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8/3/2019 Acute Glomerulo Nephritis V
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BSN IV-CEFI
GROUP 4
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INTRODUCTION
A. Background of the study
During our 1st & 2rd week of hospital exposure atQuezon Medical Center Pedia Ward, we
encountered a patient with Acute Glomerulonephritis
VS Nephrotic Syndrome, Urinary Tract Infection.
Mr. x, 15 years old, was admitted with the chiefcomplaint of abdominal pain, fever &
edema last July 21, 2010.
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Acute glomerulonephritis refers to a specific set
of renal diseases in which an immunologicmechanism triggers inflammation and proliferation ofglomerular tissue that can result in damage to thebasement membrane, mesangium, or capillaryendothelium.
There are many diseases that cause an activeinflammation within the glomeruli. Some of thesediseases are systemic and some occur solely in the
glomeruli. When there is active inflammation withinthe kidney, scar tissue may replace normal,functional kidney tissue and cause irreversible renalimpairment.
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Most original research focuses on the poststreptococcal patient. Acute glomerulonephritis is defined
as the sudden onset of hematuria, proteinuria,and redblood cell casts.
This clinical picture is often accompanied byhypertension, edema, and impaired
renal function.
Although this is primarily a disease of children,with ages 4-12 being at high risk, it can occur at almostany age. Males are more susceptible than females, with
a ratio of 1.7-2:1. No specific race is considered at highrisk of acquiring this illness, though those in lowersocioeconomic brackets are more prone to this due toenvironmental and sanitary conditions
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Nephrotic syndrome is a group of symptoms including proteinin the urine (more than 3.5 grams per day), low blood proteinlevels, high cholesterol levels, high triglyceride levels, andswelling. Autoimmune process leading to structural alterationof glomerular membrane that results in increasedpermeability to plasma proteins, particulary albumin.
Nephrotic syndrome is a disorder of the glomeruli (clusters ofmicroscopic blood vessels in the kidneys that have small
pores through which blood is filtered) in which excessiveamounts of protein are excreted in the urine. This typicallyleads to accumulation of fluid in the body (edema) and lowlevels of the protein albumin and high levels of fats in theblood.
Nephrotic syndrome is not a specific glomerular disease but acluster of clinical findings, including:Marked increase inprotein (particularly albumin) in the urine (proteinuria),Decrease in albumin in the blood (hypoalbuminemia), Edema,High serum cholesterol and low-density lipoproteins(hyperlipidemia).
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This clinical picture is often accompanied byAlbuminuria (s1), Edema(s2), Hyperlipidemia(s3) &Hypoalbuminemia(s4)
Although this is primarily a disease of children,with
1 12 and 4 yr at high risk, it can occur at almostany age. Males are more susceptible than females,with a ratio of 1.7-2:1. No specific race isconsidered at high risk of acquiring this illness,though those in lower socioeconomic brackets aremore prone to this due to environmental andsanitary conditions. People with family history ofnephrotic syndrome increases likelihood ofdeveloping nephrotic syndrome.
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Urinary tract infection (UTI) is a bacterial
infection that affects any part of the urinarytract.Although urine contains a variety offluids, salts, and waste products, it usuallydoes not have bacteria in it. When bacteriaget into the bladder or kidney and multiply
in the urine, they cause a UTI. The mostcommon type of UTI is a bladder infectionwhich is also often called cystitis.Anotherkind of UTI is a kidney infection, known as
pyelonphritis, and is much more serious.The major problem here is that urinary tractinfection causes discomfort and pain onurination.
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Incidence:
Most common renal disease in children.Almost 10 times more common in females thanin males, except in the neonatal period.Bladder is the most common site of infection25% of all women (cystitis)
Men before the age of 50 years
Risk Factors: Location of the female meatus
Sexual intercourse
y Urinary stasis and reflux in pregnant women causedby pressure on the ureters and hormonal changes.
y Tight and synthetic clothing (causes irritation)
y Presence of an indwelling catheter.
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B. Objectives of the Study
GeneralThe general objective of this case presentationis to foster and develop knowledge and skills inproviding care and management for a patient withacute glomerulonephritis vs nephrotic syndrome, urinarytract infection
Specific
KNOWLEDGE
To define acute glomerulonephritis, nephrotic syndrome,urinary tract infection
To know the clinical manifestations, nursing
management and interventions for patients who
have this disease.
To know the different medications that needs to be
taken including its side effects which can be harmful tothe patient
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SKILLS
To be able to obtain, document, and present a
comprehensive medical history. To perform initial physical examination such as
general assessment of the patientsappearance,
position and degree of comfort.
To apply necessary skills in providing care for aclient with acute glomerulonephritis VSnephrotic syndrome, UTI
ATTITUDES
To learn how to establish rapport with the clientand significant others.
to be able to recognize the importance of patient
and familial preferences when selecting among
treatment options
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C. Scope and Limitation of the Study
The scope of the study encompasses theanatomy, physiology, and pathophysiology of thedisease acute glomerulonephritis VS nephroticsyndrome, UTI. While dealing withMr. xcase, we are subjected with the followinglimitations of our study:
The group only had 2 days (July 2010) ofactual interaction with the patient at Quezon MedicalCenter, Lucena City.
The group credited the study on the referencesprior to books, researches in the internet and datacollected from the interview with the client/familymembers, physical assessment and the patientschart.
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CLINICAL SUMMARYCLINICAL SUMMARY
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A. GeneralData
Case # 10071323Name :Mr. x
Address :Brgy. Poblacion, L.C.
Age :15 y/o
Religion :Roman catholicCivil Status :Child
Nationality :Filipino
Date of Birth :July 21, 1995
Date of Admission :July 21,2010Ward and Room :PAW 04
AdmittingDiagnosis :AGN VS. NS, UTI
Attending Physician :Dra Tagle
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B. CHIEF COMPLAINT
abdominal pain, fever &
edema last July 21, 2010.
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C. History of Present Illness
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D. PAST MEDICAL HISTORY
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E. FAMILY HISTORY
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F. Physical Assessment
General Appearance
Presence of edema on both extremities
The client looks weak and pale. Hesleeps a lot and
talks only when asked.
The client experiences cold andclammy perspiration.
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Head to Toe Assessment
Head- normocephalic
no presence of lumps
Eye- no abnormal eye discharge
PERRLA (+)
Nose - symmetric
Without nasal discharge
Lips - slightly dry and pale
uvula and tongue centrally located
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Ears equal size
no swelling
upper pinna is in line with outer cantus
Neck able to move freely
no lumps upon palpation
Chest symmetrical expansion
with clear breath sound on both lung
field upon auscultation
Abdomen with tender abdomen uponpalpation
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G. Laboratory/Diagnostic Exams
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ANATOMY
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2 kidneys a pair of purplish-
brown organs located below the
ribs toward the middle of theback. Their function is to:
>remove liquid waste from the
blood in the form of urine.
>keep a stable balance of salts
and other substances in the
blood.
>produce erythropoietin, ahormone that aids the formation
of red blood cells.
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The kidneys remove urea from the blood
through tiny filtering units called nephrons.
Each nephron consists of a ball formed of small
blood capillaries, called a glomerulus, and a
small tube called a renal tubule.
Urea, together with water and other waste
substances, forms the urine as it passesthrough the nephrons and down the renal
tubules of the kidney.
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The Nephron
Is the basic structural and functional unit of the kidney.
Its chief function is to regulate the concentration of
water and soluble substances like sodium salts by
filtering the blood, reabsorbing what is needed and
excreting the rest as urine. A nephron eliminateswastes from the body, regulates blood volume and
blood pressure, controls levels of electrolytes and
metabolites, and regulates blood pH. Its functions are
vital to life and are regulated by the endocrine system
by hormones such as antidiuretic hormone,
aldosterone, and parathyroid hormone. In humans, a
normal kidney contains 800,000 to one million
nephrons.
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The GlomerulusThe glomerulus is themain filter of the nephron and is
located within the Bowman's capsule.The glomerulus
resembles a twisted mass of tiny tubes through which
the blood passes.The glomerulus is semipermeable,allowing water and soluble wastes to pass through and
be excreted out of the Bowman's capsule as urine.The
filtered blood passes out of the glomerulus into the
efferent arteriole to be returned through the medullary
plexus to the intralobular vein
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Bowman'sCapsule
The Bowman's capsule contains the
primary filtering device of the nephron, the
glomerulus. Blood is transported into the
Bowman's capsule from the afferent arteriole(branching off of the interlobular artery). Within
the capsule, the blood is filtered through the
glomerulus and then passes out via the efferent
arteriole. Meanwhile, the filtered water andaqueous wastes are passed out of the
Bowman's capsule into the proximal convoluted
tubule
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PATHOPHYSIOLOGY
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UTI
Post-streptococcal infection
(group-A, beta hemolytic)
Release of material from the organism,
into the circulation (antigen)
Formation ofantibody
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Immune complex reaction in the
glomerular capillary
Inflammatory response
Proliferation of epithelial cells lining
glomerolus & cells betweenendothelium & epithelium of capillary
membrane
Swelling capillary membrane &
infiltration with leukocytes
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Permeability of base membrane
Glomerular filtration rate
Occlusion of the capillaries of the
glomeruli vasospasm of afferent
ventrioles
Ability to form filtrate fromglomeruli plasma flow
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Retention of H2O & Na; hypovolemia;
circulatory congestion
NEPHROTIC SYNDROME
Renal injury
Excessive lost of protein in urination
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ACUTE GLOMERULOACUTE GLOMERULO--NEPHRITISNEPHRITIS
Common manifestations of the syndrome are:Proteinuria, hypoalbumenia,hypercoagulability,hypoalbuminemia,
hyperlipideminemia,hypercoagulability
Edema
Hypertension
urinary outputUrine dark in color
Anorexia
Irritability lethargy
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CLINICAL MANIFESTATIONSCLINICAL MANIFESTATIONS
Oliguria/anuria, due to decreased glomerular filtrationrate (GFR)
Elevated BUN and serum creatinine, due to decreased
urine output
Hematuria (microscopic or gross), occurs in
approximately 30% of cases; urine may appear dark,
cola-colored or tea-like
Proteinuria, primarily albumin, due to increased
permeability of glomerular membrane
Edema (facial, periorbital and/or pedal), hypertension,
anemia, increased ICP, pulmonary edema, all related to
increased circulating blood volume/excess extra-cellular fluid (ECF)
Tenderness over the costo-vertebral angle ( + kidney
punch), due to swelling of kidneys
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ASSESSMENT AND DIAGNOSTICS
History taking; 1-3 weeks post-streptococcal infection (1-2 weeks post-pharyngitis)
Urinalysis; dark urine, (+) RBC, albumin,casts; specific gravity > 1.020
CBC; decreased Hgb, HctBlood chemistry; elevated BUN and serumcreatinineKidney biopsy, electron microscopy and
immunofluorescent analysis Antistreptolysin O; increased in 60-80% of
patients
KUB; enlarged kidneys
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POSSIBLE NURSING DIAGNOSIS
Fluid volume excessrelated to decreased glomerular
filtration rate as evidenced by decreased urine output,
edema and hypertension
Imbalanced body temperature related to unknown etiology
(possible infection) as evidenced by Temp=38.4 C
Imbalanced nutrition: less than body requirementsrelatedto increased glomerular permeability as evidenced by proteinuria
Knowledge deficitrelated to medical management of the
disease as evidenced by questioning attitude by the mother
Anxietyrelated to outcome of treatment
Impaired parent-child interactionrelated to irritability of child Risk for impaired skin integrityrelated to edema/altered
skin turgor
Risk for infectionrelated ongoing disease process
(immunocompromised)
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DRUG STUDY
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Ranitidine
Therapeutic Classification
y Antiulcer Drug
Action
y Reduces gastric secretion and increases gastric mucus and
bicarbonate production, creating a protective coating on gastricmucosa
Contraindication
y Hypersensitivity to drug and its component
Toxic/Side Effects
y Nausea, vomiting, diarrhea, constipation, abdominal discomfort
or pain.
Indications
y To maintain healing of duodenal and gastric ulcers
Safety
y Renal or hepatic impairment, heart rhythm disturbances
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FUROSEMIDE
Therapeutic Classificationy Diuretic
Action
y Increases potassium excretion and plasma volume,
promoting renal excretion of water.
Contraindications
y Hypersensitivity to drug or other sulfonamides
Toxic/Side effects
y Nausea, vomiting, diarrhea, constipation, dyspepsia, oral
and gastric irritation, cramping, anorexia, dry mouth.
Indications
y For hypertension.
Safety
y Diabetes melitus, severe hepatic disease, neonates
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Asessment Nursing
Diagnosis
Planning Interventio
n
Rati
onal
e
Evaluation
S>
Namamanas na ang
kamay at
paa ko as
verbalized
by the
patient
O>
-fluppy face
-edema on
both lower
and upperextremities
-tender
abdomen
-pale in
appearance
-bodymalaise
Fluid volume
excess relatedto renal failure
After 8 hours of
nursingintervention
patient can
demonstrate
behaviors to
monitor fluid
stasus andreduce
recurrence of
fluid excess
INDEPEND
ENT-
reinstructed
patient on
NPO
-monitor
intake andouput
-elevate
edematous
extremities
-Provide
adequateactivity or
position
changes
-to
avoid
exce
ssive
fluid
reten
tion-to
mea
sure
the
intak
eand
outp
ut
-to
incre
aseveno
Goal
partially metseen patient
elevating
both legs
using pillow
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Asessment Nursing
Diagnosis
Planning Interventio
n
Rati
onal
e
Evaluation
-DEPENDENT
-Administer
diuretic as
ordered
us
return
-to
prev
ent
fluid
accumula
tion
in
depe
nden
tarea
s
-to
prom
ote
offluid
diuresis