Our Lady of Fatima University College of Nursing ACUTE GLOMERULONEPHRITIS A Group Case Study Submitted to: Ms.

Feliciano, RN In Partial Fulfillment of the Requirement for the Course NCM102 RLE Pasay City General Hospital Pedia Ward Submitted by: Macatangay Jan Alex Madriaga, Merry Grace Marquez, Carmina Martinez, Ricky Navarro Jr., Noel Palompon, Ma. Rafaela Plaza, Jeanine Louise 2Y4-2D JANUARY 2010

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Table of Contents Chapter I -Introduction -Patient’s Profile -Nursing History of Illness Chapter II -Anatomy and Physiology -Pathophysiology Chapter IV -Laboratory Examinations Chapter V -Drug Study Chapter VI -Nursing Care Plan 147 26 22 9 20 4 5 7

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Narratives News/Trends

148 171

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INTRODUCTION Acute Glomerulonephritis (AGN) is an inflammation of the internal kidney structures (glomeruli). Glomeruli itself has functions to help filter waste and fluids from the blood. This disease leads to proliferative and inflammatory changes within glomerular structure, as well as, destruction, inflammation and sclerosis of the glomeruli of both kidneys. The common signs and symptoms of AGN are as follows: Periorbital and facial edema (more prominent in the morning),decreased urinary output, cloudy, smoky, and brown-colored urine, anorexia, pallor, irritability and lethargy, headaches, abdominal or flank pain, dysuria, hypertension, proteinuria, azotemia, increased blood urea nitrogen and creatinine levels and Antistreptolysin O titer.

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The group encountered a patient with a condition as such and their clinical instructor gave them the opportunity to study the case; hence, this case study aims to help understand the disease process of AGN, and to orient one of the appropriate nursing interventions that could be offered to patients. PATIENT’S PROFILE Patient’s Name: Ajanun, Patrick Lleva Age: 4 years old Gender: Male Address: 668 D. Bautista St. Pasay City Date of Birth: April 23, 2005 Civil Status: Single Religion: Roman Catholic

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Nationality: Filipino Dialect: Tagalog Date of Admission: Time Admitted: Attending Physician: Chief Complaint: Admitting Diagnosis: Final Diagnosis:

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NURSING HISTORY OF ILLNESS

A.

History of Present Illness

-Present illness started at nine months prior to admission;the patient had on and off headache in the temporal area. He was brought to a private clinic and was diagnosed with sinusitis and was given phenypropanolamine. After one week prior to admission the patient had cough without fever and was given Salbutamol Syrup and nebulization which afforded temporary relief. After a few hours he had seizure with loss of sight and was admitted to Pasay City General Hospital (PCGH).

B.

Past Medical History -Pneumonia

C.

Family History of Past Illness -Positive Maternal Asthma -Positive PTB grandmother

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D. Medical Birth History -full term -G2P0 via Normal SD E. Nutritional History -Breastfed for one month -Bottle-fed for two months

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ANATOMY AND PHYSIOLOGY The Kidneys The kidneys are two bean shaped organs of the renal system located on the posterior wall of the abdomen one on each side of the vertebral column at the level of the twelfth rib. The left kidney is slightly higher than the right. Human kidneys are richly supplied with blood vessels which give them their reddish brown color. The kidneys measure about 10cm in length and, 5cm in breadth and about 2.5 cm in thickness. The kidneys are protected by three highly specialized layers of protective tissues. The outer layer consists mainly of connective tissue which protects the kidneys from trauma and infection. This layer is often called the renal fascia or fibrous membrane. The technical name for this layer is the renal capsule. The next layer (second

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layer from the exterior) is called the fascia and it makes a fibrous capsule around the kidneys. This layer connects the kidneys to the abdominal wall. The inner most layer is made up of adipose tissue and is essentially a layer of fatty tissue which forms a protective cushions the kidney; and the renal capsule (fibrous sac) surrounds the kidney and protects it from trauma and infection. Kidney Function The main function of the kidney is to maintain the fluid, electrolyte, and pH balance of the body by filtering ions, macromolecules, water, and nitrogenous wastes from the blood based on the body’s condition. Wastes filtered out of the blood drains from canals in the kidney into the bladder as urine. Blockage of the drainage system can cause the kidney to become congested, stretched, and potentially scarred. Functioning kidneys are necessary to maintain life, and one

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measure of their function is the glomerular filtration rate. A loss of kidney function results in the need for dialysis, which is an artificial method of removing wastes from the blood by running the blood from the body, through an artificial kidney, and then back into the body.

Cross-section of a kidney
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PARTS OF KIDNEY Capsule

The renal capsule is the membranous covering of the kidney. It directly covers the renal cortex, which forms the outer stratum Each part of the capsule Cortex links to its explanation. The cortex of the kidney is the outer section which covers the internal medulla.

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The cortex is visible near the outer edge of the crosssectioned kidney. It is composed of blood vessels and urine tubes and is supported by a fibrous Calyx matrix. The calyces (plural for calyx) are the recesses in the internal medulla of the kidney which enclose the pyramids. They are used to subdivide the sections of the kidney anatomically, with distinction being made between major calyces and Renal Column minor calyces. The renal columns are lines of the kidney matrix which support the cortex of the kidney. They are composed

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of lines of blood vessels and urinary tubes and a fibrous, Pyramid cortical material. The renal pyramids are conical segments within the internal medulla of the kidney. The pyramids contain the secreting apparatus and tubules and are also known as the malphighian pyramids.

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Renal Sinus

The renal sinus is the cavity within the kidney which houses the renal pyramid. Nerves and blood vessels pass into the renal sinus Hilus through the hilus. The hilus is the slit-like opening in the middle of the concave medial border of

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the kidney. Nerves and blood vessels pass through the hilus into the renal sinus Renal Artery within. One quarter of the total blood output from the heart comes to the kidneys along the renal artery. Two renal arteries arise from the abdominal section of the aorta; each artery supplies a lobe of the kidney. The incoming artery divides into four or five branches, eventually forming arterioles, each of which leads to the compact ball of capillaries called the Renal Vein glomerulus. Cell waste is discharged in the veins for excretion

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through the kidneys. The body circulates about 425 gallons of blood through the kidneys on a daily basis, but only about a thousandth of this is converted in urine. The remainder goes back into circulation through the renal arteries. From the Bowman's capsule, the blood is carried through the compact network of capillaries that forms the glomerulus within the capsule. The capillaries eventually reconverge into small venules which lead to the larger renal veins. There are two renal veins, one extending from each lobe of

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the kidney, and opening into the vena cava.

THE NEPHRON The nephron is the functional unit of the kidney, responsible for the actual purification and filtration of the blood. About one million nephrons are in the cortex of each kidney, and each one consists of a renal corpuscle and a renal tubule which carry out the functions of the nephron. The renal tubule consists of the convoluted tubule and the loop of Henle. The nephron is part of the homeostatic mechanism of your body. This system helps regulate the amount of water, salts, glucose, urea and other minerals in your body. The nephron is a filtration system located in your kidney that is

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responsible for the reaborption of water, salts. This is where glucose eventually is absorbed in your body. One side note, diabetics have trouble reaborbing the glucose in their body and hence a lot of it comes out in the urine - hence the name "diabetic" or "sweet urine." But that's another topic. The Loop of Henle is the part of the nephron that contains the basic pathway for liquid. The liquid begins at the Bowman's capsule (upper left) and then flows through the proximal convoluted tubule (that mess of tangled stuff up top). It is here that Sodium, water, amino acids, and glucose get reabsorbed. The filtrate then flows down the descending limb and then back up. On the way it passes a major bend called the Loop Of Henle. This is located in the medulla of the kidney. As it approaches the top again, hydrogen ions (waste) flow into the tube and down the collecting duct.

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Essentially, nutrients flow in through the left and exit through the right. Along the way, salts, carbohydrates, and water pass through and are reabsorbed.

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PATHOPHYSIOLOGY

Post-streptococcal infection (group-A, beta hemolytic) Release of material from the organism, into the circulation

Antibody Formation

Immune complex reaction in the glomerular capillary Inflammatory response

Proliferation of epithelial cells lining glomerolus & cells between endothelium & epithelium of capillary membrane

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continued
Swelling capillary membrane & infiltration with leukocytes ↑ Permeability of base membrane Occlusion of the capillaries of the glomeruli vasospasm of afferent ventrioles

↓ Glomerular filtration rate

↓ Ability to form filtrate from glomeruli plasma flow

Retention of H2O & Na; hypovolemia; circulatory congestion Edema Hypertension ↓ urinary output Urine dark in color Anorexia Irritability lethargy

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ACUTE GLOMERULONEPHRITIS

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LABORATORY EXAMINATIONS HEMATOLOGY REPORT December 24, 2009
PARAMETER NORMAL VALUES ACTUAL VALUES ANALYSIS

Segmenters

0.550.65

0.86

Lymphocytes

0.250.35

0.14

Increased; indicate high glucose level in the blood Increased; indicates infection

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BLOOD CHEMISTRY REPORT December 28, 2009
PARAMETER NORMAL VALUES ACTUAL VALUES ANALYSIS

BUN/ Urea

1.7-8.3 Mmol/L

10.10

Increased BUN levels suggest impaired kidney function. This may be due to acute or chronic kidney disease, damage, or failure.

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URINALYSIS REPORT December 28, 2009

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PARAMETER Color Transparency Reaction Specific Gravity Sugar Protein Squamous Epithelial Cells

NORMAL VALUES Yellow Amber Clear to slightly turbid 4.5-8 1.0051.030 Negative Negative Few

ACTUAL VALUES Light yellow Slightly turbid 6.0 1.010 trace +2 Few

ANALYSIS normal normal normal normal Indicative of glucosuria Indicative of proteinuria Indicative of nephrotic syndrome Hematuria, indicative of possible glomerular damage Indicative of bacterial infection Normal Normal Indicative of bacterial infection

Red Blood Cells

Few

2-7

Pus Cells Mucus Bacteria Amorp. Urates/Phosphate s

Few Few Few Few

1-3 Few Few moderate

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