ANGELES UNIVERSITY FOUNDATION

COLLEGE OF NURSING
ANGELES CITY

Nursing Care Management

Of A Pediatric Patient
Diagnosed with AGN

SUBMITTED TO
Mr. Arnold Esguerra, RN

PREPARED BY
De Vera ,Jerome
Indiongco, Cristine
Libres, Mary Angelica Teoffy
Meneses, Maria Cristina

BSN III-4
GROUP # 15

I. Introduction

Acute Glomerulonephritis
Acute glomerulonephritis (AGN) refers to a specific set of renal diseases in
which an immunologic mechanism triggers inflammation and proliferation of
glomerular tissue that can result in damage to the basement membrane,
mesangium,

or

capillary

endothelium.

Hippocrates

originally

described

the

manifestation of back pain and hematuria, which lead to oliguria or anuria. With the
development of the microscope, Langhans was later able to describe these
pathophysiologic glomerular changes.
Most

research

focuses

on

the

post

streptococcal

patient.

Acute

glomerulonephritis is defined as the sudden onset of hematuria, proteinuria, and

red blood cell casts. This clinical picture is often accompanied by hypertension,
edema, and impaired renal function. AGN can be due to a primary renal or systemic
disease.
Studies by two leading hospitals in Metro Manila indicate that the most
common underlying diseases for ESRD (end-stage renal disease) are chronic
glomerulonephritis, chronic pyelonephritis, diabetes mellitus and hypertensive
nephrosclerosis. In short, deaths from renal causes are the consequences of
prolonged or uncontrolled assault of infectious or metabolic agents on the kidneys
and are regarded as degenerative. Studies indicate that around 9,500 Filipinos
develop fatal diseases of the kidneys annually. It is expected to increase
proportionately with the incidence of degenerative or lifestyle-related diseases like
poor hygiene practices. In the United States, Glomerulonephritis represents 10-15%
of glomerular diseases. Variable incidence has been reported due in part to the
subclinical nature of the disease in more than one half the affected populations.
Despite sporadic outbreaks, incidence of poststreptococcal glomerulonephritis has
fallen over the last few decades. In the international view it has been found that
with

some

exceptions,

reduction

in

the

incident

of

post

streptococcal

glomerulonephritis has occurred in most western countries. It remains much more

common in regions such as Africa, the Caribbean, India, Pakistan, Malaysia, Papua
New Guinea and South America.

Most epidemic cases follow a course ending in complete patient recovery (as
many as 100%). Sporadic cases of acute nephritis often progress to a chronic form.
This progression occurs in as many as 30% of adult patients and 10% of pediatric
patients. Glomerulonephritis is the most common cause of chronic renal failure
(25%). The mortality rate of acute glomerulonephritis in the most commonly
affected age group, pediatric patients, has been reported at 0-7%.
A male-to-female ratio of 2:1 has been reported which means that males tend
to become more affected by the condition rather than the females. Most cases
occur in patients aged 5-15 years. Only 10% occur in patients older than 40 years.
Acute nephritis may occur at any age, including infancy.
No More Dialysis
Immunologists Develop Method to Decrease Rejections of Kidney Transplants
October 1, 2007 A nephrologist has found that a specialized type of anti-rejection
therapy using intravenous immunoglobulin can make kidney transplants possible for
patients with high 'anti-donor' antibodies. 25 to 30 percent of patients on the kidney
transplant list could benefit from this therapy. Tissue compatibility issues exist with
any organ transplant, but the risk is greatly increased for those with high exposure
to antigens received through blood transfusions, previous transplantation, or even
pregnancy. Seventy-thousand Americans are waiting for a kidney transplant. A third
of them are parked on dialysis because their antibody levels are too high for a
transplant. But that's no longer a barrier for some people. Dialysis is something
Kohanzadeh would rather forget, but if telling her story saves lives, it's worth it.
Kohanzadeh -- like many kidney failure patients -- developed high levels of "antidonor" antibodies through blood transfusions. Her highly sensitized immune system
would likely reject any donated kidney. But Kohanzadeh is no longer here, thanks to
intravenous immunoglobulin therapy or IVIG. Here's how it works: during dialysis,
patients are given blood containing a mix of immunoglobulins, which "turn-off" the
anti-donor antibodies' attack response without suppressing the patient's immune
system.
Through their website, this mother-daughter team works to spread the word
of a little known therapy that could save thousands in need of a kidney. IVIG is

covered by Medicare and can be used in both living and cadaver-donor transplants.
Nearly 30 percent of patients on the kidney transplant list might benefit from this
therapy.
BACKGROUND: About one-third of kidney patients are often told they cannot
have a transplant even if they have a donor with an otherwise perfectly matched
tissue and blood type. Their anti-donor antibody levels are so high that any
transplanted organ would be rejected by their highly sensitized immune system.
Now there is a specialized type of anti-rejection therapy using intravenous
immunoglobin (IVIG), which injects antibodies from healthy people into the blood
supply, to modulate the immune system without suppressing it. This makes kidney
transplant possible for as much as 25-30% of this group of patients, who would
otherwise not be eligible for a transplant because of their high antibody levels.
DEALING WITH REJECTION: Tissue compatibility is an issue for all patients
receiving organ transplants, but rejection risks are much higher for those with high
exposure to human leukocyte antigens (HLAs) that are not produced by their own
bodies. Exposure may be the result of blood transfusions, previous transplantation,
or even pregnancy if the mother is exposed to the father's antigens, which are then
expressed in the cells of the developing fetus. The immune system is then
'sensitized' to those antigens -- primed with antibodies that attack any foreign
tissue, even if the antigens arrive in the form of a life-saving donated organ.
Reasons why the group chose acute glomerulonephritis are to have an
overview and to know the factors which primarily may cause the disease.
Knowledge regarding the disease is very important to aid in the prevention and
possible treatment of its occurrence.
This case study leads to a broader knowledge regarding the disease and to
understand the factors that lead in the occurrence of the disease. This may be
useful for future nurses to be equipped with adequate knowledge in the care of
patients with the disease and may apply certain preventive measures.

Objectives:
After the completion of the study, the student nurses shall have:

Able to know the risk factors about the disease condition

Knowledge about the disease condition

Determine the degree of impairment

Assess level of progress

Assess causative/contributing factors about the underlying disease condition

Correct/minimize growth deviations and associated complications.

Determine degree of deviation from growth/developmental norms

After the completion of the study, the patient/SO shall have:

Patient/SO is able to express feelings and concerns appropriately.

Patient/SO be able to identify precipitating factors contributed to the patient

disease

Patient/SO be able to verbalized ability to cope adequately with existing

situation, provide support/monitoring

Patient/SO be able to adopt lifestyle changes necessary for the patients

wellness and recovery as well as to prevent further complication of the
disease.

Patient/SO will verbalize desire to seek higher level of wellness

Patient/SO will be able to set their own progress short-term goals that could
had to the patient recovery, wellness and prevention of further complications.

Patient/SO will able to identify long-range needs of the client and who will be
responsible for actions to be taken

Patient/SO is able to verbalize understanding of illness, treatment regimen

and prognosis.

II. Nursing Assessment

1.

Personal Data
Our patient is Baby AGN, female, five years of age and currently residing at

Baliti, Arayat Pampanga. A Filipino and naturally born Kapampangan on August 05,
2002 at Magalang Pampanga. Her parents are Mr. AGN and Mrs. AGN. She was
admitted last June 20, 2008 (Friday) 7:15 pm at a secondary type of government
hospital. The patient was discharged last June 26, 2008. The group had their
assessment, patient, interaction & interview for 2 days in the Pedia Ward of the said
hospital.
2.

Pertinent Family History

After establishing rapport with the patient and her significant others, we

interviewed the SO and asked some question about their family history. The family
of Baby AGN is a nuclear type of family. Mr. & Mrs. AGN are blessed for having five
children, two girls & three boys. Baby AGN is the fourth child of her parents. She is
a preparatory student at the Baliti, Arayat Elementary School. Mrs. AGN gave birth
to her five children by a Normal Spontaneous Delivery (NSD) in a hospital at Arayat
Pampanga. All of her children were delivered through a NSD in the said hospital.
Mrs. AGN still believes in the possible complications of pregnancy thats why she
doesnt want to have a home delivery.
Mr. AGN is a farmer in Baliti, Arayat. He was also diagnosed to have a kidney
disease together with his brother (uncle of Baby AGN) but had been treated, the
informant doesnt know the specific kidney disease, according to him he manifested
malaise, nausea and abdominal cramps) last 1998. Mrs. AGN is a housewife. The
family lives in a 200 square meter house with an adequate ventilation due to the
presence of five windows. The house is concrete built surrounded by some farm
land. Total number of members in the family is seven with five children, the eldest
is a thirteen year old male, next is a eleven year old male, nine year old female, five
year old female and four year old male. Mr. AGN earns around Php 2,000 a month.
The familys religion is Catholic. Mrs. AGN included that they attend the mass. About
their cultural beliefs and practices, they do not consult herbularios/ albularios but

rather choose to seek for medical advice from the physician when someone in the
family experiences some illness.

SCHEMATIC DIAGRAM OF THE FAMILY HEALTH-ILLNESS

HISTORY
Father side
Grandfather

Uncle

Uncle

Mother side

Grandmother

Father
(Mr. AGN)

Aunt

Grandfather

Aunt

Grandmother

Mother

(Mrs. AGN)

Legend:
Male

Female

No health problem

Died

With kidney disease

With AGN

Looking at the legend of the family history of Baby AGN, her grandfather in
mother side died because of old age and her grandparents in her father side doesnt
have any health problem and are still living. Her parents are still alive, and her
father was diagnosed with a kidney disease. Among the five children, only baby
AGN have been diagnosed with acute glomerulonephritis.

3.

Personal History
According to Mrs. AGN, her menarche started at the age of twelve years old

during sixth grade. During the pregnancy of Mrs. AGN, she didnt experience any
problem in giving birth to her five children. She gave birth to her children with no
specific birth gap. Her eldest was born in the year 1994, next child was born in the
year 1996, the third child was born in year 1998, the fourth child was born in 2002
and the youngest was born in the year 2003. As said in the family history, she gave
birth through Normal Spontaneous Delivery (NSD) in the hospital. She doesnt
consult a hilot or kamadrona. Mrs. AGN had a full age of gestation (the
informant has forgotten her LMP). Mrs. AGN breastfed her five children. According to
Baby AGNs mother, she had a complete immunization during her infancy stage at
their Health center in Baliti, Arayat.
Frueds Personal Development: Preschooler: Phallic stage

Childs personality development appears to be non-reactive or dormant. Help

the child to have positive experiences as his/her self-esteem continues to
grow and child prepares for the conflict of adolescence.

In this stage, child learns sexual identity through awareness of genital area.
Baby AGN is assisted by Mrs. AGN on the meticulous guidance on what to
know and expect about her sexual identity to prevent confusion and establish
understanding. In addition, Mrs. AGN practices Baby AGN on the proper care
towards the childs genital area.

Ericksons Personality Development: Initiative vs. Guilt

Preschooler child development task is to form a sense of initiative versus

guilt. Child is introduced to the teachers. Mrs. AGN accompanies her daughter
for several days in school since in this stage the child fears to be left out.

Baby AGN enjoys playing games when she gets home from school. She is a

talkative child but seems silent when she feels sick or ill. On the days of
hospitalization of Baby AGN, she was silent primarily because she was weak
and the condition that she had was making her feel uncomfortable.

Piagets Stage of Cognitive Development: Preconventional Thought(2-7 y)

Preconventional thought has not yet developed the sense of time. It also

includes that the child must be presented of a specific activity to be able to

know what will happen by that time. Baby AGN achieve this development by
telling her other family members that her father is about to leave for work
whenever she sees him gathering his things for work.

Baby AGN is capable of drawing a straight line, circle, square and triangle

or diamond. She can drive a three wheel bike.

Baby AGN takes a bath and brushes her teeth before she goes to school

and takes a half bath before going to sleep but she does not brushes her teeth
anymore.
Kohlbergs Stage of Moral Development: Preconventional (Level 1) (4-7)
Preconventional

includes

individualism.

Starts

to

develop

sense

of

instrumental purpose and exchange.

Baby AGN shows a characteristic of being possessive. Whenever she

arranges her things for school she wanted to elaborate her own things not
to be used by her other siblings .
4.

History of Past Illness

Based on our interviews, Mrs. AGN told us that Baby AGN had no minor

hospitalization prior to admission and claims (she wasnt diagnose and didnt take
any medications) to have asthma when she was 3 years old. They used to not allow
Baby AGN become exhausted and kept her from allergic causing objects. Baby AGN
had some minor illnesses such as fever, colds and chicken pox. The family consults
the Health Care Provider for medical assistance.

5.

History of Present Illness

Days before Baby AGNs hospitalization, she had acquired a streptococcal

infection which resulted to an Upper Respiratory Tract Infection. Due to a bad
hygienic practices which includes a once a day routine of brushing of teeth that lead
to streptococcal infection.
Few hours prior to admission, Baby AGN had an undocumented fever and
edema. This prompted the family to consult a clinic in Arayat, Pampanga. The
assessment in the clinic revealed an elevated blood pressure and diagnosed that
the patient have an Acute Glumerulonephritis. The hospital didnt do any treatment
because they can no longer handle the condition of Baby AGN (we dont know the
specific medications but according to our informant, they gave some medications.
But our informant was not there so she cant tell the specific medications that Baby
AGN had taken) so Baby AGN was referred to the secondary type of government
hospital.
Upon admission, Baby AGN still manifested fever accompanied by facial
edema, hematuria and elevated BP 140/80. She was admitted last June 20, 2008
with a diagnosed of an Acute Glumerulonephritis versus Nephrotic Syndrome.

6. Physical Examination:

June 20, 2008 (Upon Admission)

LIFTED FROM THE CHART:
Vital signs: T- 38.40C

PR- 84bpm

RR- 22cpm BP- 140/80

Skin: (-) pallor, (+) edema, warm to touch

Head EENT: pinkish palpebral conjunctiva, (-) icteric sclera, (+) periorbital edema
Lymph nodes: (-) swelling/ enlargement
Chest: symmetrical, no retractions
Lungs: normal breathing pattern and clear breath sounds

June 24, 2008

ACTUAL NURSE-PATIENT INTERACTION:
Vital signs: T- 36.70C

PR- 68 bpm RR- 60 cpm BP- 110/80

Appearance and Behavior

Mental state: patient is conscious and coherent
Language: patient is able to speak
Posture: with good posture
Built: normal built
Integumentary: patient has a fair complexion, good skin turgor.
Head: normal contour; (+) periorbital edema.
Eyes: no discoloration, (+)periorbital edema, pinkish palpebral conjunctiva, (-)
icteric sclera, pupils equally reactive to light, eye movement synchronous in all
directions, eye brows are symmetrical.

Ears: symmetrical, no discharged noted.

Nose: symmetrical, no discharges note.
Mouth: no dentures, able to move tongue.
Neck: able to move neck and no engorgement of veins.
Chest and lungs: clear breathe sounds.
Heart: normal rate and rhythm.
Abdomen: no rebound tenderness, no abdominal distention, normal bowel sounds.
Extremities: able to move hands and feet, no fractures and deformities, with dry
nails, and edema noted.
Bowel and Bladder: no difficulty during urination and defecation.
Genitalia: no lesions and no pubic hair noted.

June 25, 2008

Vital signs: T-36.10C

PR- 97bpm

RR-18cpm BP- 90/60

Appearance and Behavior

Mental state: patient is conscious and coherent
Language: patient is able to speak
Posture: with good posture
Built: normal built
Integumentary: patient has a fair complexion, good skin turgor.

Head: normal contour, (+) periorbital edema.

Eyes: no discoloration, (+) periorbital edema, pinkish palpebral conjunctiva, (-)
icteric sclera, pupils equally reactive to light, eye movement synchronous in all
directions, eye brows are symmetrical.
Ears: symmetrical, no discharged noted.
Nose: symmetrical, no discharges note.
Mouth: no dentures, able to move tongue.
Neck: able to move neck and no engorgement of veins.
Chest and lungs: clear breath sounds.
Heart: normal rate and rhythm.
Abdomen: (-) rebound tenderness, (-) abdominal distention, normal bowel sounds.
Extremities: able to move hands and feet, no fractures and deformities, with dry
nails and edema noted.
Bowel and Bladder: doesnt have difficulty in urination and defecation.
Genitalia: no lesions and no pubic hair noted.
7. Diagnostic and Laboratory Procedure
Diagnostic/
Date
Indications
Laboratory
Ordered
or Purpose
Procedure Date Result

Results

Normal
Values

Analysis
and
Interpretati
on

1.)CBC
A.

D.O: 06-20-

The amount

118.9

125-155 g/L Indication of

Diagnostic/
Date
Indications
Laboratory
Ordered
or Purpose
Procedure Date Result

Results

Normal
Values

Analysis
and
Interpretati
on

Hemoglobin
(hgb)

08
D.R: 06-2008

of hgb
determines
how much
oxygen the
RBC's are
capable of
carrying to
other cells.

anemia due
to hematuria
because of
decrease
erythropoieti
n
leads to
damage in
the kidney.

B.
Hematocrit
(hct)

D.O: 06-2008
D.R: 06-2008

The hct
shows the
oxygencarrying
capacity of
the blood.
This value
also tells
whether the
blood is too
thick or too
thin.

0.35

M: 0.40-0.52
F: 0.38-0.48

Indication of
anemia due
to hematuria
because of
decrease
erythropoieti
n
leads to
damage in
the kidney.

C.
White Blood
Cells (WBC)

D.O: 06-2008
D.R: 06-2008

WBC count is
the count of
the so-called
leukocytes.
WBC's
defend the
body against
infection and
make up part
of the
immune
system.

10.20

6-10 g/L

More than
required
WBC count.
Indicates
infection.

Diagnostic/
Date
Indications
Laboratory
Ordered
or Purpose
Procedure Date Result

Results

Normal
Values

Analysis
and
Interpretati
on

D.
Lymphocytes

D.O: 06-2008
D.R: 06-2008

The second
most type,
are cells that
produce
antibodies,
regulate the
immune
system and
fight viruses.

0.41

0.20-0.60

Range is
within
normal
range.
Indicative of
antibody
production.

E.

D.O: 06-2008
D.R: 06-2008

Responsible
for blood
coagulation
and
determines
bleeding
tendencies.

358

150-400 x
108L

Range is
within
normal
range.
Indicative of
coagulation.

0.57

.55-.70

Range is
within
normal
range.

0.02

0 0.02

Range is
within
normal
range. Fights
parasitic and
allergic
reaction.

Platelet

F.
Segmenters

D.O: 06-2008
D.R: 06-2008

G.
Eosinophils

D.O: 06-2008
D.R: 06-2008

Eosinophils
become
active when
you have
certain
allergic
diseases,
infections,
and other
medical
conditions.

Diagnostic/
Date
Indications
Laboratory
Ordered
or Purpose
Procedure Date Result

Results

Normal
Values

Analysis
and
Interpretati
on

CBC
A.
Hemoglobin
(hgb)

D.O: 06-2408
D.R: 06-2408

The amount
of hgb
determines
how much
oxygen the
RBC's are
capable of
carrying to
other cells.

10.0

12-16

Indication of
anemia due
to hematuria
because of
decrease
erythropoieti
n
leads to
damage in
the kidney.

B.
Hematocrit
(hct)

D.O: 06-2408
D.R: 06-2408

The hct
shows the
oxygencarrying
capacity of
the blood.
This value
also tells
whether the
blood is too
thick or too
thin.

0.32

M: 0.40-0.52
F: 0.38-0.48

Indication of
anemia due
to hematuria
because of
decrease
erythropoieti
n
leads to
damage in
the kidney.

C.
White Blood
Cells (WBC)

D.O: 06-2408
D.R: 06-2408

WBC count is
the count of
the so-called
leukocytes.
WBC's
defend the
body against
infection and
make up part
of the
immune
system.

4,000

5-10x 10 to
the 3rd power

Indicates
infection.

Diagnostic/
Date
Indications
Laboratory
Ordered
or Purpose
Procedure Date Result

Results

Normal
Values

Analysis
and
Interpretati
on

D.
Lymphocytes

D.O: 06-2408
D.R: 06-2408

The second
most type,
are cells that
produce
antibodies,
regulate the
immune
system and
fight viruses.

54

25-40

Body have
adequate
amt. of
lymphocytes
to produce
antibodies,
regulate the
immune
system and
fight viruses.

E.

D.O: 06-2408
D.R: 06-2408

Responsible
for blood
coagulation
and
determines
bleeding
tendencies.

218

150-450 x
108L

Range is
within
normal
range.
Indicative of
coagulation.

40

50-70

1-4

Platelet

F.
Segmenters

D.O: 06-2408
D.R: 06-2408

G.
Eosinophils

D.O: 06-2408
D.R: 06-2408

Eosinophils
become
active when
you have
certain
allergic
diseases,
infections,
and other
medical
conditions.

Active.
Indicative of
certain
allergic
diseases,
infections,
and other
medical
conditions.

Nursing Responsibilities:

Explain the procedure to the patient's significant others that these test

assess response to treatment.

Tell the patient's significant others that blood sample or specimen will be
taken.

Plan to obtain the specimen when the patient is calm and physically still.

Ensure the specimen/blood sample is not taken from the hand or arm that
has an intravenous line in the vein because of the dilution effect on the red
blood cells concentration.

Diagnostic/
Laboratory
Procedure

Date
Ordered
Date
Result

Indications
or Purpose

Results

Normal
Values

Analysis
and
Interpretati
on

D.O: 06-2008
D.R: 06-2008

To evaluate
any type of
renal
dysfunctions
.

.86

.3-.7 g/dl

Result is
within
normal
values.
Indicative of
(+)renal
dysfunction.

2) Serum
Creatinine
A.
Creatinine

Nursing Responsibilities:

Explain the procedure to the patient's significant others that these test
assess response to treatment.

Tell the patient's significant others that blood sample or specimen will be
taken.

Plan to obtain the specimen when the patient is calm and physically still.

Ensure the specimen/blood sample is not taken from the hand or arm that
has an intravenous line in the vein because of the dilution effect on the red

blood cells concentration.

Diagnostic/
Laboratory
Procedure

Date
Ordered
Date
Result

Indications
or Purpose

Results

A.
Total Protein

D.O:06-2108
D.R: 06-2108

69.0

B.
Albumin

D.O:06-2108
D.R: 06-2108

To
determine
nutritional
status or to
screen for
certain liver
and kidney
disorders as
well as
other
diseases. To
determine
the extent
of protein
loss.
Albumin
maintains
the amount
of blood in
the veins
and arteries.
When
albumin
levels
become
very low,
fluid can
leak out
from the
blood
vessels into
nearby
tissues,
causing
swelling in
the feet and

Normal
Values

Analysis
and
Interpretati
on

3) Blood
Chemistry

34.0

64-83 gm/L

3550 g/L

Range is
within
normal
range.

Range is
below the
normal
range.
Indicative of
proteinuria
and edema.

C.
Globulin

D.O:06-2108
D.R: 06-2108

D.
A/G Ratio

D.O:06-2108
D.R: 06-2108

ankles. Very
low levels of
albumin
may
indicate
liver
damage.
Globulin is
carrier of
some
hormones,
lipids, metal
&
antibodies.

35.0

20-35 g/L

Range is
within
normal
range.

1.5-1

0.8-2.0

Result is
within
normal
values.

Nursing Responsibilities:

Explain the procedure to the patient's significant others that these test
assess response to treatment.

Tell the patient's significant others that blood sample or specimen will be
taken.

Plan to obtain the specimen when the patient is calm and physically still.

Ensure the specimen/blood sample is not taken from the hand or arm that
has an intravenous line in the vein because of the dilution effect on the red
blood cells concentration.

Diagnostic/
Laboratory
Procedure

Date
Ordered
Date
Result

Indications
or Purpose

Results

Normal
Values

Analysis
and
Interpretati
on

4) Serum
Electrolyte
A. Na

D.O:06-2108
D.R: 06-21-

Sodium is
both an
electrolyte

162.0

136145

Solutes
milliequivale absorbed by

08

B. K

D.O:06-2108
D.R: 06-2108

and mineral.
It helps
keep the
water (the
amount of
fluid inside
and outside
the body's
cells) and
electrolyte
balance of
the body.
Sodium is
also
important in
how nerves
and muscles
work.
It helps
keep the
water (the
amount of
fluid inside
and outside
the body's
cells) and
electrolyte
balance of
the body.

nts per liter

(mEq/L) or
136145
millimoles
per liter

the kidney
results to
damage
and
decrease
reabsorptio
n

(mmol/L)

4.0

3.44.7
mEq/L or
3.44.7

Result is
within
normal
values.

mmol/L
(in children)

Nursing Responsibilities:

Explain the procedure to the patient's significant others that these test
assess response to treatment.

Tell the patient's significant others that blood sample or specimen will be
taken.

Plan to obtain the specimen when the patient is calm and physically still.

Ensure the specimen/blood sample is not taken from the hand or arm that
has an intravenous line in the vein because of the dilution effect on the red
blood cells concentration.

Diagnostic/
Date
Indications
Laboratory
Ordered
or Purpose
Procedure Date Result

5) Routine
Urinalysis

D.O: 06-2308
D.R: 06-2308

Urinalysis
was ordered
for Baby AGN
to determine
whether the
urine
contains
substances
indicative or
normally
absent from
urine and
detected by
urinalysis are
proteins,
glucose,
acetone,
blood, pus
and casts.

Results

Normal
Values

Analysis
and
Interpretati
on

Color: yellow

Color: light
yellow to
dark amber

Color:
Normal

Transparenc
y: sl. Tubid

Transparanc
y:Normal

Sugar:
negative

Sugar:
negative

Albumin: +1

Albumin:
negative

Sugar:
Normal

Microalbimin
uria. It
Reaction:
indicates
acidic
spillage of
Specific
Specific
protein from
gravity:
the damaged
1.000
gravity:
glumerulus.
1.001-1.035
Normal.
Reaction
Pus cells:4-6
Normal.
Pus cells: 0-3
Bacteria:
Gravity
negative
Bacteria:
slightly
lower
none
than normal.
Reaction:
acidic

Pus cells
increased
value
indicates
infection.
Bacteria:
Normal

Nursing Responsibilities:

Explain the procedure to the patient's significant others that these test
assess response to treatment.

Tell the patient's significant others that blood sample or specimen will be
taken.

Plan to obtain the specimen when the patient is calm and physically still.

Ensure the specimen/blood sample is not taken from the hand or arm that
has an intravenous line in the vein because of the dilution effect on the red
blood cells concentration.

For urinalysis, instruct the SO to collect urine specimen.

Collect urine by clean catching.

If there is a necessary urine collection, instruct SO to collect the urine in

every urination and put it in the bedside.

III. Anatomy and Physiology

The Urinary System
The urinary tract is composed of four structures:

Kidney

Ureters

Bladder

Urethra

The kidneys balance the urinary excretion of substances against the

accumulation within the body through ingestion or production. Consequently, they
are a major controller of fluid and electrolytes homeostasis. The kidneys also have
several no excretory metabolic and endocrine functions, including blood pressure
regulations, erythropoietin regulation and vitamin D metabolism.
Filtration at the renal glumerulus is the first steps in urine formation.
Normally, a volume equal to plasma volume is filtered every 24 minutes and a
volume equal to total body water is filtered every 6 hours. This glomerular filtrate is
similar to plasma, but it lack cells and large-molecular-weight proteins. The
glomerular filtrate is modified by active transport, diffusion and osmosis as it passes
through

the

renal

tubules.

Reabsorption

of

filtrate

components

enhances

elimination of organic acids and bases (and some drugs). The remnants of the
glomerular filtrate exit the kidney through the uterus.

The ureters conduct urine from the kidney to the bladder by peristaltic
contraction. The bladder is distensible chamber that stores urine until it is excreted.
The urethra is the exit passageway from the bladder that carries urine for
elimination from the body.

Structures of the Urinary System

The kidneys are located retro peritoneal, in the posterior aspects of the
abdomen, on either side of the vertebral column. They lie between the 12 th thoracic
and the third lumbar vertebrae. The left kidney is usually positioned slightly higher
than the right. Adult kidney average approximately 11 cm in length, 5 to 7.5 cm in
width and 2.5 cm in thickness. Affixing the kidneys in position behind the parietal
peritoneum is a mass of perirenal fat (adipose capsule) and connective tissue called
Gerota's (subserosa) fascia. A fibrous capsule (renal capsule) forms the external
covering of the kidney except for the hilum. The kidney is further protected by
layers of muscles of the back. Flank abdomen as well as by layer of fat,
subcutaneous tissues and the skin.
The kidney has a characteristics curve shape, with a convex distal edge and a
concave medial boundary. In the innermost part of the concave section is hilus,
through which pass the renal artery, renal vein, lymphatic, nerves and renal pelvis
(the natural upper extension of the ureter). A fibrous capsule surrounds each kidney
and adheres the renal parenchyma. Each kidney is divided in to three major areas:
(1) cortex, (2) medulla and (3) pelvis.
The cortex of the kidney lies just under the fibrous capsule, and portions of
the extend down into the medulla layer to form the renal columns (columns of
Bertin) or cortical tissue that separates the pyramids. The medulla is divided into
eight to 18 cone shaped masses of collecting ducts called the renal pyramids. The
bases of the pyramids are positioned on the corticomedullary boundary. Their
apices extend toward the renal pelvis, forming papillae. The papillae have 10-25
openings each on the surface, through which the urine empties into the renal pelvis.
Eight or more groups of papillae are present in each pyramid; each empties into a

minor calix and several minor calices join to form a major calix. The two or three
major calices are outpouching of the renal pelvis (inner area of the kidney). They
channel urine from the pyramids to the renal pelvis. The renal pelvis is a cavity
lined with transitional epithelium. The combined volume of the pelvis and calices is
approximately 8 ml. Volumes in excess of this amount damage the renal
parenchyma tissue. The renal pelvis narrows and reaches the hilus and becomes
the proximal end of the ureter.
Within the cortex lies the nephron, the functional unit of the kidney,
consisting both vascular and tubular elements. Filtration begins at the glumerulus.
The glomerular tuft (glumerulus) contains capillaries and the beginning of the
tubule system, Bowman's capsule. Filtrate from the glumerulus enters the
Bowman's capsule and the passes through a series of tubule segments that modify
the filtrate as it passes through the renal cortex and medulla and finally, flows into
the renal calices. A second capillary bed, the peritubular capillaries, carries the
reabsorbed water and solutes back towards the vena cava..

Renal Blood Flow, Glomerular Filtration

The kidneys receive 20% to 25% of the cardiac output under resting
conditions, averaging more that 1 L of the arterial blood per minute. The renal
arteries branch from the abdominal aorta at the level of the second lumbar of
vertebra, enter the kidney, and progressively branch into lobar arteries, inner lobar
arteries, accurate arteries and interlobular arteries. Blood flows from the inerlobular
arteries through the afferent arteriole and the peritubular capillaries carry a small
amount of blood (5% of renal blood flow) to the renal medulla in the vasa recta
(long, straight blood vessels) before entering the venous drainage. The blood leaves
the kidney in a venous system closely corresponding to the arterial system:
interlobular veins, accurate veins, interlobular veins, and the renal vein. The renal
circulation then empties the inferior vena cava.

Ureters

The ureters from the medial tapering of the renal pelvis at the hilus of the
kidney. Usually 25-35 cm long in the adult, the ureters lie in the extraperitoneal
connective tissue and descend vertically along the psoas muscle towards the pelvic
cavity. After dipping into the pelvic cavity, the ureters course anteriorly to join the
bladder in its posterolateral aspect. At each ureterovesical junction, the ureter runs
obliquely through the bladder wall for about 1.5 to 2 cm before opening into the
lumen of the bladder.

Each ureter has elastic characteristics and is made of three tissues layers; (1)
an inner mucosa (transitional epithelial membrane) lining the lumen, (2) a muscular
layer and (3) a fibrous outer layer. The musculature is generally designed as inner
longitudinal and outer circular. Along most of the ureter, however, the muscle fiber
actually run obliquely and blends with one another to form a mesh-like tissue. The
muscle arrangement allows urine to propel down by the ureter by peristaltic action.
Peristalsis is regulated by a myogenic pacemaker located near the renal calices.
Blood is supplied to ureters by one or more vessels that run longitudinal
along the tube. The number and assortment of articles anastomosing with the
ureteric vessels vary with each individual. Because the ureters travel through
several anatomic areas, the urethral vessels are fed several of the following
arteries: (1) renal (frequently), (2) testicular or ovarian, (3) aorta and common iliac,
(4) internal iliac (frequently), (5) vesical, (6) umbilical and (7) uterine.

Bladder
The urinary bladder is a hallow organ located in the anterior half of the pelvis
behind the symphisis pubis. The space between the bladder and symphisis pubis is
filled with a loose connective tissue that allows the bladder to stretch cranially as it
fills. The peritoneum covers the top border of the bladder, and the base is held
loosely in place by the true ligaments. The bladder is also enveloped by a loose
fascia.

Urethra
The urethra differs greatly in females and males. The urethra is a muscular
tube that connects the bladder with the outside of the body. The function of the
urethra is to remove urine from the body. It measures about 1.5 inches (3.8 cm) in a
woman but up to 8 inches (20 cm) in a man. Because the urethra is so much shorter
in a woman it makes it much easier for a woman to get harmful bacteria in her
bladder this is commonly called a bladder infection or a UTI. The most common
bacteria of a UTI is E-coli from the large intestines that have been excreted in fecal
matter. Female urethra. In the human female, the urethra is about 1-2 inches long
and opens in the vulva between the clitoris and the vaginal opening.
Men have a longer urethra than women. This means that women tend to be more
susceptible to infections of the bladder (cystitis) and the urinary tract.

Pathophysiology (client-centered)
A. Schematic Diagram
Non Modifiable Factors
1.) Female
2.) Age (5 years old)
3.) Familial history of kidney disease

Modifiable Factors
1.) Streptococcal infections (URTI)
2.) Skin infections (presence of lesions)
3.) Poor personal hygiene
4.) Lack of Financial Support
5.) Compromise Defense Mechanism

Antigen Anti-body reaction

Insoluble immune complexes develop and become entrapped in glomerular tissue
Renal function is
depressed.

destruction and inflammation of kidneys

S.O;
admission)
Decreased in circulating
plasma

lysosomes released during

the inflammatory response

triggered stimulation
pus is
of renin
presence of

damage top glomerular basement membrane

inflammatory
Response of the body.
(hyperthermia)
(Date: reported by
occurred prior

Presence of
may be due to
Streptococcus

Angiotensin I
Angiotensin Converting
Enzyme

Angiotensin II

Increased aldosterone secretion

increase permeability

of protein in urine

leaking RBC in urine

promoted renal
retention of Na and H2O
`
&
increased
Sumptoms of
circulating fluid
Anemia

Hematuria Volume

Signs

serum albumin is
decreased and released
(UA dated:06-23-08)
( + 1 albumin)(UA Dated:06-23-08)

Hemoglobin &
hematocrit count
decreased
(CBC
dated:06-20-08)
(CBC
dated:06-24-08)
increased cardiac
workload
08)

fluid shifted from intravascular

into interstitial spaces

transient in
uremic &
+3 RBC in urine
(UA Dated:06-23-

decrease osmotic pressure

Elevated Blood pressure
(Date: upon admission)
edema (+ facial edema)

Tea-colored
urine (UA Dated:06-

23-08)

(Date: apparent upon admission June 20&

still slight apparent until discharge June 26,2008)

IV. Patients Illness

Synthesis of the Disease
a. Definition of the disease
Acute glomerulonephritis is the term generally reserved for the variety of
renal disease in which inflammation of the glomerulus. Manifested by
proliferation of the cellular elements, is secondary to an immunologic
mechanism. Most incidence of AGN appears to be associated with a post
infection state. Several bacterial and viral infections have been incriminated in
its causation. It follows streptococcal infections of the respiratory tract or less
commonly, skin infections such as impetigo. AGN is most common in males ages
6-10 but can occur at any age. Up to 95% of children and up to 10% of adults
with AGN recover fully; the remainder of patients may progress to chronic renal
failure within months.
Acute glomerulonephritis results from the entrapment and collection of
antigen-body complexes produced as an immunologic mechanism in response to
streptococci in the glomerular capillary membranes, including the inflammatory
damage

and

impending

glomerular

function.

Sometimes

the

immune

complement further damages the glomerular membrane. The damage and

inflamed glomerulus loses the ability to be selectively permeable and allow RBC
and CHONs to filter through as the glomerular filtration rate falls.
b. Modifiable:
Patient ages 5 years old has familial history of kidney disease. During this
age she acquired streptococcal infection. According to Black, streptococcal
infection is one of the factors that may cause acute glomerulonephritis. According
to the informant, she acquired sore throat and also skin infection, due to this
factors these may contribute to the disease condition of the patient. Although she

is suffering infection, the patient did not seek medical attention instead just
neglect it and continue her poor personal hygiene.
c. Signs and Symptoms and its Rationale:
1.) Shortness of breath and cough- due to extra fluid in the lungs.
(Date: June 20, 2008)
2.) Elevated Blood Pressure- due to impaired renal function results to decrease
circulating plasma that triggered the stimulation of renin, to angiotensin I converted
by Angiotensin Converting Enzyme to Angiotensin II that acts on adrenal cortex
causing secretion of aldosterone. Increased in aldosterone promoted renal retention
of Na and H2O which means that there would be increased in circulating fluid that
would increase the heart's workload resulting to increased Blood Pressure.
(Date: June 20, 2008)
3.) Hematuria due to increased permeability that lead to leaking RBC in urine.
(CBC dated: June 20, 2008)
(CBC Dated: June 24, 2008)
4.) Fever due to the inflammatory response, swelling and death of some tissues.
(Date: June 20, 2008)
5. ) Edema- due to the leakage of proteins in the urine that resulted in decreased
serum osmotic pressure that leads to retention of fluid in interstitial spaces. Also
due to the increase in aldosterone that promoted the retention of Na and H 2O
resulted to edema.
(Date: apparent upon admission June 20 & still slight apparent until discharge
June 26,2008)

6.) Abnormal Neurological examination or altered level of consciousness-because of

malignant hypertension or hypertensive encephalopathy.
(Date: June 20, 2008)

d. Health promotion And Preventive Aspects

When glomerulonephritis is caused by an infection, the first step in treatment
is to eliminate the infection. If bacteria caused the infection, antibiotics may be
given. However, children who develop the disease following a streptococcal
infection often recover without any specific treatment.
When glomerulonephritis has slowed the amount of urine a person is
producing, he or she may be given medications called diuretics, which help the
body to rid itself of excess water and salt by producing more urine. More severe
forms of the disease are treated with medications to control high blood pressure, as
well as changes in diet to reduce the work of the kidneys. A small percentage of
people with severe glomerulonephritis may be treated with medications called
immunosuppressive drugs, which decrease the activity of the immune system, such
as corticosteroids and/or cyclophosphamide (Cytoxan).
To prevent glomerulonephritis following an infection, the infection must be
treated promptly. Most forms of glomerulonephritis cannot be prevented.

V. PATIENT AND HIS CARE

A. Medical Management
Medical
Date
General
Management
ordered
Description
Date
Performe
d
Date
Changed
Hypertonic solution
DO: 06-20- which causes cell
D5 0.3 NaCl
08
shrinkage
500 cc x KVO
DP: 06-2008
DC: 06-2608

Indication(s)
Or
Purposes

To replace fluid loss and

serve as a vehicle for
administration of drugs.

Nursing Responsibilities in IVF insertion:

Wash hands before preparing the equipment.

Check the health practitioners order for the
type and amount of solution.
Check integrity of the IV solution and
equipment.
Prepare IV solution label with clients name,
date, time, additives, and initial of the
administering nurse.
Explain to the client what you are doing before
taking the equipment into the clients room.

Clients
initial rxn to
treatment

Patient cried
when IV
insertion is
done.

Clients
response to
the treatment

Patient was able

to maintain
hydration status.
KVO: To not
aggravate fluid
retention.

Instruct the patient to limit his movement of

puncture site and notify for any problems or
discomfort.
Assess patient for any signs of edema and
swelling.
Nursing Responsibilities on the patient with
IVF:
Explain the procedures to the patient.
Assist patient with care since mobility is limited.
Check solution for clarity and correct IV type.
Regulate flow.
Monitor intake

B. Drugs
Name of drug

Date
ordered/Date
taken

Route of
administration/dos
age and frequency
of administration

GN: Penicillin G.
Sodium

DO: 06-20-08
DP: 06-20-08
D/ C: 06-26-08

IV 375,000 U every 6
hours

GN:
Paracetamol

DO: 06-20-08
DP: 06-20-08
D/C: 06-24-08

IV 200 mg every 4
hours

GN:
Metoclopramide

DO: 06-20-08
DP: 06-20-08
D/C: 06-21-08

IV amp now

General
action/Function
al
classification/
Mechanism of
Action
To treat
moderate to
severe systemic
infections caused
by penicillinsensitive
microorganisms
Antipyretic

Increases
sensitivity to
acetylcholine;
results
in increased
motility of the
upper GI tract
and relaxation of
the pyloric
sphincter and
duodenal bulb.

Initial reaction

Clients
response to
the medication

Patient dislikes
the feeling of IV
administration of
drugs

Patients WBC
count decreased

Patient dislikes
the feeling of IV
administration of
drugs
Patient dislikes
the feeling of IV
administration of
drugs

Patients
temperature
decreased
Patient did not
vomit.

Nursing Responsibilities:

Check name of patient before administering any medications

Check right dosage and route before administration

Check expiration date of medications

Prepare medications aseptically

Administer medications at the right time

Observe patient for any manifestation of adverse effect

C. Diet
Type of Diet

Low salt, Low fat

Date ordered
Date Performed
Date Changed

General
Description

Indication(s)
Or
Purposes

DO: 06-20-08
(Patient was
advised to
maintain this
type of diet even
after discharge)

A type of diet
wherein foods
provided to the
patient are low in
fat and sodium
content.

To prevent fluid
retention,
decrease
metabolic
demand and help
decrease blood
pressure

Specific foods
taken

Rice, fish

Clients
response
and/or rxn to
the diet
Development of
further edema
was prevented.

Low Protein

High Protein

DO: 06-26-08
(Patient was
advised to
maintain this
type of diet after
discharge)

A type of diet
wherein foods
provided to the
patient are low in
protein content.

To allow kidney
function to rest.

Bread, chocolate

Development of
further edema
kidney
disfunction will be
prevented.

DO: 06-26-08
(Patient was
advised to
maintain this
type of diet after
discharge)

A type of diet
wherein foods
provided to the
patient are high
in protein
content.

To allow tissue
repair.

Fish, cheese

Stronger and
healthier body
will be achieved.

Nursing Responsibilities:
Explain the reason for suggested diet and exercise
Monitor foods taken by the patient

D. Activity/Exercise
Date ordered
Date
Type of
Performed
exercise
Date Changed
Bed rest
DO: 06-20-08
(Patient was
advised to
maintain this
type of exercise
even after
discharge)

General
Description

Purposes
A type of
activity wherein
the patient is
kept on bed with
limitations to
activity

Nursing Responsibilities:
Explain the reason for suggested exercise

C. Nursing Management

Indication(s)
Or

To reduce oxygen demand

and prevent fatigue

Clients
response to the
activity/exercise
Patient shows
gradual increase in
strength.

1. Nursing Care Plan

Assessme
Nursing
nt

Objectives

Interventi

Rationale

Expected

- To have a

Outcome
SHORT TERM:
Patients body

explanation
People suffer heat-

SHORT TERM:

on
- Monitor

O= patient

related illness when

After 4 of NI,

VS and

baseline

manifests:

the body's

patients boby

note level

data and to

of

reveal

shall have

consciousn

alteration

decreased

S=

diagnosis
Hyperthermia

Scientific

temperature control
-body
malaise
-pale
palpebral
conjunctiva
-pale skin
-activity
intoleran
ce
VS as
follows:
T - 38.40C
PR

system is overloaded.
The body normally

temp. will
decrease rom
0

38.4 C to 37 C.

from 38.40C to

ess

370C

cools itself by
sweating. But under
some conditions,
sweating just isn't
enough. In such

LONG TERM:
After 8 days of

cases, a person's

NI, patients SO

body temperature

verbalize

rises rapidly. Very

understanding

high body
temperatures can
damage the brain or
other vital organs.

temperature

o the underlying
cause factors

- performed

- to

TSB (tepid

promote

sponge

wellness
LONG TERM:

bath)

patients SO
shall have

-instructed
- to

increase

promote

understanding

fluid intake

wellness

o the

and importance
of treatment

verbalized

patient

underlying
cause factors

-Instruct

and

84bpm, RR

patient to

22 bpm

avoid

-To

strenuous

conserve

importance of
treatment

activity

energy

-Provide
foods rich
in Iron and
Vitamin C

- To
promote

-Encourage

wellness

use of
relaxation
techniques
-To avoid
fatigue

Assessme

Nursing

nt

diagnosis
Activity intolerance

S=

Scientific
explanation
The kidneys are

Objectives
SHORT TERM:

O= patient

remarkable in their

Ater 4 o NI the

manifests:

ability to compensate

pts SO will use

-appears
weak
-body
malaise
-pale
palpebral
conjunctiva
-pale skin
-activity
intoleran
ce

for problems in their

identified

function. That is why

techniques to

chronic kidney
disease may progress

enhance activity
tolerance

without symptoms for

Interventi

Rationale

Expected

on
- adjust

- to prevent

Outcome
SHORT TERM:

activities

overexertio

the pts SO

perform so many
functions for the
body, kidney disease
can affect the body in
a large number of
different ways.
Symptoms vary

enhance

- to

tolerance

enhance
ability to

function is left.
Because the kidneys

techniques to
activity

-promote
measures

very minimal kidney

- to reduce
fatigue

comfort

a long time until only

identified

- encourage
rest periods

shall have used

participate
in activities

LONG TERM:
After 5 days of
NI the pt. will
actively or
willingly
participate in
necessary
activities

-assist
client in
learning

pt. shall have

- to prevent
injuries

use of

different body

relaxation

willingly
necessary

measures

greatly. Several

actively or
participated in

safety

-Encourage

LONG TERM:

activities
-To avoid
fatigue

techniques
systems may be
affected.

-plan
maximal
activity

- to

within the

promote

clients

wellness

ability

Assessme
nt

Nursing

Scientific

S=

diagnosis
Poor personal

explanation
It is generally known

O= patient

hygiene

that unclean
conditions and poor

manifests:

hygiene are the main

promoters of

Objectives

Interventi

Rationale

Expected

on
- instruct

- to

After 4 the pt.s

proper

promote

the pts SO

SO will verbalize

bathing

wellness

shall have

SHORT TERM:

understanding
of proper

Outcome
SHORT TERM:

verbalized

-implement

understanding

proper

-to assist in

bowel/

correcting

of proper

-body

bladder

situations

hygiene

malaise

training

-appears
weak

bacterial growth.

hygiene

LONG TERM:

-pale
palpebral
conjunctiva

LONG TERM:
After 3-4 days of

-pale skin

NI the pt. will

-with facial

perform self-

edema

care activities

pt. shall have

- instruct
proper
handwashin
g

performed self- to
promote
wellness

within level of
own ability

- encourage
food and
fluids
choices that -to assist in
correcting
meets
nutritional

situations

care activities
within level of
own ability

needs
-make
home visit
- to assess
environmen
tal needs

Assessme
nt

Nursing

Scientific

Objectives

S=

diagnosis
Fluid volume

explanation
The inflammation

O= patient

excess r/t

disrupts the

After 4 the pt.s

manifests:

disruption of

functioning of the

SO will verbalize

regulatory

glomerulus, which is

mechanism

the part of the kidney

of individual

that controls filtering

fluid restrictions

-body
malaise
-pale
palpebral
conjunctiva
-pale skin
-with facial
edema

SHORT TERM:

Interventi

Rationale

on
- Establish

- To gain

rapport

the trust of

the pts SO

the client

shall have

understanding
- To have a

VS and

baseline

and excretion. This

note level

data and to

disruption results in

of

reveal

consciousn

alteration

appearing in the

LONG TERM:
After 3-4 days of

urine, and the build

NI the pt. will

up of excess fluid in

stabilized fluid

the body.

volume as
evidenced by

Outcome
SHORT TERM:

verbalized
- Monitor

blood and protein

Expected

understanding
of individual
fluid
restrictions

ess

-Monitor I &
O

- To reveal
alteration in

LONG TERM:

fluid status

pt. shall have

balance I&O

stabilized fluid
volume as
- Restrict
fluid/sodiu
m intake as
indicated

-To reduce

evidenced by

further

balance I&O

edema

-Administer

-To

diuretics as

promote

ordered

fluid
excretion

Assessmen

Nursing diagnosis

Scientific

Objectives

Interventio

Rationale

Expected

S=

Altered tissue

explanation
Patients with

SHORT TERM:

n
-Establish

-To gain

O= patient

perfusion related to

kidney problems

After 6 of NI,

rapport

trust of the

Patients SO

manifested:

decreased

manifest anemia

patients SO will

client

was able to

hemoglobin

due to the

be able to

- Monitor VS

level/concentration

interruption in

verbalize

and

- To have a

in the blood

the release of

understanding

note level of

baseline

of condition

of condition and

consciousnes

data and to

and therapy

reveal

-body
malaise
-pale skin
-activity
intolerance
-decreased
performanc
e

erythropoietin, an
enzyme

therapy

responsible for

regimen

RBC production

periorbital

NI, patient will

edema

be able to
demonstrate

taken as

increased

follows:

perfusion as

T:36.10C

individually

PR:97

appropriate

BP: 90/60

regimen

alteration

LONG TERM:
After 8 days of

RR:18

understanding

-To increase

-with

-vital signs

verbalize

-Elevate HOB

and presence of
hematuria.

Outcome
SHORT TERM:

gravitationa
-Check for
calf
tenderness

-Provide
quiet, restful
environment
-Instruct

l blood flow

LONG TERM:

- May

Patient was

indicate

able to

thrombus

demonstrate

formation

increased
perfusion as

-To promote

individually

relaxation

appropriate

-To

The patient
may

patient to

conserve

avoid

energy

strenuous

manifest:

activity

-Provide

dehydration

foods rich in

- To

-inappropri-

Iron and

promote

Vitamin C

RBC

ate urine
output for
intake

production
-Encourage
use of

-To avoid

relaxation

fatigue

techniques

Assessme

Nursing

Scientific explanation

Objectives

Interventio

Rationale

nt
S=

diagnosis
Fatigue

Patients with anemia

SHORT TERM:

n
- Establish

- To gain

O= patient

related to

experience fatigue which is

After 6 of NI,

rapport

the trust of

manifest:

increased

due to increased oxygen

patient will be

-body

metabolic

demand caused by decreased

able to report

malaise

demands

ability of the blood to provide

an improved

-pale skin

and

adequate tissue perfusion.

-activity

anemia

Moreover, presence of edema

sense of
energy

the client

- Monitor VS

- To have a

and

baseline

note level of

data and

may increase level of fatigue

consciousnes

to reveal

-decreased

due to hematuria which

alteration

performanc

decreases oxygen and leads

to a decrease in cerebral

-with

tissue perfusion.

LONG TERM:
After 8 days of
NI, patient will

edema

be able to

-vital signs

report

taken as

improved

follows:

sense of

T:36.1 C
PR:97
RR:18
BP: 90/60
The patient

Patient was
able to report
sense of
energy

LONG TERM:

periorbital

Outcome
SHORT TERM:

an improved

intolerance

Expected

energy

-Accept
reality of
patients
report of

- For
proper

improved

sense of
energy

- Provide
supplementa
l oxygen as
-To
support
-Provide

able to report

assessmen

fatigue

indicated

Patient was

oxygen
demand

may

environment

manifest:

conducive to

relief of

-To reduce

dehydratio

fatigue

exhaustion

And to

-inappropri-

-Assist

promote

ate urine

patient with

comfort

output for

activity

intake

-For safety
-Assist

measures

patient to

Assessme

Nursing

Scientific explanation

Objectives

identify

- To

appropriate

promote

coping

sense of

behaviors

control

Interventio

Rationale

Expected

nt

diagnosis

S=

Decreased

The excessive urine output of

SHORT TERM:

- Establish

O= patient

cardiac

the patient is due to failure of

After 6 of NI,

rapport

manifested:

output

regulatory mechanism

patient will be

related to

resulted to altered circulation/

able to display

altered

increased in blood pressure

hemodynamic

blood

due to albuminuria which

pressure

causes edema and leads to an

-with
history of
hematuria
-with
history of
frequent
urination
but small
amount of
urine in
yellow color
-appears
weak
-with good
skin turgor
-decreased
food intake
-VS taken
as follows:

- Monitor VS

stability

Outcome
- To gain
the trust of
the client

SHORT TERM:

- To have a
baseline
data and
to reveal
alteration

able to

After 6 of NI,
patient was
display
hemodynamic
stability

increase in blood volume that

-Promote

triggered the stimulation of

renin, to angiotensin I
converted by Angiotensin
Converting Enzyme to
Angiotensin II that acts on
adrenal cortex causing
secretion of aldosterone.
Increased in aldosterone
promoted renal retention of
Na and H2O which means that
there would be increased in
circulating fluid that would

LONG TERM:
After 3-4 days
of NI, patient
will be to
demonstrate
an increase in
activity
tolerance

adequate
rest by
decreasing

- To
maximize
sleep
periods

After 3-4 days

stimuli,

of NI, patient

providing

was able to

quiet

demonstrate

environment

an increase in

. Schedule

activity

activities

tolerance

and
assessments

increase the heart's workload

resulting to increased blood
pressure.

- Provide
supplementa

LONG TERM:

-To
increase
oxygen

T:36.80C

l oxygen as

PR:72

indicated

RR: 19
BP: 80/72

-Encourage
relaxation

The patient

available
to the
tissues
-To reduce
anxiety

techniques

may
manifest:

-Provide for

maintain

diet

dehydratio

restrictions

(e.g. low

sodium,

adequate
nutrition
and fluid

inappropria

bland, soft,

te urine

low calorie/

output for

residue/ fat

intake

-To

valance

diet, with
frequent
small
feedings as
indicated

Assessm
ent
S=

Nursing
diagnosis
Risk for

Scientific
explanation
The presence of

Objectives
SHORT TERM:

Interventio
n
- Establish

Rationale
- To gain the

Expected
Outcome
SHORT TERM:

O= patient impaired

edema interferes

manifeste

Skin

with cellular

d:

Integrity

--with
history of

After 6 of NI,

rapport

trust of the client

Patient was able

patient will

to demonstrate

nutrition, which

demonstrate

behaviors to

related to

makes the patient

behaviors to

- Monitor VS

- To have a

prevent skin

edema

more susceptible

prevent skin

and

baseline data

breakdown

to skin breakdown.

breakdown

note level of

and to reveal

consciousne

alteration

hematuria

ss

-with
history of
frequent

-Assess skin

urination
but small

LONG TERM:

amount of

After 6 days of NI,

urine in

patients edema

yellow
color

will
decrease/subside

condition

- To reveal
abnormality/skin
disruption

- Monitor
weight daily

-To monitor
presence of
edema

-with good

decreased

-Provide
meticulous
skin care

-To prevent skin

breakdown

food
intake
-VS taken

was able to
e

weak

Patients edema
decrease/subsid

-appears

skin turgor

LONG TERM:

-Keep bed

-To prevent

as follows:

linens dry

T:36.80C

moisture which
may promote

PR:72

skin breakdown

RR: 19
BP: 80/72

-Frequently

-To promote

change

proper circulation

The

patients

and prevent

patient

position

excessive

may
manifest:
dehydratio
n
inappropriate urine
output for
intake

pressure on skin

Assessme
nt

Nursing

Scientific

Objectives

Interventi

Rationale

Expected

S=

diagnosis
Risk for spread of

explanation
Viruses and bacteria

SHORT TERM:

O= patient

infection

both enter your body

After 4 the pt.s

through your mouth

SO will identify

or nose either

interventions to

identified

reduce spread

interventions

manifests:

-appears
weak
-body
malaise
-pale
palpebral
conjunctiva
-pale skin
-with facial
edema

because you breathe

in particles that are

- to reduce

Outcome
SHORT TERM:

proper

existing risk

the pts SO

hygiene

factors

shall have

- instruct

- to reduce

to reduce

released into the air

proper

existing risk

spread of

when someone

handwashin

factors

infection

coughs or sneezes, or

because you have

hand-to-hand contact
with an infected
person or use shared
objects such as
utensils, towels, toys,
doorknobs or a
telephone.

of infection

on
- instruct

LONG TERM:
After 3-4 days of
NI the pt.s SO
will demonstrate
techniques,

- promote

- to prevent

clean

inection

pt. shall have

demonstrated

environmen

techniques,

lifestyles

LONG TERM:

- to correct

changes to

- change

existing risk

promote safe

linens an

factors

environment

dressings
as needed
- to

lifestyles
changes to
promote safe
environment

-emphasize

promote

necessity of

wellness

taking
antibiotics
as directed
-encourage

- to

proper

promote

nutrition,

wellness

appropriate
exercise
program
and need
for rest

C. Nursing Management (Actual SOAPIERS)

June 24, 2008 (Tuesday)

A.1)

S>
O > received patient sitting in bed with ongoing IVF of D5.3 NaCl 500 cc x 10-11
ugtts/min at 100 cc level, appears weak with periorbital edema good skin turgor
moist mucous membrane decreased food intake, vital signs taken as follows: T36.80C PR-72bpm RR-19cpm
A > Excess fluid volume related to albuminuria secondary to acute
glomerulonephritis
P > After 6 hours of nursing interventions, the patient will be able to stabilize fluid
volume as evidenced by absence of edema
I>

Established rapport.

Monitored and recorded vital signs.

Checked patency of IVF.
Regulated IVF x 10-11 ugtts/min at 9:24am.
Noted amount or rate of fluid intake from sources.
Noted presence of edema (puffy eyelids dependent swelling ankles/feet if
ambulatory or up in chair; sacrum and posterior thighs when recumbent),
anasarca
Set an appropriate rate of fluid intake infusion 24 hour period.

 Discussed the importance of fluid restrictions ad :hidden sources of intake

(such as foods high in water content).
Provided adequate rest periods.
Due meds given.
Attended needs.
Endorsed.
E > Goal met after 6 hours of NI, as evidenced by stabilized fluid volume of the
patient which is evident by absence of edema

June 24, 2008 (Tuesday)

A.2)

S>
O > received patient sitting in bed with ongoing IVF of D5.3 NaCl 500 cc x 10-11
ugtts/min at 100 cc level, appears weak with periorbital edema good skin turgor
moist mucous membrane decreased food intake, vital signs taken as follows: T36.80C PR-72bpm RR-19cpm
A > Activity intolerance due to prolonged bedrest
P > After 6 hours of nursing interventions, the patient will be able to identify
negative factors affecting activity tolerance and eliminate or reduce their effects
when possible
I>

Established rapport.

Monitored and recorded vital signs.

 Encourage expression of feelings contributing to condition.

Increase exercise or activity levels gradually; teach methods to conserve
energy, such as stopping to rest for three minutes during a 10-minute walk.
Encourage participation in recreation or social activities hobbies appropriate
for situation.
Due meds given.
Attended needs.
Endorsed.
E > Goal met after 6 hours of NI, as evidenced by patients capability to identify
negative factors affecting activity tolerance and eliminate or reduce their effects
when possible

June 25, 2008 (Wednesday)

B.1)

S>
O > received patient sitting in bed with ongoing IVF of D5.3 NaCl 500 cc x 10-11
ugtts/min at 100 cc level, appears weak with periorbital edema with reduced
interaction with people and environment with polyuria, vital signs taken as follows:
T-36.10C PR-97bpm RR-18cpm
A > Risk for deficient fluid volume AEB frequent urination related to disease
condition
P > After 6 hours of nursing interventions, the patient will not be able to manifest
signs and symptoms of dehydration
I>

Established rapport.

Monitored vital signs.

Provided adequate rest periods.
Seen on rounds by Dra. Aguillar with new order made and recorded (Order:
KVO)
IVF to KVO
Due meds given.
Attended needs.
Endorsed.
E > Goal met after 6 hours of NI, as evidenced by patient was not able to manifest
the signs and symptoms of dehydration

June 25, 2008 (Wednesday)

B.2)

S>
O > received patient sitting in bed with ongoing IVF of D5.3 NaCl 500 cc x 10-11
ugtts/min at 100 cc level, appears weak with periorbital edema with reduced
interaction with people and environment with polyuria, vital signs taken as follows:
T-36.10C PR-97bpm RR-18cpm
A > Social isolation related to altered state of wellness
P > After 6 hours of nursing interventions, the patient will be able to verbalize
willingness to interact with others
I>

Established rapport.

Monitored vital signs.

Provided adequate rest periods.
Introduce client to those with similar or shared interests and other supportive
people.
Provide environmental stimuli (open curtains, TV, radio and pictures).
Due meds given.
Attended needs.
Endorsed.
E > Goal met after 6 hours of NI, as evidenced by patient was able to verbalize
willingness to interact with others

VI. Clients Daily Progress in the Hospital

1. Clients Daily Progress Chart

Nursing Problems

Clients daily Progress

06-21-08
06-22-08
06-2308

Hyperthermia

Admission
(06-20-08)

Activity intolerance

Poor personal hygiene

Fluid volume excess r/t

disruption of regulatory
mechanism
Altered Tissue
Perfusion

Fatigue

Decreased cardiac
output

Risk for impaired Skin

Integrity related to
edema

Risk for spread of

infection

38.4C

37.3

37

36.8C

36.1C

Vital Signs
Temperature

06-24-08

06-25-08

Discharge

Pulse rate
Respiratory rate
Blood Pressure
*Temp, PR, RR and BP
were not available in
the chart for some
dates
Diagnostic
Procedure
CBC
Serum Creatinine
Blood Chemistry
Serum Electrolyte
Routine Urinalysis
Medical Management
A. IVF
D5 0.3 NaCl
B. Drugs
Pen G Sodium
Metoclopramide
Paracetamol
C. Diet
Low salt, Low fat

84
22
90/60

80/60

70/60

72
19
80/72

97
18
90/60

Low Protein

High Protein

D. Activity

Bed rest

2. Discharge Planning
a. General condition of the client upon discharge
Baby AGN was discharged last June 26, 2008 (Thursday). She still has slight
facial edema, normal body temperature, (-) hematuria and stable vital signs. She
has still lesions on her scalp and minimal lesions on her extremities.
b. Method
S>
O > Received patient sitting on bed; pt. still has slight facial edema; (-) hematuria,
pt. still has lesions on her scalp and minimal lesions on her extremities; appears
slightly weak; with stable vital signs.
A > For home maintenance and health management.
P > After 1 hour of nursing interventions, the patient and SO will verbalize
understanding of health teachings.
I>
M > Instructed patient to take the following home medications
E > Instruct the patient to do some activities of daily living.
T > Instruct the patient to take the medications religiously.
H > Instructs patients to eat nutritious foods such as fruits and vegetables
that

are not contraindicated.

> Instructs patient to have proper personal hygiene.
O > Instructed patient to come back for follow-up check
D > Instructed patients SO to provide foods that are low in salt and fat.

E > Goal met as evidenced by patients SO verbalized understanding of health

teachings.

VII. Conclusions

Acute Glomerulonephritis is relatively common bilateral inflammation of the

glomeruli. It follows a streptococcal infection of the respiratory tract or less
commonly, a skin infection. It is a must that we shouldgive enough attention to
those suffering of such disease so as to prevent aggravation and further
complications that could possibly occur.To help patient to cope up with his/her
condition we are to perform proper monitoring and treatment.
As a student nurse, the student should be competetive enough, equipt with
enough and accurate knowledge of the disease. Not just with learning through
lectures and theories is the way to understand these diseases. Through interaction,
knowledge acquired from theories was much appreciated by the students since
he/she can actually assess the patients condition. Equipt with enough and accurate
information and enhance skills, she/he may be able to be competetive enough to
handle future situations and patients suffering from the mentioned condition.

Bibliography:

www.yahoo.com

www.emedicine.com

Medical Surgical Nursing

PDR Nurses Drug Handbook 2005

Nurses Pocket Guide

http://en.wikibooks.org/wiki/Human_Physiology/The_Urinary_
System#Urethra