdominal Distention:amount. 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/ALMP:

Briefly describe the patients ability tofollow treatments (diet, meds, etc.) forchronic health problems (if present):

The patient is properly following her medications


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SUBJECTIVESKIN INTEGRITY:[ ] dry Comments: wala man[ ] itching - nanghupong

[x] other - edematous lang ko as[ ] denied verbalized by the

Patient.

ACTIVITY/SAFETY:

[ ] convulsions Comments: dili man[ ] dizziness hinuon, bug-at lang[ ] limited motion of joints gyud ako tiil

Kay nanghupongNaman 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 hinuonFrequency, As verbalizedRemedies) by the patient.

[ ] nocturia[ ] sleep difficulties[x] denied

COPING:Occupation : FarmerMembers of household:

6Most supportive person:

Wife

SPECIAL

PATIENT

INFORMAT

ION_______________ Daily weight

_____________ __ PT/OT________________________________ BP q shift_______________ Irradiation


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_______________ Neuro VS______________ Urine test_______________

_______________ CVP/SG.Reading

______________________ 24 hour urinecollection

Date

Ordered

Diagnostic/laboratory

exams

Date done Date

ordered

I.V.

Fluids/Blood

Date disc.

01/27/09 CBC 01/27/09 01/27/09 0.9 Nacl iL@ KVO rate

01/27/09 Urinalysis

VII. NURSING MANAGEMENT

A. Ideal Nursing Management

Nursing Diagnosis:

Excessive fluid volume related to glomerulonephritis

INTERVENTIONS RAT

Monitor intake and output To check fluid balance

Observe for fever To check for infection

Elevate edematous extremities, change position frequently To reduce tissue pressu

After elevating, place in semi-fowlers position To facilitate movementrespiratory effort

Provide quiet environment To promote ventilation

Administer furosemide I amp of 12h as prescribed by the For the treatment for e


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physician

Nursing Diagnosis:

Ineffective airway clearance related to productive cough

INTERVENTIONS RAT

Assess the airway patency To check the effectivit

management

Elevate the head part of the bed/change position q 2h To enhance drainage o

segments

Encourage deep-breathing and coughing exercise To mobilize secretions

Monitored the fluid intake To help liquefy secreti

Instruct to have proper clothing, not too tight and not too

loose

To provide warm body

Nursing Diagnosis:

Acute pain related to edema

INTERVENTIONS RAT

Monitor vital signs Because vital signs are

Acknowledge patients verbalization of pain & allow him todescribe it

Pain is subjective expecan felt about it

Perform pain assessment each time occurs To rule out worsening complication


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Elevate edematous extremities, change position frequently To reduce tissue pressu

Provide quiet environment

To promote ventilation

Administer Spironolactone 50mg itab TID P.O. asprescribed by the physician

For the treatment for e

B. Actual Nursing Management

S Bug-at lang akong tiil kay nanghupong naman ko.As verbalized by the patient

O

Edema Oliguria Restlessness

A Fluid volume excess related to Glomerulonephritis

P

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 excessivefluid volume.


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I

1) Monitor vital signs especially temperature To check & assess for infection since the pt. has a higher risk2) Monitor intake & output To monitor & check fluid volume & prevent dehydration

3) Elevate the edematous extremities To reduce tissue pressure & risk in skin breakdown4) Place in a semi-fowlers position, change position frequently To facilitate movement of diaphragm & improve respiratory

effort5) Administer furosemide 1 ampule every 12h as prescribed by the

physician For the treatment of edema

E 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

MEDICATIONSEncourage to follow the dosages and proper timing of hismeds. Such as the Furosemide 1 ampule every 12hours x3doses, Omeprazole 20mg 1capsule once a day, Captopril25mg 1tablet twice a day, & Spironolactone 50mg 1 tabletthrice a day. As prescribed by his physician.

EXERCISEEncourage bed rest and frequent changes of position, earlyambulation, and deep breathing exercise.

TREATMENT

Encourage/instruct to keep the edematous extremities toelevate as often; limit of water intake; monitor intake andoutput; provide warm environment; provide egg white aday; weight the pt. daily, at the same time.


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OUT-PATIENT(Check-up)

Encourage pt. that when his discharged, he must have aregular check-up to his physician until its needed. Toevaluate the progress of his condition.

DIET Instruct to limit intake of salty & fatty foodsandenrich/increase the intake of foods rich in potassium such asbananas

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.


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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.


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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 NursingPractice, 8th edition, volume 1.

Deglin, et al. Daviss Drug Guide for nurses, 9th edition.

Smeltzer, Suzanne C. et al. Textbook of Medical-Surgical Nursing, 11th edition, volume 2.


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Acute Glomerulonephritis 42-m