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Glomerulonephritis is a type of kidney disease that damages the kidneys' ability to remove waste andexcess fluids. Also called glomerular disease, glomerulonephritis can be acute a sudden attack of

inflammation or chronic coming on gradually. Most original research focuses on thepoststreptococcal patient. Acute glomerulonephritis (AGN; also called Glomerular Disease) is an

inflammation of the glomeruli, bundles of tiny vessels inside the kidneys, which predominantly affectschildren aging two to twelve.The damaged glomeruli cannot effectively filter waste products and excesswater from the bloodstream to make urine. The kidneys appear enlarged, fatty, and congested.

Around two to three weeks after a streptococcal infection, symptoms of Acute Glomerulonephritis mayoccur and begin with swelling. This could progress to an increase in blood pressure, visual disturbances,

shortness of breath, blood in the urine, and a reduction of urine production.

II. NURSING ASSESSMENT

A. PERSONAL DATA

The patient, Christy, is a 4-year old little girl who was born on May 11, 2007. According to Mrs. Tita,who is the auntie of Christy and the researchers informant, Christy is the fourth child of Mr. and Mrs. U, the

parents of Christy. She also has three older sisters and 2 younger siblings. Christy resides in Mt. View,Balibago, Angeles City, Pampanga. This is also the place where she was born and spent her first four yearsof life. She is born Filipino, and her religion is Roman Catholic.

A round 11:30pm, January 1, 2012, she was admitted to a secondary hospital in Angeles City withchief complaint of hematuria, fever and vomiting. She was diagnosed Acute glomerulonephritis and was

brought for confinement to the pedia ward of the said hospital. After 5 days of confinement, she wasdischarged last January 5, 2012.GROWTH AND DEVELOPMENT

Sigmund Freuds Psychoanalytic Theory. In this theory, the development of a child is described asbeing a series of psychosexual stages in which the childs interests become focused on a particular body

site. Since Christy is now 4 years old, she is in the Phallic stage. In this stage, a child learns sexual identitythrough awareness of genital area, and children play with their bodies largely out of curiosity . Also, thisphase is where the Oedipus/Electra complex. The researchers observed that Ana often would ask if her

father would come to see or to stay with her in the hospital.

Erik Eriksons Psychosocial Development. This theory considers the importance of culture and

society in personality development. Moreover, the successful resolution of each conflict, oraccomplishment of the developmental task of that stage, allows the individual to go on the next phase ofdevelopment. Christy is on stage of Initiative versus Guilt. In here, the child learns to do things and find

doing these things desirable. The crisis at this time, according to E. Erikson, is the development of self-concept. Shesolves problems in accordance to her consciousness and she knows and wants to solve her

little problems by her own. She also likes to explore new places and do activities involving water like helpingher mother at home in washing dishes although she does not know how to do it properly.

However, during her hospitalization, she relied totally on her auntie when it comes to food choicesor other little decisions which she can solve in her non-illness state. Her enthusiasm when it comes to

exploring new places or new things was lessened during her illness state. She wanted to stay in bed most ofthe time.

Cognitive development of Piaget. According to his theory, to progress from one period to the next,the child recognizes his or her think process to bring them closer to reality. Christy is now on herPreoperational thought. A child still has an immature perception and is often influenced by role fantasy.

They do not understand relationships and they learn through trial and error. She likes being read storiesabout animals and children; she believes that her dreams are real as day-time events; and she alsobelieves that her wishes will come true and that they are real.

Kohlbergs theory of Moral Development helps to identify how a child might feel about an illness,whether the child can be depended on to carry out self-care activities, or whether the child has


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internalized standards of conduct so he or she does not cheat when away from external control. Christy isin the Preconventional stage. During this stage, a child tends to do good out of self-interest rather than out

of true intent to do good or because of strong spiritual motivation. The moral behavior developed in thisstage is taking turns at play or sharing.She offered a slice of apple to the other patient beside her when

Mrs. Tita was feeding her. Furthermore, she usually imitates what she sees.

5. HISTORY OF PRESENT ILLNESS

The common foods eaten by Christy are junk foods that are rich in sodium or salt content, such as

Tempura, Lala crackers, chips, and so on. She also prefers to drink carbonated drinks like colas or Sprite,and she has minimal water intake amounting to 15-30mL per day, as cited by Mrs . Tita. She urinates at amaximum of 3 times a day. She also likes to play outside the house. Sometimes, she is not able to take a

shower at night and even brush her teeth before going to bed. A week prior to admission, Christyexperienced fever of 40C with cough at night. She also experienced fever the same high grade fever thefollowing nights. In the next day, she was rushed to the OPD of the same hospital and was given with

antibiotic and antipyretic. 1 day prior to admission, she experienced vomiting and fever. She was givenwith paracetamol and was relieved. 3 hours prior to admission, she experienced hematuria whichprompted the family to bring her again to the hospital . At January 1, 2012, 11:30pm, she was admitted in

the pedia ward of the secondary hospital with a diagnosis of acute glumerulonephristis.

B. Synthesis of the Disease (Patient based)1. Definition of the Disease

Christy was diagnosed with acute glomerulonephritis (AGN) which refers to a syndrome of disorders

characterized by an abrupt onset of hematuria and proteinuria in conjunction with azotemia and renalsodium and water retention.

There are several etiologies that can be linked to the development of AGN. In the patients case,it is the High Sodium diet (junk foods and carbonated drinks) triggers the occurrence of acuteglumerulonephritis.

2. Non-modifiable and Modifiable Factors

Non-modifiable

y Age. Christy is four years old

.

The age bracket for children at risk of developing AGN is two totwelve.

Modifiable

y Diet: Increase sodium and fat intake. Sodium consumption can be an important factor in thedevelopment of hypertension. Excessive amounts of salt encourage increased release ofnatriuretic hormone that may indirectly increase blood pressure. Sodium loading also stimulates the

vasopressor mechanisms within the central nervous system. Furthermore, this kind of diet increasessodium and water retention in the blood which in turn increases peripheral vascular resistance

resulting to decrease in renal perfusion. On the other hand, high fat diet promotes accumulation offats in the blood vessels that narrows the lumen leading also to decrease perfusion in the kidneys .Christy likes to eat foods that are rich in sodium particularly junk foods.

y Decreased knowledge/awareness. Acute glomerulonephritis usually occur because of untreatedor undetected infections. This failure often results from lack of knowledge or awareness about the

disease condition, the proper management for its alleviation or even the possible complicationsthat may arise. On the case of the patient, her significant others have not done any managementin order to treat the throat infection she experienced which is regarded to be one of the mainfactors why she developed AGN.

y Low socioeconomic status. This may contribute to the disease because low income results to poorchoice of food or diet which is usually high in salt and fat. More so, because of insufficient earnings,there will be prioritization as to where the money of the family goes. Most of the time, health carecosts are compromised which makes them unable to access health care services or to avail

essential and prescribed treatments.


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3. Signs and Symptoms

Urinary changes Proteinuria or Albuminuria. (01-03-2012) Proteinuria or albuminuria results from the increased

permeability of the glomerular wall which then allows the passage of substances that werepreviously restricted to enter the glomerular space. Hence, proteins come with the urine andgive it a cloudy or turbid appearance.

Hematuria. (01-01-12 to 01-03-12) This is also due to the increased permeability of theglomerular wall leading to passage of Red blood cells that are normally restricted to enter the

glomerular space. Hematuria can be gross or microscopic and is usually revealed by reddish ortea-colored urine.

Oliguria. (01-01-12) Because proteins which play important role in the oncotic pressure are

excreted, there will be shifting of fluids from the intravascular to the interstitial spaces resultingto fluid retention. This then will cause a decrease in blood volume (hypovolemia) . Inhypovolemia, there is a reduction in blood supply and therefore perfusion in the different parts

of the body. Low renal perfusion means that there will be less amount of blood being filteredwhich in turn results to less urine output or oliguria.

Hematologicchanges

Normocytic, Normochromic anemia; Decreased Hemoglobin; Decreased hematocrit. (01-01-12) Due to the increased permeability of the glomerular wall, Red blood cells are able to pass

through the glomerular wall.

This results to decrease in number of erythrocytes in the bloodleading to anemia, low hemoglobin and low hematocrit. Leukocytosis. (01-01-12) During inflammatory process, the body tries to boost the production of

white blood cells in order to eliminate infection.

Cardiovascular changes Hypertension. Because of decreased renal perfusion along with decreased glomerular filtration

rate, the Renin-angiotensin-aldosterone system was stimulated. In here, Angitensiotensin II, avasoconstrictor, is formed from the conversion of Angiotensin I by Angiotensin-ConvertingEnzyme. Vasoconstriction increases peripheral vascular resistance which results to

Hypertension.

Respiratory changes Tachypnea. Because of hypertension, the body tissues do not receive enough oxygen. With

this, the respiratory system tries to compensate by increasing the rate of respiration .

Integumentary changes

Edema. The loss of plasma proteins in the urine caused a decrease in the oncotic pressurewhich eventually resulted to shifting of fluids from the intravascular to the interstitial spaces.More so, the activation of renin-angiotensin-aldosterone system brought by decreased renal

perfusion contributed to the fluid retention as because aldosterone secretion was stimulated.

Neuromuscular changes Weakness. Normocytic, normochromic anemia may develop due to the significant loss of

erythrocytes in the urine. With this, there will be reduced perfusion to the body tissues. Thepatient typically experience weakness or easy fatigability.

Others Fever. During inflammation, there is an increased production of white blood cells in the body.

With this, the release of pyrogens will be stimulated which in turn affects the brains

hypothalamus thermoregulation center to increase the production and conservation heat.Hyperthermia or fever results.

4. Health Promotion and Preventive Aspects of the DiseaseSufficient health teachings to Christys SO could cause an increase in knowledge or awareness

about AGN. Also, the factors that have contributed to the development of the disease condition may

have been reduced too. She could have changes in lifestyle, primarily by eating nutritious foods instead ofjunk foods and fresh foods instead of the canned and preserved ones.


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CONCLUSION

Acute glomerulonephritis refers to a specific set of renal diseases in which an immunologic mechanism

triggers inflammation and proliferation of glomerular tissue. Hippocrates originally described themanifestation of back pain and hematuria, which lead to oliguria or anuria . With the development of themicroscope, Langhans was able to describe the corresponding glomerular changes.

Most original research focuses on the poststreptococcal patient. Acute glomerulonephritis is currentlydescribed as a clinical syndrome that frequently manifests as a sudden onset of hematuria, proteinuria,

and red cell casts. This clinical picture often is accompanied by hypertension, edema, and impaired renalfunction.

As a student nurses, they should be knowledgeable enough regarding the diseases. However, learningthrough lectures and theories is not enough to completely understand these diseases. Through interaction,

knowledge acquired from theories was much appreciated by the students since he/she can actuallyassess the patients condition. With enough information and enhance skills, she/he may be able to handlefuture situations and patients suffering from the mentioned condition.


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7. DIAGNOSTIC AND LABORATORY PROCEDURES

Blood Chemistry

Diagnostic or

LaboratoryProcedures

Date Ordered, Date

Results

Indications or Purposes Results Normal Values

Creatinine Date Ordered:January 1, 2012

Date Results in:January 2, 2012

This is to reveal if there isalteration with the excretoryfunction of the pt.s kidney andit suggests its chronicity sinceit tends to rise in the later partof the disease condition.

143 mmol/l 62-106 mmol/l

Diagnostic orLaboratory

Procedures

Date Ordered, DateResults

Indications or Purposes Results Normal Values

Urinalysis 1st

Date Ordered:

January 1, 2012


Urinalysis is done to checkfor early signs of

glomerulonephritis. It mayalso be used to monitor and further evaluate thecondition of the patientskidney since she had tea-colored urine.

Color:

Reddish

Transparency:Cloudy

Specific Gravity:

1.010

pH: 6.0

Color:Light yellow to Amber

yellow

Transparency: Clear

Specific Gravity:

1.010-1.030

pH: 4.6-8.0


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Glucose:

(-) Negative

Albumin: +2

RBC: Too many tocount/hpf

Pus Cells: 3-6

Epithelial cells: Few

Glucose:

(-) Negative

Albumin: None

RBC:


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2nd

Date Ordered:January 3, 2012


Color:Reddish

Transparency: Turbid

Specific Gravity:

1.012

pH: 6.0

Glucose:(-) Negative

Albumin: +2

Few

Color:Light yellow to Amber

yellow

Transparency: Clear

Specific Gravity:

1.010-1.030

pH: 4.6-8.0

Glucose:(-) Negative

Albumin: None


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RBC: over 100/hpf

Pus Cells: 1-2

Epithelial cells: Few

RBC:


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*Hemoglobin (Hgb)

Hematocrit (Hct)

Erythrocyte (RBC)

Leukocytes (WBC)

Platelets

This is to measure thetotal Hgb in the blood inthe peripheral blood. It is

used as a rapid indirectmeasurement of the redblood cell.

It is an indirectmeasurement of red

blood cell number andvolume.

This test is to count fornumber of circulation ofred blood in theperipheral venous blood.

It determines the totalnumber of circulatingWBC per cubic mm inthe blood. It is used todetect for infection andan indicator of immunefunction.

The platelet count isdone to determine theactual count of thenumber of platelets(thrombocytes).This is to assess theclotting ability of the

WBC: 17.6

Platelets: 300

Lymphocytes: 0.54

Segmenters:0.46

Hgb: 120-170g/dL

Hct: 0.37-0.54

RBC: 4.0-5.0 x 12x12/L

WBC: 5.10 x 10^9/L

Platelets: 150-450 x10/L

The reindicatesufficien

to the pThe pat3, 2012)

Based fthe patindicate

red bloodue todilutionintravascauses of fluid January(Januar

The resto the cthe urin

The resuinflammhyperth

Based fpatient that the and is aresponsblood in


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Lymphocytes

Segmenters

blood.

Lymphocytes are white

blood cells of theagranulocyte type,originally from stemcells, that produceantibodies and attack

harmful cells. The test oflymphocyte is to evaluatechronic bacterial andacute viral infection.

It is used to helpdiagnose conditionsassociated with acute and

chronic inflammation,including infections.

Lymphocytes: 0.20-0.40

Segmenters:0.50-.0.70

An incrpresenc

infection

Based othe norm

A. MEDICAL MANAGEMENT1. Intravenous Fluids

MEDICALMANAGEMENT

OR TREATMENT

DATE ORDERED

DATE PERFORMEDDATE CHANGED or

D/C

GENERAL DESCRIPTION INDICATIONS OR PURPOSE

D5 0.3 Nacl 500 cc xKVO

Date Ordered: January1, 2012

Date Performed:

January 1-5, 2012

Date Discontinued:January 5, 2012

D5 0.3 Nacl is a D5% 0.33NACL, ahypertonic solution. A solution with ahigher salt concentration than in normal

cells of the body and the blood

When hypertonic fluids are infused,osmosis pulls water out of the cells. Thiscauses the cells to shrink. When theyshrink at the site of IV infusion, the basement membrane of the lining of thevein is exposed.

Used only when high sodium and/ocontent without large amount of fluid i(e.g. electrolyte and fluid loss repla

sodium-free fluids, excessive wate

resulting in drastic dilution of bodemergency treatment of severe salt deple


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b. Drugs

Name of the drugs;Generic name and

Brand name

Date Ordered; Dateperformed; Date Changed or

Date Discontinued

Route, Dosage, andFrequency

General Action and Mechanismof Action

Indication

1. Generic Name:

Paracetamol

Brand Name:Tempra

Date Ordered:

January 1, 2012Date Performed: January 1, 3,2012

135 mg IV q 4 PRN

if T >37.8 C

Classification: Antipyretics

AnalgesicAction: Reduces fever by actingdirectly on the hypothalamic heat-regulating center to causevasodilation and sweating, whichhelps dissipate heat.

For body te

more than 37.8 C.

Name of the drugs;Generic name and

Brand name

Date Ordered; Dateperformed; Date Changed or

Date Discontinued

Route, Dosage, andFrequency

General Action and Mechanismof Action

Indication o

2. Generic Name:Cefuroxime sodium

Brand Name:Zinacef

Date Ordered:August 11, 2010

Date Performed:August 12-13, 2010

450 mg IV q 8 Classification:AntibioticSecond-generation cephalosporinAction: Bactericidal: Inhibitssynthesis of bacterial cell wall,causing cell death.

It was give patient infection csensitive org


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c. Diet

Type of Diet Date Ordered; Date Changed General Description Indication or Purpose Specific fo

Low sodium

Low fat

Date Ordered:

January 1, 2012Date Performed:January 1-5, 2012


Date Performed:

January 1-5, 2012

The patient should

only take foods thathave limited sodiumcontent.

The patient shouldonly take foods thathave limitedcholesterol and highdensity lipoprotein

content.

To reduce accumulation of fluid in

the body causing edema and todecrease blood pressure.

To prevent further in lipid andcholesterol level in the blood ofthe patient.

Tinola, sopas

rice, crackers

Type of Diet Date Ordered; Date Changed General Description Indication or Purpose Specific f

Limit fluid intake to800 ml/day


Date Performed: January 1-5,2012

The patient shouldonly take fluid inlimited or smallamount.

This type of diet helps to reduceedema and prevent fluid retention.

Small amousoups


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Diaphoresis

Chills

Seizures

fever production.

Pyrogens affect the body

temperature regulating

mechanism in the

hypothalamus of the

brain. As a consequence,

heat production and

conservation increases,

fever promotes activities

of the immune system,

such as phagocytosis and

inhibits the growth of

some microorganisms.

Promote adequate rest

and sleep periods

Provide tepid sponge

bath

Loosen clothing

Provide oxygen therapy in

extreme cases ordered

Administer meds as

ordered

demand

To pro

cooling

To pr

ventilati

promote

heat

evapora

To off

oxygen

consum

To

tempera


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Problem No. 2: Impaired Urinary Elimination

ASSESSMENT NURSING DIAGNOSIS SCIENTIFIC EXPLANATION OBJECTIVES NURSING INTERVENTIONS

S=

O=

The patient manifest

Oliguria 110

ml in 8 hours

Hematuria

Albuminuria

(+2)

Periorbital

edema

Facial

Edema

Weakness

Irritability

The patient may

manifest

Incontinenc

e

retention

Impaired Urinary

elimination r/t

compromised

regulation

mechanism AEB tea

colored urine and

decreased urine

output, facial edema

albuminuria,

weakness 2 AGN

Post infectious causes

Group A beta hemolytic

streptococcal infection of

the throat that precedes

the onset of

glumerulonephritis by 2-3

weeks deposition of

antibody and antigen

complex in glomerulus

that may lead to the

thickening of the

glomerular filtration

membrane. The scarring

and loss of glomerular

filtration membrane will

decreased glomerularfiltration rate. The

decrease in filtration rate

will dec. the production

of the urine output

Short term:

After 4 of NI the

patients SO will

verbalize

understanding of

condition and

demonstrate

behaviors/

techniques to

prevent infection

and to maintain fluid

status

Long term:

After 4 days of NI the

patient will improve/

achieve elimination

pattern

Identify condition that

may be present such as

Urinary tract infection

Assist with physical

examination(cough test,

palpation of bladder

retention)

Determine clients usual

daily food intake

Review medication

regimen

Review results of

diagnostic studies

Encourage client to

verbalize fears/ concern

Check frequently for

bladder distention and

observe for overflow

To a

factor

To ass

factor

To help

of DHN

For dru

bladde

To ide

type

proble

Open

client

feeling

proble

To red

infectio


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Problem No. 3: Fluid Volume Excess

ASSESSMENT NURSING DIAGNOSIS SCIENTIFIC EXPLANATION OBJECTIVES INTERVENTION

S=

O= patient

manifest:

-edema

-poor skin turgor

-dry, scaly skin

-restlessness

-decreased urine

output

Fluid Volume Excess

related to

compromised renal

perfusion

Glomerulonephritis is an immunologic

disorder that causes inflammation and

increased cells in the glomerulus. Because

the primary function of the glomerulus is to

filter blood, most cases result when antigen-

antibody complexes become trapped in

the glomerulus. This entrapment causes

inflammatory damage, reducing the

glomerular membranes capacity for

selective permeability, which results in loss

of protein in the urine. The resulting

hypoalbuminemia alters oncotic pressure in

the vascular tree and fluid moves into

interstitial spaces, causing edema.

Short term:

After 3-4 hours of NI,

pt will be able to

demonstrate

behaviors to

monitor fluid status

and reduce

recurrence of fluid

excess

Long-term:

After 3 days of NI, pt

will be able to

stabilize fluid

volume AEB

balanced I/O, VS

within clients

normal limits, stable

weight, and free of

signs and symptoms

of edema.

- Monitor VS

and

note level of

consciousness

-Monitor I & O

- Restrict

fluid/sodium

intake as

indicated

-Evaluate

mental status


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-Measure

abdominal girth

-Administer

diuretics as

ordered


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Problem # 4: Ineffective Renal TissuePerfusion

ASSESSMENTNURSING

DIAGNOSIS

SCIENTIFIC

EXPLANATIONPLANNING INTERVENTIONS RATIONAL

S:

O: patient

manifested the

following:

>oliguria

>has pale

conjunctiva

>generalized pallor

>weakness

>irritability

>Elevated

creatinine level

patient maymanifest the

following:

Ineffective renal

tissue perfusion

r/t decreased

hgb

concentration in

the blood

secondary to

AGN

AGN usually leads to

decreased hgb

because of rbc exretion

though urne.

Decreasing the blood

flow as well as to the

kidneys.

Short Term:

After 2 hours of

Nursing intervention

patient will identify

interventions to

prevent agrivation of

condition

Long Term:

After 4 days of nursing

intervention, the

patient will achieve

improvement in in

tisssue perfusion AEB

normal vs , balance

intake and absence

of edema

Establish Rapport

Assess patients condition

Monitor and record V/S

Review lab studies

Weight pt. weekly and

PRN

Reinforced diet as ordered

Regulate IVF as ordered

Administer meds as

ordered

To gain the trust

patient

To note for

abnormalities r/t

condtion

To establish base

data

To assess for prog

And to and to no

comparison of th

present and prev

state

Best wat to asses

hydration status

To prevent furtheagravtion of the

condtion

To regulate entry

fluid and to cont

amount of fluid

through the bod


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>fever

>increased vital

signs

>elevation of BUN

>paralysis

>hematuria

Refer to other members of

the team and collaborate

to treatment regimen a

ordered

To provide thera

management

For better therap

care manageme

process and for

efficient nursing

Problem # 5: Altered TissuePerfusion

CUESNURSING

DIAGNOSIS

SCIENTIFIC

EXPLANATIONPLSNNING INTERVENTIONS RAT

S=

0= Pt. manifested

>Body malaise

>Pale palpebral

conjunctiva

>Pale skin

>Activity intolerance

>poor skin turgor

>delayed capillary

refill

>low Hgb level

>Restlessness

>Irritability

Altered tissue

perfusion r/t

decrease Hgb

level/

concentration in

the blood 2o TO

AGN

Pt. with kidney problems

manifest anemia due to

the interruption in the

release of erythropoietin

and enzymes

responsible for RBC

production

Short-term

After 6 of NI pt.s SO

will verbalize

understanding of

condition and

therapy regimen

Long-term

After 8 days of NI pt.

will demonstrate

increase perfusion as

individually

appropriate

>Establish rapport

>Monitor VS and note level

of consciousness

>Elevate HOB

>check for calf tenderness

>To gain

>to have

data and

alteration

>To increa

gravitatio

flow

>May ind

thrombus

>to prom


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>Weakness

>Fatigue

The pt. may

manifest the ff.

:

>Dry skin

>Tenting of skin

>Blurring of vision

>Delayed wound

healing

>cold and clammy

skin

>Provide quiet and restful

environment

>instruct pt.

to avoid

strenuous activity

>Provide foods rich in iron

and vit. C and iron

>Encourage to use

relaxation techniques

>Provide adequate rest

periods

>Provide comfort and

safety measures

>Administer due

medications as ordered

particularly ferrous sulfate.

>to conse

>To prom

productio

>To avoid

>To prom

>To prom

>To prom


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