OBJECTIVES

GENERAL

The general objective of this case presentations to foster and develop

knowledge and
skills in providing care and management fora patient with acute
glomerulonephritis.

SPECIFIC

To define acute glomerulonephritis

To know the clinical manifestations, nursing management and interventions
for patients who have this disease.
To know the different medication that needs to be taken including its side
effect which can be harmful the patient.
To be able to obtain, document and present a comprehensive medical
history.
To apply necessary skills in providing care for a client with acute
glomerulonephritis.
To learn how to establish rapport with the client and significant others.
To be able to recognize the importance of patient and familial preference
when selecting among treatment option.
INTRODUCTION

Acute glomerulonephritis (AGN) is active inflammation in the glomeruli. Each kidney

is composed of about 1 million microscopic filtering "screens" known as glomeruli that
selectively remove uremic waste products. The inflammatory process usually begins with an
infection or injury (e.g., burn, trauma), then the protective immune system fights off the
infection, scar tissue forms, and the process is complete.

There are many diseases that cause an active inflammation within the glomeruli.
Some of these diseases are systemic (i.e., other parts of the body are involved at the same
time) and some occur solely in the glomeruli. When there is active inflammation within the
kidney, scar tissue may replace normal, functional kidney tissue and cause irreversible renal
impairment.

The severity and extent of glomerular damagefocal (confined) or diffuse

(widespread) determines how the disease is manifested. Glomerular damage can appear as
subacute renal failure, progressive chronic renal failure (CRF); or simply a urinary abnormality
such as hematuria (blood in the urine) or proteinuria (excess protein in the urine).

Epidemiology

Over the last 2-3 decades, the incident of acute glomerulonephritis has
declined in the United Sates as well as in other countries, such as Japan, Central
Europe, and Great Britain. The estimated worldwide burden of AGNs is
approximately 472,000 cases per year, with approximately 404,000 cases being
reported in children and 456,000 cases occurring in less developed countries.
AGN associated with skin infections is most common in tropical areas where
pyoderma is endemic, while pharyngitis-associated AGN predominates in
temperate climates. (WHO, 2011)
PATIENTS PROFILE

Patients Name: L.P

Age: 5 years old
Gender: Female
Address: Pasig City
Civil Status: Child
Religion: Roman Catholic
Date of Birth: April 17, 2011
Date of Admission: January 28, 2017
Time of Admission: 11:30pm
Nationality: Filipino
Initial Diagnosis: AGE with moderate signs of dehydration, AVI: R/I UTI
Final Diagnosis: Acute Glomerulonephritis
Chief Complaint: Fever

Present History:
5 days PTA, patients experienced headache associated with undocumented
fever which caused her to slip and fall hitting her buttocks to the floor,
without hitting her head and loss of consciousness. Non associated
symptoms of vomiting, chills, with good appetite and activity. Patient was
given Biogesic and temporary relief noted. No onset done.
3 days PTA, still with persistence of symptoms now with abdominal pain,
loss of appetite and no bowel movements for 3 days, patient bought to
consult at AFPMC, CBC & UA was done which lead to the diagnosis of UTI.
Patient was sent home and given Amoxicillin but was not given.
 2 days PTA, patients still has persistence of symptoms with fever max of
39C, patient was given paracetamol suppository given every 4 hours which
the mother claimed to be effective for 1hour of temporary relief.
1 day PTA, still with persistence of symptoms, now with reddish
pigmentation on the neck and hands. Patient was given paracetamol
suppository and was brought to consult in our constitution thus admission.
Past History:
(+) Bronchial Asthma
(+) hospitalization d/t asthma

Family History:
(-) Dm
(-) HPN
(-) Cancer

Natal History:
Born to a G2P1 mother, full term via NSD in a V. Luna assisted by an OB-
Gyne with a birth weight of 3.1 kg. no feto-maternal complications noted. Patient
passed out meconium within 24 hrs of life, NBS OAE were done which revealed
normal. Patient was discharged as well baby.
PHYSICAL ASSESSMENT

General Symptomatology loss weight gain

Integumentary No itchiness

Head and Neck No stiffness

Eyes
Ears No ear discharge
Nose No nasal discharge
Mouth and Throat No sore throat
Respiratory No fast breathing
Cardiovascular No fast heart rate
Digestive (+) Constipation
Genitourinary No dysuria
Musculoskeletal No myalgia
Endocrine No palpitation
Nervous No tremors
General Irritability, not in cardio respiratory
distress
Vital Signs HR: 142bpm RR: 22cpm Temp:
39.8C SPO2: 98%
Anthropometrics Wt. 35.5kg Ht. 36ft Inaccessible
Water loss. 420 Total Fertility Rate.
933
Skin Reddish pigmentation in the neck
and mandible
HEENT: Swelling of eyelids, malting, dry lips.
Chest/Lungs Symmetrical chest expansion, no
retraction, clear breath sound.
Heart A dynamic pericardium normal rate,
regular rhythm, no murmur
Abdomen No lesion
Genitalia Grossly female genitalia
Extremities Grossly normal extremities, full equal
pulse, no cyanosis
Cerebrum Awake, conscious, GCS 15
Cerebellum Steady gait, no ataxia
Cranial Nerve
I: can smell
II: Pupils round equally reactive to light
and accommodation
III, IV, VI: Intact EOM
V: Intact facial sensation
VII: No facial asymmetry
VIII: Can hear
IX, X (+) Gag reflex
XI: Can shrug shoulders
XII: No tongue deviation
GORDONS HEALTH STUDIES

CATEGORY BEFORE DURING

HOSPITALIZATION HOSPITALIZATION
HELATH PERCEPTION >Patient is healthy. >She is not aware of
her health condition.
>She start to take
prescribed medication
>Theres an IV line that
hooked in her.
NUTRITIONAL >she eats 3 times a >Low salt
METABOLIC day >Eats whatever the
>She eat whatever hospital provides.
food is served.
ELIMINATION >Patient voids at least >She defecates once a
3-4 times a day. day.
>She defecates once a >She voids 3 times a
day. day with minimal
amount.
ACTIVITIES-EXERCISE >Energetic Sobrang >Decrease energy
malikot as verbalized matamlay na siya as
by the mother verbalized by the
mother.
>She sleeps most of
the time.
COGNITIVE- >The patient is >The patient still
PERCEPTUAL oriented to time, place oriented to time, place
and person. and person.
SLEEP REST >She sleep late at >The patient
night sometimes lack of
>She sleeps almost 8 sleep because of
hours daily. changing IV bottle.
SELF- >She use too socialize >She is not socialize to
PERCEPTION/SELF- and mingle to other. others.
CONCEPT >She always think of a
playing a game.
SEXUALITY Not Applicable Not Applicable
REPRODUCTIVE
VALUES-BELIEFS >The patient is Roman >She still believe in
Catholic God.
>She truly believe that
God loves her.
ROLE RELATIONSHIP >She lives with her >The patient is
family confined at hospital
>She is good and and her grandmother
disciplined daughter. and mother is her
companion.
ANATOMY AND

PHYSIOLOGY
 The kidneys are two bean-shaped organs, each about the size of a fist.
They are located just below the rib cage, one on each side of the spine.
Every day, the two kidneys filter about 120 to 150 quarts of blood to produce
about 1 to 2 quarts of urine, composed of wastes and extra fluid. The urine flows
from the kidneys to the bladder through two thin tubes of muscle called ureters,
one on each side of the bladder. The bladder stores urine. The muscles of the
bladder wall remain relaxed while the bladder fills with urine. As the bladder fills
to capacity, signals sent to the brain tell a person to find a toilet soon. When the
bladder empties, urine flows out of the body through a tube called the urethra,
located at the bottom of the bladder. In men, the urethra is long, while in women
it is short.

The kidneys are important because they keep the composition, or makeup, of the
blood stable, which lets the body function. They;

prevent the buildup of wastes and extra fluid in the body

keep levels of electrolytes stable, such as sodium, potassium, and
phosphate
make hormones that help
regulate blood pressure
make red blood cells
bones stay strong

How do the kidneys work?

The kidneys purify toxic metabolic waste products from the blood in several
hundred thousand functionally independent units called nephrons. Each nephron
filters a small amount of blood. The nephron includes a filter, called the
glomerulus, and a tubule. The nephrons work through a two-step process.
The tubular epithelial cells reabsorb water, small proteins, amino acids,
carbohydrates and electrolytes, thereby regulating plasma osmolality,
extracellular volume, blood pressure and acidbase and electrolyte balance.
The glomerulus lets fluid and waste products pass through it; however, it prevents
blood cells and large molecules, mostly proteins, from passing. If the glomerulus
is unable to prevent or filter blood cells and large particles incorrectly, then it
leads to a problem called glomerulus nephritis and even kidney failure. The
filtered fluid then passes through the tubule, which sends needed minerals back
to the bloodstream and removes wastes. The final product becomes urine.

PATHOPHYSIOLOGY

PATHOPHYSIOLOGY DIAGRAM OF ACUTE GLOMERULO-NEPHRITIS

NON-MODIFIABLE RISK FACTORS MODIFIABLE RISK FACTORS

Gender - Female Poor personal hygiene
Aged 5-11 years old
Family history of kidney disease

Antigen-antibody reaction
Insoluble immune complexes developed and become entrapped to glomerular
tissue

Destruction and inflammation of kidneys fever

Damaged on glomerular basement membrane

Increased permeability

Leakage of protein proteinuria

Protein and RBCs going to interstitial space

Periorbital edema

COURSE IN THE WARD

January 27, 2017 (NO DUTY)

Received patient conscious and coherent with fever and no cough and
colds. Patient has a weak faces and loses good appetite. Vital sign taken and
recorded. Patient body temperature after checking was 38.7C. Not distress and
pink palpebral was observed.
PNSS 350 ml. Paracetamol syrup 30 mg/ml to 6ml every 6 hours and Monitor the
Intake and Output.

January 28, 2017 (NO DUTY)

 For continuity of care same patient, the patient has macculopapule
rash on mouth, extremities no signs of fever, chilling, bleeding and DOB. Physical
assessment done Anterior posterior, normal rate regular rhythm. (-) murmurs,
Saturated Calomel Electrodes, (-) reactions. Capillary Blood Sugar , soft Normal
Active Sounds and non-tender. Patient also lack of sleep and non-cooperative and
not in distress. PNSS 280 ml at paracetamol every 6 hours . To start Ampillicin 200
mg TID every 6 hours After Negative Skin Test at 100 ml per day. For Complete
Blood Count once 12 hour. And facilitate the Fecal Analysis and Urine Analysis.

January 29, 2017 (NO DUTY)

Patient was (+) fever, (+) macculopapule rash. Difficulty of breathing,

(+) periorbital edema. Decrease appetite and activity. She was asleep, non-
cooperative and not in distress. And, Nasal Respiratory Resistance, (-) murmur.
Saturated Calomel Electrodes (-) reaction. PNSS 380ml at 350 ml every 8 hours.
For repeat Complete Blood Count once 12 hours a febrile. To follow up the Urine
Analysis and Monitor Input and Output shifts.

January 30, 2017 (NO DUTY)

Patient was (+) for fever and chills. Her appetite and physical
activities were decreased. Signs of bleeding and abdominal pain was negative.
She was examined while sleeping, there was no cardio pulmonary distress, skin
was warm to touch and good anger. For repeat Complete Blood Count within
every 8 hours of Antibiotics. Strict monitor the BP every 4 hours and Input and
Output monitoring. Paracetamol syrup 30mg/ 5 ml to 6 ml every 6 hours.

January 31,2017 (NO DUTY)

Patient was (+) for fever, periorbital swelling. She was conscious
coherent and not in distress. Symmetrical chest expansion, clear breath sound,
full and equal pulse. Give Paracetamol and Monitor the Input.
February 1, 2017 (NO DUTY)

Nursing care done, for continuity of care same patient, Vital signs are
monitored and recorded due to medicine given. The patient has normal Blood
pressure 110/60, pulse rate 94 and temperature 37.7C but (+) on edema on
eyelids R/L. Full equal pulses, symmetric chest expansion no reaction and breath
sounds. PNSS 350 ml. Give Cetirizine, Ceftriaxone Day 2 and 3
Continue prevent medications.

February 2, 2017 (ON DUTY)

Patient is conscious and coherent and in cardiorespiratory distress,

Anicteric, pink palpebral conjunctiva, has signs of periorbital edema. Symmetrical
chest expansion, normal breath sounds, precordium, negative from murmurs,
flabby abdomen, soft and non-full and equal pulses. (-) edema and (-) vomiting
was observed. Patient has normal vital sign. BP 90/60, Temperature 37.2, PR 98.
Appetite id now on fair to good as well as her activity. PNSS 350ml. Oral Cetirizine
and give Furithalmic eye drops. Monitor the Urine Analysis. Start the Permethrine
shampoo and for abdominal Ultrasound (Schedule)

February 4, 2017 (ON DUTY)

Patient was (-) for fever, (+) edema, no bleeding and no abdominal
pain. Vital signs: BP 90/60, CR 71, RR 36, TEMP. 36.3. She was conscious
coherent, not in distress. PNSS decrease 250 ml every 8 hours (1.4 cc /kg/hr).
Limit intake 1 Liters (include PNSS to oral intake) . No need Furosemide and
Albumin. Weight patient daily (pre breakfast). Monitor Input and Output every
shift and rounds. For schedule the Ultrasound.

February 6, 2017 (NO DUTY)

Patient had no complain, assessment was done. She was (-) for fever
and no eye contact but she was awake. There was decrease facial edema. Vital
signs: BP 90/60, CR 82. She has a good appetite and in good condition.
Emphasized 11-7 to limit oral fluid intake as ordered. Still which facial edema. For
Complete Blood Count.

February 7,2017 (NO DUTY)

Patient was conscious coherent with good appetite and good in

activity. Assessment and vital signs were recorded. She was (-) for fever, edema
and seizures and also the pink palpebral conjunctiva and dynamic precordium
was clear, breath sounds with normal rate.
Monitor Input and Output monitor.

February 11,2017 (0N DUTY)

Patient was (-) for fever, edema, bleeding, vomiting. She had good
activity and appetite. She was conscious coherent, not in stress. Vital signs: BP
90/60, CR 119, RR 28. Pink palpebral sclera. Symmetrical chest expansion, clear
breath sound. For abdominal Ultrasound on Feb 13 for cranial.

February 12, 2017 (No Duty)

Patient was (-) fever, vomiting, headache and pain. Good oral intake,
Conscious coherent and not in distress. Vital signs: BP: 110/60 CR: 90 RR: 23
Temperature: 36.3. Pink palpebral conjunctiva anicteric sclera. Angina Pectoris,
Nasal Respiratory Resistant (-) murmur. Her abdomen was soft and non-distended.

February 13, 2017 (No Duty)

Patient was (-) for seizure, vomiting, and fever. She was conscious
coherent and not in distress. Vital signs: CR 92, RR 24, TEMP. 36.5. She had Pink
palpebral conjunctiva and anicteric sclera. Saturated Calomel Electrodes (-)
reaction, clear breath sounds. A dynamic precordium normal rate, irregular
rhythm murmur. Input and Output monitoring every shift.
 February 14, 2017 (No Duty)

Patient was (-) for vomiting, fever. She had a good activity and good
appetite. She was a conscious coherent and not in distress. Vital signs: CR 90, RR
25, TEMP36.7. She had Pink palpebral conjunctiva anicteric symmetrical chest
expansion and clear breath sounds (-) No Apparent Distress and (-) Canine
Leukocyte adhesion Deficiency. For abdominal Ultrasound. Continue permethrin
shampoo and continue present medication.

February 15, 2017 (No Duty)

Patient was (-) fever, seizure, pain and (+) scalp itchiness. She was
conscious coherent and not in distress. She had Saturated Calomel Electrodes and
(-) reaction. Angina Pectoris Nasal Respiratory Resistant (-). Continue present of
medication and management. Follow up the permethrin shampoo. May transfer
back to ward once with proper condition.

NURSING CARE PLAN (1)

Assessme Diagnos Backgrou Planning Intervent Rationale Evaluation

nt is nd ion
knowledg
e
 Subjective: Fever Infectious After 4hrs - Monitor - Assist in After 4hrs of
Mainit ang related Agents of nursing clients determining nursing
anak ko to (Pyrogens) interventio temperatu the intervention
as as inflamm n the re and diagnosis. s the
verbalized ation of patient note for Room patient was
Monocytes
by the glomerul will presence temperatur able to
patients i. maintain of chills/ e should be maintain
mother Pyrogenic core profuse changed to core
cytokines temperatu diaphoresi maintain temperatur
re within s; also near normal e within
Objectve: normal note for temperatur normal
(+) fever Anterior range. degree e. range.
(+) Hypothala and
periorbital mus pattern of - To obtain
edema occurrenc baseline
(+) chills e. data.
Elevated
-
thermoreg
decreased - Monitor
ulatory set
appetite the -Can help
point
- temperatu reduce
decreased re of the fever
activity Increased environme
Conservati nt. -
VS : on Antipyretics
- Temp -Monitor acts on the
: the vital hypothalam
Increased
38.3 signs us, reducing
heat
- PR: hyperthermi
production
113 - Provide a
- RR: warm
24 FEVER water
compress

- - Water
Administer regulates
antipyretic body
s as temperatur
prescribed e.
by the - Providing
physician. health
teachings to
- client could
Encourage help client
client to cope with
increase disease
fluid condition
intake and could
help
-Educate prevent
client of further
signs and complicatio
symptoms ns of
of hyperthermi
hyperther a.
mia
 NURSING CARE PLAN (2)

Assessme Diagnosis Backgro Planning Intervent Rationale Evaluatio

nt und ion n
Knowled
ge
Subjective: Fluid After 7 >Establis >To gain After 7
Nagmama volume Renal days of h rapport trust to the days of
nas yung excess Failure nursing patient. nursing
paligid ng related to interventio >Monitor interventio
mata ng decrease ns, patient the vital >To obtain ns, the
anak ko as golumerul will able to signs. baseline goal was
verbalized ar filtration Loss of maintain data. met the
by the secondary albumin fluid >Asses patient
patients to volume, patients maintaine
mother. glomerular normal VS, appetite >To prevent d fluid
inflammati and free fluid volume,
Objective: on. Reduction from signs >Record overload the puffy
-(+) in of the eyelids
Periorbital colloidal periorbital amount of easily
edema osmotic edema. fluid >To monitor gone and
-puffy pressure intake. fluid went to
eyelids retention back to
-Reddish in and normal
palpebral evaluate and, free
conjuctiva Edema >Record degree of from
I&O excess . periorbital
Temp: accurately edema.
38.2C and >Weight
BP: 90/60 calculate gain
CR: 113 fluid indicates
RR: 24 volume. fluid
retention or
>Restrict edema.
sodium
and fluid >To monitor
intake. kidney
function.
>Explain
to the >Understan
mother ding
the promotes
conseque patient and
nce of familys
fluid cooperation
retention with fluid
restriction.
NURSING CARE PLAN (3)

Assess Diagnosi Background Planning Interve Rationale Evaluati

ment s knowledge ntion on
Subjecti Imbalanc General body After 7-14 >Establis To facilitate After 7-14
ve: e weakness days of hed cooperation days of
Mataml Nutrition: related to nursing rapport as well as to nursing
ay at Less than Acute interventi gain patients interventi
trust.
mahina body Glomerulonep on the on, the
siyang requireme hritis patient patient
>Daily To assess
kumain nts will physical weigh t gain manifeste
as related to Poor appetite manifest and or weight loss. d increase
verbaliz dietary and desire to increase weight in
ed by restriction eat and drink in monitorin appetite,
the as appetite, g To provide mood
mother. evidence Decrease mood foods that will improvem
by improvem >Assess increase her ent and
intake of food
Objectiv decrease ent and nutritional appetite. weight
and fluids
e: desire to weight status improvem
To maintain
- eat. Nutrition improvem >Increase fluid balance. ent from
Weakne imbalance ent fluids per 35.5kg to
ss between doctors 50kg.
-Patient 50kg to order.
To prevent
untouch 52.3kg Goal was
>Assess dehydration
ed to met.
and and
her encourag nutritional
food. e the deficit.
-150ml patient ti
water increase
intake fluid and
- increase
wt.35.5k food To prevent
g intake. further water
Temp: retention due
>Provide to acute
38.2C
low salt glomerulonep
BP: diet. hritis
90/60
CR: 113
RR: 24

RECOMMENDATION

MEDICATION -Explain to the mother of the

patient and family members the
importance of taking medicines

> Ampicillin - tiv q6 after ANST

> ceftriaxone - IVq 12 hours.
> cetirizine - at bedtime
>Paracetamol - q6 PRN
> glycerin Given once
EXERCISES -Advise the mother of the client
to have an exercise to her child
such as walking.

-As time and experiences

increases the client can move to
higher intensity exercise.

>Advice the mother of the

patient to have or maintain safe
and clean environment
TREATMENT -Ensure follow up and self-care.

-Advice the mother or significant

others to take in time prescribe
medicines specially in kidney
function.

-Advise the mother of the patient

to limit water intake; that she
drink and monitor output.

Health Teachings >Describe to the family of the

patient the signs and symptoms
to be reported
immediately (Blood in the urine,
foamy urine, swelling and
swelling on her face.
> Advise significant others to
immediately consult her
physician if signs and symptoms
of the diseases occurs persist.

OUTPATIENT Encourage the mother of the

(CHECK UP) patient that when her child
discharged, she need to have a
regular checkup, to her physician
until is needed. To check
 regularly her condition.
DIET -limit the amount of protein,
potassium, and salt that be
eaten of her child.

-eat healthy foods and get plenty

of exercise.

- eat high in protein and low sodium

foods that will help not worsen
her condition.

Spiritual >Advise relatives or significant

others to provide moral support
and widen their understanding.
>Tell to the significant other to
pray for the client to help with
the recovery.
>and also Instruct the patient to
pray for her fast recovery and
guidance.