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STI COLLEGE STA. MARIA
A CASE PRESENTATION PRESENTED TO
MR. RONALDO V. RAYMUNDO
BY
COLLEGE OF NURSING
NCM 107
CARRIE ANN S.FERNANDEZ
ACUTE GLOMERULONEPHRITISI. INDRODUCTION
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Acute glomerulonephritis (AGN) is active inflammation in the glomeruli.
Glomerulonephritis is a type ofkidney disease that involves theglomeruli. The glomeruli are very small, important structures in thekidneys that supply blood flow to the small units in the kidneys that filterurine, called the nephrons. During glomerulonephritis, the glomerulibecome inflamed and impair the kidney's ability to filter urine.
There are many diseases that cause an active inflammation within the glomeruli.Some of these diseases are systemic and some occur solely in the glomeruli.
This is a common disease in children and it is one of the diseases thatare presented commonly with hematuria
ETIOLOGY
Streptococcal infection(The most common infectious cause of acute GN is infection byStreptococcus species (ie, group A, beta-hemolytic). Two types have been described,involving different serotypes:
Serotype 12 - Poststreptococcal nephritis due to an upper respiratory infection,
occurring primarily in the winter months
Serotype 49 - Poststreptococcal nephritis due to a skin infection, usually observed in
the summer and fall)
Impetigo
Acute viral infection
Medications
Foreign serum
Immunologic problem
RISK FACTORS
Predisposing Factors:
Age: 5-10 years old
Gender: Male
Precipitating Factors:
B-hemolytic Streptococci
Post infection
Poor intake of vitamin rich foods
SIGNS AND SYMPTOMS
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H-hematuria
H-hypertension
E-edema(due to increase salt and water retention, and decrease oncotic pressure)
P-proteinuria
A-azotemia
Other:
Headache
Malaise
Flank pain
Tenderness over the CVA area
Circulatory overload
Confusion
Somnolence
Seizures
DIAGNOSTIC TEST
Urine test Blood tests Imaging tests Electron microscopy and immunoflorescence Kidney biopsy ASO or anti Dnase B titer
COMPLICATIONS:
Hypertensive encephalopathy
Heart failure
Pulmonary edema
NURSING DIAGNOSIS
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Acute Pain
Fluid volume excess
NURSING MANAGEMENT
Assessment patient pertaining to his condition.
Check the patients vital signs and electrolyte values.
Monitor intake and output and daily weight.
Instruct for fluid and diet restrictions.
Instruct patient to schedule follow-up evaluations of blood pressure,
urinalysis for protein, and BUN and creatinine studies to determine if disease
has worsened.
Instruct patient to notify physician if infection or symptoms of renal failure
occur: fatigue, nausea, vomiting, diminishing urinary output.
Allow the patient to resume normal activities gradually as symptoms subside.
Provide low salt, low sodium, low potassium and high protein diet.
Explain the prescribe medication to the patient. Provide best rest during theacute phase.
Perform passive range of motion exercises for the patient on bed rest.
The goal of treatment is to stop the ongoing inflammation and lessen the
degree of scarring that ensues. Depending on the diagnosis, there are different
treatment strategies. Often the treatment warrants a regimen of
immunosuppressive drugs to limit the immune systems activity. This
decreases the degree of inflammation and subsequent irreversible scarring.
MEDICAL MANAGEMENT
Kidney disease diet:
Low calorie diet Low protein Low sodium diet Low potassium diet Low phosphorus diet Calcium supplements Vitamin B supplements
http://www.freemd.com/kidney-disease/home-care-diet.htmhttp://www.freemd.com/swelling/home-care-low-salt-diet.htmhttp://www.freemd.com/hypokalemia/overview.htmhttp://www.freemd.com/acute-glomerulonephritis/treatment.htm#/ed/calcium-supplements.htmhttp://www.freemd.com/kidney-disease/home-care-diet.htmhttp://www.freemd.com/swelling/home-care-low-salt-diet.htmhttp://www.freemd.com/hypokalemia/overview.htmhttp://www.freemd.com/acute-glomerulonephritis/treatment.htm#/ed/calcium-supplements.htm -
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Fluid restriction:
Limiting the amount of fluid in the diet
Oral corticosteroid medications:
Prednisone Methylprednisolone (Medrol)
Diuretic medications:
Furosemide (Lasix)
Medications that suppress the immune system:
Cyclophosphamide (Cytoxan, Neosar, Procytox)
OBJECTIVES
General Objectives
Enable for us, nursing students, to have an enhanced understanding of the
condition, AGN.
Specific Objectives
To determine the kidneys anatomy and its normal function.
To gain knowledge about the causes and risk factors of AGN.
To elaborate the different nursing and medical interventions that can be
rendered to clients with AGN.
T o explain the different laboratory data and the pertinent findings about the
clients condition.
To provide health teachings to the client and family members on how they
can manage and prevent the occurrence of AGN
ANATOMY AND PHYSIOLOGY
http://www.freemd.com/acute-glomerulonephritis/treatment.htm#/ed/corticosteroid-medications.htmhttp://www.freemd.com/acute-glomerulonephritis/treatment.htm#/ed/prednisone.htmhttp://www.freemd.com/acute-glomerulonephritis/treatment.htm#/ed/methylprednisolone.htmhttp://www.freemd.com/acute-glomerulonephritis/treatment.htm#/ed/medrol.htmhttp://www.freemd.com/acute-glomerulonephritis/treatment.htm#/ed/diuretic-medications.htmhttp://www.freemd.com/acute-glomerulonephritis/treatment.htm#/ed/furosemide.htmhttp://www.freemd.com/acute-glomerulonephritis/treatment.htm#/ed/lasix.htmhttp://www.freemd.com/acute-glomerulonephritis/treatment.htm#/ed/cyclophosphamide.htmhttp://www.freemd.com/acute-glomerulonephritis/treatment.htm#/ed/cytoxan.htmhttp://www.freemd.com/acute-glomerulonephritis/treatment.htm#/ed/neosar.htmhttp://www.freemd.com/acute-glomerulonephritis/treatment.htm#/ed/procytox.htmhttp://www.freemd.com/acute-glomerulonephritis/treatment.htm#/ed/corticosteroid-medications.htmhttp://www.freemd.com/acute-glomerulonephritis/treatment.htm#/ed/prednisone.htmhttp://www.freemd.com/acute-glomerulonephritis/treatment.htm#/ed/methylprednisolone.htmhttp://www.freemd.com/acute-glomerulonephritis/treatment.htm#/ed/medrol.htmhttp://www.freemd.com/acute-glomerulonephritis/treatment.htm#/ed/diuretic-medications.htmhttp://www.freemd.com/acute-glomerulonephritis/treatment.htm#/ed/furosemide.htmhttp://www.freemd.com/acute-glomerulonephritis/treatment.htm#/ed/lasix.htmhttp://www.freemd.com/acute-glomerulonephritis/treatment.htm#/ed/cyclophosphamide.htmhttp://www.freemd.com/acute-glomerulonephritis/treatment.htm#/ed/cytoxan.htmhttp://www.freemd.com/acute-glomerulonephritis/treatment.htm#/ed/neosar.htmhttp://www.freemd.com/acute-glomerulonephritis/treatment.htm#/ed/procytox.htm -
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If you were to cut a kidney in half, you would see the following parts:
Renal capsule - a thin, outer membrane that helps protect the kidney Cortex - a lightly colored outer region
Medulla - a darker, reddish-brown, inner region Renal pelvis - a flat, funnel-shaped cavity that collects the urine into the
ureters
If you look closely at the cortex and medulla, you can see many tiny, tubularstructures that stretch across both regions perpendicular to the surface of thekidney. In each kidney, there are one million of these structures, called nephrons.
The nephron is the basic unit of the kidney. It's a long, thin tube that is closed at
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one end, has two twisted regions interspaced with a long hairpin loop, ends in along straight portion and is surrounded by capillaries.
The parts of the nephron are as follows:
Bowman's capsule - This closed end at the beginning of the nephron islocated in the cortex.
Proximal convoluted tubule or proximal tubule - The first twisted regionafter the Bowman's capsule; it's in the cortex.
Loop of Henle - A long, hairpin loop after the proximal tubule, it extendsfrom the cortex down into the medulla and back.
Distal convoluted tubule or distal tubule - This second twisted portion ofthe nephron after the loop of Henle is located in the cortex.
Collecting duct - This long straight portion after the distal tubule that is theopen end of the nephron extends from the cortex down through the medulla.
Each part of the nephron has different types ofcells with different properties -- this
is important in understanding how the kidney regulates the composition of theblood.
The nephron has a unique blood supply compared to other organs:
Afferent arteriole - connects the renal artery with the glomerular capillaries Glomerular capillaries - coiled capillaries that are inside the Bowman's
capsule Efferent arteriole - connects the glomerular capillaries with the peritubular
capillaries Peritubular capillaries - located after the glomerular capillaries and
surrounding the proximal tubule, loop of Henle, and distal tubule
Interlobular veins - drain the peritubular capillaries into the renal vein
The kidney is the only organ of the body in which two capillary beds, in series,connect arteries with veins. This arrangement is important for maintaining aconstant blood flow through and around the nephron despite fluctuations insystemic blood pressure.
Regulating the composition of the blood involves the following:
Keeping the concentrations of various ions and other important substancesconstant
Keeping the volume of water in your body constant Removing wastes from your body Keeping the acid/base concentration of your blood constant
The kidney does this by a combination of three processes:
It filters 20 percent of the plasma and non-cell elements from the blood intothe inside of the nephron (the lumen).
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It reabsorbs the components that the body needs from the lumen back intothe blood.
It secretes some unwanted components from the blood into the lumen of thenephron.
Anything (fluid, ions, small molecules) that has not been reabsorbed from the lumen
gets swept away to form the urine, which ultimately leaves the body. Through theseprocesses, the blood is maintained with the proper composition, and excess orunwanted substances are removed from the blood into the urine.
PATHOPHYSIOLOGY:
Immunologic Response
Antigen(group A beta-hemolytic
Antigen-antibody product
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GENERAL DATA
Name: Mr. N.M.DC
Age: 7 years old
Address: 947 Baloongan
Pantoc, Meycauayan, Bulacan
Date of Admission: November 25, 2012
Occupation: None
Religion: Roman Catholic
Deposition of antigen-antibody
complex in glomerulus
Increased production of epithelialcells lining the glomerulus
Leukocytes infiltrate the glomerulus
Thickening of the glomerular filtration
membrane
Scarring and loss of glomerular
filtration
Decreased glomerular filtration rate
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Birthday: November 07,
2005
Status: Child
Chief Complaint: Bloody urine/ edema
Final Diagnosis: Acute
Glomerulonephritis
Attending Physician: Cusay, M.D; Federico
D.
Pertinent Physical Finding:
Vital Signs:
T -------------------- 36.20C
PR -------------------- 90bpm
RR -------------------- 20cpm
BP -------------------- 130/70mmHg
HISTORY OF PRESENT ILLNESS:
November of 2012, one week prior to admission, the patient
experienced of generalized edema. No consultation was done. Until the client
complained of bloody urine and Mr. N.M.DC a 7 years old male was admitted at
Rogaciano M. Mercado Memorial Hospital on November 25, 2012 with a chief
complain of generalized edema and bloody urine.
PAST MEDICAL HISTORY:
Before admission, Mr. N.M.DCs relative stated that he has never
been hospitalized before. Also, theyre unable to go to the nearby barangay
center/clinic for consultation about his condition due to financial constraints.
FAMILY HISTORY:
Mr. N.M.DC relative stated that the clients grandmother died
because of cardiac problems.Other than that, there is no related history of kidney
diseases that runs in their family.
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SOCIAL HISTORY:
Patient N.M.DC is the youngest among 6 siblings,a Grade I student in
a public school and he stated that during their break time he prefer to eat some
street foods such as fish ball,kikiam and also junk foods to somehow relieve his
hunger; drinking of palamig to relieve his thirst. Mr. N.M.DC and his family live inMeycauayan for 10 years alongside of many industrial unit where pollution and
other polluted chemicals are profound.
LIFESTYLE:
Patient N.M.DC prefer to play in a unoccupied area beside a plastic
factory.
PHYSICAL ASSESSMENT
LABORATORY EXAMINATION
URINALYSIS
(November 30,2012)
INSPECTION PALPATION PERCUSSION
AUSCULTATION
General Weak inappearance
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Skin Pale in color Dry skin - -Head Eyes PERRLA - - -
Ears - - - -Nose - - - -
Throat - - - -Neck - - - -
Chest - - - - Increase heartrate and
increase BPAbdomen - Flank pain,
hematuria- - -
Extremities - With edemaat lower
extremities
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RESULT
NORMAL VALUES
Color yellow
pale yellow to amber
Specific gravity 1.010
1.010-1.025
WBC TNTC
0-5/hpf
Transparency turbid
transparent
pH 6.0
4.5-8.0
CHON +3
negative
Leukocytes +4
negative
RBC TNTC
0-2/hpf
Interpretaion:
Significant numbers typically indicate the presence of infection.
Excess turbidity results from the presence of suspended particles in the
urine.
Finding protein in the urine is not a normal finding. Seriously elevated levels
may indicate that there is a problem with kidney function.
Leukocytes in the urine typically indicate a past or current infection in the
urinary tract.
The presence of abnormal numbers of red cells in urine due to any of several
possible causes, e.g. glomerular damage
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BLOOD CHEMISTRY
November 26, 2012
TEST NORMAL VALUES RESULTS
BUN
7-18mg/dL 9.3mg/dL
CREATININE
0.4-1.4mg/dL 0.6mg/dL
Interpretation:
Increased BUN levels suggest impaired kidney function. This may be due to
acute or chronickidney disease, damage, or failure. It may also be due to a
condition that results in decreased blood flow to the kidneys
Elevated serum creatinine levels are most often seen in patients with renal
disease that has seriously damaged 50% or more of the nephrons of the
kidneys.
HEMATOLOGY
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ASO TITER
November 30,2012
Remarks:
Result Normal Values
ASO=400
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DISCHARGE PLANNING
Discharge: November 10, 2012
Final Diagnosis: Acute
Glomerulonephritis
Condition upon Discharge: Improved
Final Disposition: May go home with
medications
MInstruct the patient and family to follow the home medications as prescribed by
the physician regarding proper administration, dosage, time, frequency and to
take medications with food if not contraindicated.
EEncourage early ambulation if not contraindicated or promote exercise to the
client especially ROM, and advise patient to have adequate rest and sleep.
TExplain the need of treatment after discharge and must take it seriously so as to
prevent such complications to the patient.
HEncourage patient to perform proper personal hygiene to promote comfort and
cleanliness which is very much needed in the therapeutic process.
OInform the patient that follow-up check-up is important to have continuous
monitoring and care.
DLow salt, low protein and fluid restriction
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Medication: Paracetamol 250 mg
oral AS NEEDED
Cefuroxime 250/5ml
1tsp. TID