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Table of contents
I. a. b. c. Introduction Overview of the Case Objective of the Study Scope and Limitation of the Study
II. Health History a. Profile of patient b. Personal Health History c. History of Present Illness d. Chief Complaint III. Developmental Data
IV. Medical Management a. Medical Orders and rationale b. Drug study V. Pathophysiology with Anatomy and Physiology VI. Nursing Assessment (System Review & Nursing Assessment II) VII. Nursing Management a. Ideal Nursing Management (NCP) b. Actual Nursing Management (SOAPIE) VIII. IX. Referrals & Follow-up Evaluation and Implications
X. Bibliography
I. INTRODUCTION
A. Overview of the Case
Acute Glomerulonephritis is the disease of the kidney in which there is an inflammation of the glomerular capillaries. In most cases, the stimulus of the reaction is group A streptococcal infection, which ordinarily precedes the onset of glomerulonephritis by 2 to 3 weeks.
The study generally aims to investigate the condition of an adult man and further understand the extent of the case.
Specifically, the health care provider sought to; Perform Physical Assessment, Data Base and History taking that solidifies the present diagnosis of the client. Identify the development and changes encountered by the client. Identify the nursing problems which will be the basis of the care plan. Develop Plan of the Care and Implement nursing interventions relevant and suitable for the case.
As nursing students they will be able to improve their skills in accordance to patients needs and condition.
The purpose of the study is to gather significant data to broaden our knowledge with regards to the condition of the patient and to improve our abilities as future health care providers. Moreover, this case study will enable us to apply the acquired skills we obtained in the classroom set-up.
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.
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
invested in unresolved psychosexual developments, the greater his capacity will be to develop normal relationships with the opposite sex. If, however, he remains fixated, particularly on the phallic stage, his development will be troubled as he struggles with further repression and defenses.
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.
Give 1 egg white a day 0.9 NaCl @ KVO rate Furosemide i amp q 12h x 3doses
I & O q shift
01/28/09
IVF 0.9 NaCl @ KVO rate Spironolactone 50mg itab TID P.O. Continue meds. Weight patient daily pre-breakfast
To monitor body fluids & prevent dehydration To counteract potassium loss caused by other diuretics To treat the disease & remove the symptoms To monitor if the symptoms are relieved
01/29/09 Continue meds. IVF of D5nm iL @ KVO rate To treat the disease & remove the symptoms To monitor fluids
B. Drug Study
Generic Name of Ordered Drug Cefuroxime Date Ordered Classification Dose/ Frequency/ Route 750 mg q 8h IVTT Mechanism of Action Specific Indication Contraindication Side Effects/ Toxic Effects Hypersensitivity, nephrotox icity, pain at injection site Nursing Precaution
01/27/09
Assess for hepatic or renal impairment Assess for skin status Check for sensitivity tests
Date Ordered
Classification
Mechanism of Action
Specific Indication
Contraindication
Side Effects/ Toxic Effects Polyuna, Nocturia, Rash, Anemia, Muscle spasms, Cardiac arrythmia s
Nursing Precaution
01/27/09
Loop Diuretic
Inhibits reabsoption of Na and Cl from the proximal and distal tubules and ascending limb of the loop of Henle, leading to a Na-reach diuresis
Assess for allergy to furosemide Assess for skin color, lesions and edema CBC, serium electrolytes
Date Ordered
Classification
Mechanism of Action
Specific Indication
Contraindication
Side Effects/ Toxic Effects Rash, alopecia, nausea, vomiting Epistasis, fever
Nursing Precaution
01/27/09
Gastric acid First line Contrapump treatment indicated with inhibitor: for hyperSupresses heartburn sensitivity to gastric acid and short omeprazole or secretion by term its specific treatment of component. inhibition of active Use hydrogenduodenal cautiously K ATPase ulcer pregnancy enzymes lactation system at secretory surface of the gastric parietal cells.
Assess for hypersensiti vity to omeprazole Assess for skin lesions Assess for urinary output
Date Ordered
Classification
Mechanism of Action
Specific Indication
Contraindication
Side Effects/ Toxic Effects Polyuria, Tachycardia, proteinuri acough dry mouth
Nursing Precaution
01/27/09
ACE inhibito r
Treatment hypertension
Assess for allergy to captropil Assess for skin color and lesions For CBC and differential
Date Ordered
Classification
Mechanism of Action
Specific Indication
Contraindication
Nursing Precaution
01/28/09
Diuretic s
Cause loss of sodium bicarbonate and calcium while saving potassium and hydrogen ions
Hypersensitivity; Hyperkalemia
Monitor intake & output Daily weight during therapy Monitor BP before administering
V. PATHOPHYSIOLOGY
VI. ASSESSMENT
EENT:
[ ] impaired vision
[ ] blind GENITO URINARY and GYNE: [x] pain [x] urine color [ ] vaginal bleeding [ ] hermaturia [ ] discharge [ ] nocturia [ ] no problem
RESPIRATORY: [ ] asymmetric [ ] tachypnea [ ] apnea [ ] rales [x] cough [ ] barrel chest [ ] bradypnea [ ] shallow [ ] rhonchi [x] sputum [ ] diminished [ ] dyspnea [ ] orthopnea [ ] labored [ ] wheezing [ ] pain [ ] cyanotic [ ] no problem
NEUROLOGICAL: [ ] paralysis [ ] stuporous [ ] unsteady [ ] seizures [ ] vertigo [ ] vision [ ] lethargic [ ] tremors [ ] grip [ ] comatose [ ] confused [x] no problem
MUSCULOSKELETAL: [ ] appliance [ ] stiffness [ ] petechiae [ ] hot [ ] swelling [ ] itching [ ] drainage [ ] lesion [ ] deformity [ ] skin color [x] pain
CARDIO VASCULAR: [ ] arrhythmia [ ] tachycardia [ ] numbness [ ] diminished pulses [ ] edema [ ] fatigue [ ] irregular [ ] bradycardia [ ] murmur [ ] tingling [ ] absent pulses [x] pain [ ] no problem
[ ] prosthesis
GASTRO INTESTINAL TRACT: [ ] obese [ ] distension [ ] mass [ ] dysphagia [ ] rigidly [ ] pain [x] no problem
NURSING ASSESSMENT II
SUBJECTIVE
COMMUNICATION: [ ] Hearing Loss [ ] Visual Changes [x] Denied Comments: wala man wala gihapon As verbalized by the husband [ ] Glasses [ ] Contact lens R L Pupil Size: 3-5 mm Reaction: PERRLA
OBJECTIVE
[ ] Language [ ] Hearing Aide [ ] Speech difficulties
OXYGENATION:
[ ] dyspnea [ ] smoking history Oftentimes [x] cough [x] sputum [ ] denied Comments: Nah! gapanigarilyo mana siya -giubo pd siya karon oh. As verbalized by the wife Comments: Sakit! bug-at nanghubag na man gni ako mga tiil As verbalized by the patient
Respiratory: [x] regular [ ] irregular Describe: regular breathing but associated with pain Right: Right lung is symmetrical to left lung. Left: Left lung is symmetrical to right lung. Heart Rhythm [x]regular [ ] irregular Ankle Edema: present in lower extremities Pulse Carotid Radial DP Femoral Right: 62 65 60 not assessed Left: 62 65 60 not assessed Comments: Pulse sites are palpable and its rate are within normal range. [ ] dentures Upper Full [] Partial [ ] [ ] [x] none With Patient [ ] [ ]
CIRCULATION:
[ ] chest pain [x] leg pain [x] numbness of extremities [ ] denied
Lower []
ELIMINATION:
Usual bowel pattern Once a day [ ] constipation Remedy January 27, 2009 Date of last BM [ ] diarrhea character [ ] urinary frequency once daily [ ] urgency [x] dysuria [ ] hematuria [ ] incontinence [ ] polyuria [ ] foly in place [ ] denied Comments: urinate once daily due to pain and excrete small amount. Bowel Sounds: Audible sounds Abdominal Distention: Present [ ] Yes [x] No Urine (color, consistency, odor) tea color of urine, inconsistent
Briefly describe the patients ability to follow treatments (diet, meds, etc.) for chronic health problems (if present):
The patient is properly following her medications
SUBJECTIVE
SKIN INTEGRITY: [ ] dry [ ] itching [x] other - edematous [ ] denied Comments: wala man - nanghupong lang ko as verbalized by the Patient.
ACTIVITY/SAFETY: [ ] convulsions Comments: dili man [ ] dizziness hinuon, bug-at lang [ ] limited motion of joints gyud ako tiil Kay nanghupong Naman kaya Limitation in man hinuon nako. ability to as verbalized by the [ ] ambulate patient [ ] bathe self [ ] other [x] denied COMFORT/SLEEP/AWAKE: [ ] pain Comments: ok (location, raman hinuon Frequency, As verbalized Remedies) by the patient. [ ] nocturia [ ] sleep difficulties [x] denied COPING: Occupation : Farmer Members of household: 6 Most supportive person: Wife
_____________ __ Neuro VS _____________ _ Urine test _____________ __ _____________ __ CVP/SG. Reading ________ _____________ _ 24 hour urine collection
Date disc.
RATIONAL
physician
Nursing Diagnosis:
Ineffective airway clearance related to productive cough INTERVENTIONS Assess the airway patency
Encourage deep-breathing and coughing exercise Monitored the fluid intake Instruct to have proper clothing, not too tight and not too loose
Nursing Diagnosis:
Monitor vital signs Acknowledge patients verbalization of pain & allow him to describe it Perform pain assessment each time occurs
Elevate edematous extremities, change position frequently Provide quiet environment Administer Spironolactone 50mg itab TID P.O. as prescribed by the physician
Long term: At the end of 2 days, pt. will be able to lessen or diminished the symptoms of glomerulonephritis that produces excessive fluid. Short term: At the end of 8 hours, the pt. will be able to reduce the excessive fluid volume.
1) 2) 3) 4)
Monitor vital signs especially temperature To check & assess for infection since the pt. has a higher risk Monitor intake & output To monitor & check fluid volume & prevent dehydration Elevate the edematous extremities To reduce tissue pressure & risk in skin breakdown Place in a semi-fowlers position, change position frequently To facilitate movement of diaphragm & improve respiratory effort 5) Administer furosemide 1 ampule every 12h as prescribed by the physician For the treatment of edema At the end of 8 hrs, the pt reduces the excess fluid in his body thru excretion of stored fluids.
HEALTH TEACHINGS
MEDICATIONS
EXERCISE
TREATMENT
Encourage/instruct to keep the edematous extremities to elevate as often; limit of water intake; monitor intake and output; provide warm environment; provide egg white a day; weight the pt. daily, at the same time.
OUT-PATIENT (Check-up)
Encourage pt. that when his discharged, he must have a regular check-up to his physician until its needed. To evaluate the progress of his condition. Instruct to limit intake of salty & fatty foodsand enrich/increase the intake of foods rich in potassium such as bananas
DIET
X. BIBLIOGRAPHY Doenges, Marilyn E. et.al Nurses Pocket Guide: Diagnoses, Interventions and Rationale. 9th edition pages 278-279, 472-477, 576-578 F. A Davis Company Philadelphia, 2004.
Lippincott Williams & Wilkins, Manual of Nursing Practice, 8th edition, volume 1.
Deglin, et al. Daviss Drug Guide for nurses, 9th edition. Smeltzer, Suzanne C. et al. Textbook of MedicalSurgical Nursing, 11th edition, volume 2.