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Nursing Care Management 103A1 Related Learning Experience
Case Presentation (Acute Glomerulonephritis)
Submitted by: BSN122 Group 87 Gratuito, Rachel S. Jacinto, Arvie D. Jornacion, Catrisha Elaine T. Macaballug, Katrina B. Maningding, Marvic S. Mariano, Lalaine B. Matibag, Michelle A. Mendoza, Kristeen Frieda O. Mislang, Angel Marie P. Mora, Danica V. Muñoz, Joseph James J.
April 30, 2010
Submitted to: Mrs. Rosalie Catanghal R.N.
Table of contents
I. BIOGRAPHIC DATA
II. NURSING HEALTH HISTORY a. Past Health History b. Present Health History c. Family History III. PATTERNS OF FUNCTIONING IV. ACTIVITIES OF DAILY LIVING V. PHYSICAL ASSESSMENT VI. COURSE IN THE WARD 1. Diagnostics and Laboratories 2. Medications/Drug Study VII. PATHOPHYSIOLOGY VIII. ECOLOGIC MODEL IX. PROBLEMS IDENTIFIED X. NCP XI. DISCHARGE PLAN
Name: Mr. L.R. Address: Valenzuela City Age: 18 yrs. old Gender: Male Religious Affiliation: Christian Marital Status: Single Occupation: N/A (Student) Room and Bed #: Rm. 311 Chief Complaint: Abdominal pain, DOB, cough Provisional Diagnosis: Acute Glomerulo Nephritis (AGN), UTI, Bilateral pleural effusion Attending Physician: Dr. Mary Calalang
According to Mr. L.R. he doesn’t remember any childhood diseases except for having a chicken pox when he was 10 years old. He also said that he was fully immunized. The client said the he has an allergy to a certain medication for tonsillitis, but doesn’t remember what exactly drug it is. He also added that his left arm was dislocated when he was 13 years old. Other than that, the client doesn’t have any accidents or injuries encountered. Mr. L.R. said that it is his first time to be confined in a hospital. According to the client, he doesn’t have any foreign travel yet, but have been in Corregidor, Palawan and Tagaytay 3 years ago for a field trip.
Past Health History
B. History of Present Illness
According to the client 3 days prior to confinement, he had experienced cough with productive secretions and difficulty of breathing. The client verbalized “bago ako na admit dito namanhid din yung mukha ko, tapos parang namamanas yung mga paa ko.” Mr. L.R. also complained for experiencing abdominal pain few hours before he was admitted.
C. Family History
According to the client, his family has a history of having hypertension and diabetis mellitus, both his grandparents died because of acquiring such condition. His father was also hypertensive and her mother was diagnosed of having diabetis mellitus.
Patterns of Functioning
A. Psychological Health Coping Patterns According to the client the most stressful event that happen to him is his situation today because he cannot do what he want and also because it is his first time to be confined in a hospital. The client stated that “yung mga hobbies ko katulad ng basketball di ko na magawa dahil nga nandito ako sa ospital atsaka yung mga sakit ko naman dati e sipon at ubo lang, ngayon lang ako nagkaron ng ganitong sakit na kailangan iconfine pa.” The client stated the he manage his stress by just watching DVD and playing basketball but since he is in the hospital, he manage his stress by texting to his girlfriend to visit him in the hospital, walking in the hallway and watching TV. The client also said that he is more open to his mother than to his father. The client verbalize “mas open ako kay mommy kasi mas kasundo ko si mommy sa mga bagay pwera lang sa babae.” The client said that he frequently do have mood swings because of family problems. The client also state that when he is not in the mood he just kept quiet and eventually his mood becomes better even without sharing it to any person. Interaction Pattern The client said that he is very sociable. The client said that “madali naman ako makapaghalubilo sa ibang tao kasi sanay naman ako makipagusap sa mga tao dahil nag part-time model ako dati.” In his family, the client usually talks to her mother in Dubai atleast 3-4 times a day and that is the way of his communication to his mother. The client seldom talks to his father. The client said that “minsan lang kami magusap ni daddy kasi nagkakasundo lang kami kapag ang topic ay babae pero sa iba hindi na lalong lalo na pagdating sa luho ko.” Self-concept The client said that he feels good about himself even he is confined in the hospital. He stated that “ok naman ako wala naman nagbago sa pagtingin ko sa sarili ko kahit na nandito ako sa ospital.” The client says that he is a pessimistic kind of person because he is going to perform or do something he always thinks that he cannot do it. The client stated that “kapag mag peperform o may gagawin sa school ang naiisip ko kagad yung negative side na mangyayari pero kapag gagawin na nagagawa ko naman
talaga lang na negative ako magi sip sa umpisa.” He rates himself as 9 when we asked about his self-confidence as 10 being the highest and 1 being the lowest. Cognitive Pattern The client goes to the hospital together with his father for regular check-up especially for the signs of hypertension because her father does have hypertension. The client also had a check-up for his tonsillitis because he frequently had tonsillitis even before he was just a kid. Emotional Pattern The client frequently has mood swings because of family problems. The client stated that he is easily hurt emotionally than physically. When someone or his classmates teases him he just kept quiet and the suddenly his anger subsides. He usually shares his problem to his mother than to his father. Sexuality When it comes to the sexual activity the client sated that he do have sex with his girlfriend before his hospitalization. They do it atleast twice a week and they both feel satisfied or solved. They practice withdrawal and 10days after the menstruation. The client is not aware of the testicular self examination.
Family Coping Pattern The client said that he is more open to his mother than to his father. But sometimes when in terms of his girlfriend he is more open to his father because his mother doesn’t want his girlfriend. INTERPRETATION AND ANALYSIS: According to Erikson, the developmental task applicable to the client is intimacy vesus isolation wherein the behaviors that indicates a positive resolution and also present to the client is establishing a close and intimate relationship with another person, making a commitment to that relationship, even in times of stress or sacrifice, and accepting sexual behaviour as desirable. On the other hand the behaviours indicating negative resolution and is not present to the client are remaining alone and avoiding close interpersonal relationship. According to Jean iaget cognitive development the client is in formal operational stage. The formal operational period is the fourth and final of the periods of cognitive development in Piaget's theory. This stage, which follows the Concrete Operational stage, commences at around 11 years of age (puberty) and continues into adulthood. In this stage, individuals move beyond concrete experiences and begin to think abstractly, reason logically
and draw conclusions from the information available, as well as apply all these processes to hypothetical situations. The abstract quality of the adolescent's thought at the formal operational level is evident in the adolescent's verbal problem solving ability. The logical quality of the adolescent's thought is when children are more likely to solve problems in a trial-and-error fashion. Adolescents begin to think more as a scientist thinks, devising plans to solve problems and systematically testing solutions. They use hypotheticaldeductive reasoning, which means that they develop hypotheses or best guesses, and systematically deduce, or conclude, which is the best path to follow in solving the problem. During this stage the young adult is able to understand such things as love, "shades of gray", logical proofs and values. During this stage the young adult begins to entertain possibilities for the future and is fascinated with what they can be. Adolescents are changing cognitively also by the way that they think about social matters. Adolescent Egocentrism governs the way that adolescents think about social matters and is the heightened selfconsciousness in them as they are which is reflected in their sense of personal uniqueness and invincibility. Adolescent egocentrism can be dissected into two types of social thinking, imaginary audience that involves attention getting behavior, and personal fable which involves an adolescent's sense of personal uniqueness and invincibility. Reference: Kozier and Erb’s Fundamentals of Nursing 8th Edition Volume 2 page 1004 B. Socio-cultural patterns Cultural Patterns The culture of their family is respecting the one who is older than to him. And his parents usually give them punishment if they do something wrong. They are not active in any community celebrations. Significant relationships The client states that he has a girlfriend that is very supportive to him and he loves her very much although her mother does not agree to their relationship. Recreation patterns The client stated that his recreational activities are playing basketball atleast 4 times a week before his hospitalization and watching DVD until 1am. Environment The client said that the only problem with their environment before his hospitalization is the unfinished project of maynilad. The client states that
“ang problema lang naman sa lugar naming e yung mga bungkal na ginawa ng maynilad tapos hindi naman sinasara basta na lang tinatabunan ng buhangin. Puro bungkal nga dun sa amin e at ok naman yng lugar naming e hindi naman magulo o mausok.” Economic The client states that his mother works as staff nurse in Dubai while his father is a supervisor in a company near North station MRT. According to the client the income of his parents are enough to meet the need of the family. INTERPRETATION AND ANALYSIS: Based on the data presented above the only problem that the client has in socio-cultural pattern is deficient exercise. According to Kozier and Erbs people participate in exercise programs to decrease the risk factors of cardiovascular disease and to increase their health and well being. The client has less exercise because his only form of exercise is playing basketball then it is one reason why he had hypertension at early age. Reference: Kozier and Erb’s Fundamentals of Nursing 8th Edition Volume 2 page 1004 C. Spiritual Patterns Religious beliefs and practices The client is a Christian and before he graduated in highschool he became very active in their church, in fact he joined in many projects of their religion. He graduated from a Christian school in Valenzuela City. But when he is in college he becomes not active in different activities in the church and he cannot attend Sunday Mass because he is busy at school. Values and Valuing According to the client his philosophy in life is God is the most important above all and next is his parents then the third one is his health . Based on the client he said that they are disciplined because their parents teach him to become disciplined all the time. The client also added that he is not interested in the community projects even before and also he will not vote for all the elections because he does not believe in election. But he usually follows rules and regulations in the place where he is. INTERPRETATION AND ANALYSIS: Based on Kohlbergs moral development the client is on conventional stage.The conventional level of moral reasoning is typical of adolescents and adults. Those who reason in a conventional way judge the morality of actions by comparing them to society's views and expectations. Conventional morality is characterized by an acceptance of society's conventions concerning right and wrong. At this level an individual obeys rules and
follows society's norms even when there are no consequences for obedience or disobedience. Adherence to rules and conventions is somewhat rigid, however, and a rule's appropriateness or fairness is seldom questioned. Reference: Kozier and Erb’s Fundamentals of Nursing 8th Edition Volume 1
Activities of Daily Living Nutrition
Before hospitalization, the client said that he has a good appetite. The client verbalized “ for breakfast usually 1 cup of milk muna then kakain ako ng corned beef or tuna pero hindi ko na yun niluluto tapos yung rice sasabawan ko ng toyo, yung nasa pack, mga ¼ nun pag hindi ako nakuntento nilalagyan ko pa sya ng suka hangggang sa maghalo yung alat at asim. Sa lunch, mga 2 gatang ng kanin nauubos ko yung 1 ½ inch per gatang, half square, ganon din may toyo at suka, pero sa dinner 1 cup of rice nalang. Tapos mahilig ako sa mga masasabaw na pagkain, paborito ko yung sinigang lalo na yung taba non tapos may ketchup, mga kalahating bote ng ketchup nauubos ko.” Mr. L.R said that he only eats vegetables once a week and fruits at least twice a week. The client also added that he is consuming at least 1 liter of softdrinks (coke) each meal and 6 liters of water per day. During hospitalization, the client said the he doesn’t have good appetite unlike before. The client verbalized, “ngayon naospital ako, nakaka 1 rice lang ako minsan pa nga half lang, kase pag nagutom ako at kumain ako ng konti, nabubusog na ko agad. Parang punong puno na hangin yung tiyan ko.” The client said that during his stay in the hospital, he lessen his fluid intake as what the doctors had advised to him. He also added that he is now only consuming of at least 4 glasses of water a day. Interpretation and analysis: Based on the data, there is a big difference to the nutrition of the client before hospitalization and after hospitalization. Patients who are hospitalized may have an inadequate dietary intake because of the illness or disorder that necessitated the hospital stay or because the hospital’s food is unfamiliar or unappealing. The client has loss his appetite during hospitalization and he has less fluid intake because the doctored order him to limit his fluid intake. A person must drink at least 8 glasses of fluid every day. Inadequate intake of fluids everyday may lead to different problems particularly fluid volume deficit and constipation. The nutritional habits is established
during aldulthood often lay for the foundation for the patterns maintained throughout the person’s life. Many young adults are aware of the food groups but may not be knowledgable about how many servins of each group they need or how much a serving constitutes. Reference: Kozier and Erb’s Fundamentals of Nursing 8th Edition Volume 2 page 1242-1243
Before hospitalization, the client used to void 7 times a day and defecates at least 3 times a week. He said that his urine is yellow in color and has an aromatic odor, while he describes his stool as brown in color, formed and semi-solid. He also added that he doesn’t feel any difficulty in voiding and defecating. During hospitalization, the client said that he usually voids 14 times a day may be because of the medications that was given to him and defecates once a day since he was admitted. According to the client the only changes with regards to her urine is it becomes dark yellow in color while his stool is sometimes semi-formed. Still, the client doesn’t experience any discomfort in voiding and defecating. Analysis and interpretation: Based on the data the client voids a lot during his hospitalization because he is given furosemide which is classified as diuretics. Although people’s patterns of urination are highly individual, most people void about 5 to 6 times a day. Normal characteristics of urine are straw, amber or transparent in color, faint aromatic, no microorganisms present, and should be 1,200ml-1,500ml in amount per day. Usually the frequency of defecating is highly individual. It varies depending on the person’s level of activity and fluid intake. The normal characteristics of feces are brown in color for adult, formed, semisolid, soft, moist, cylindrical in shape, and aromatic in odor. Reference: Kozier and Erb’s Fundamentals of Nursing 8th Edition Volume 2
Before hospitalization, the client said that he is fund of playing basketball wherein he considered it as a form of exercise. He said that he usually plays 4 times a week for 2-3 hours.
During hospitalization, the client verbalized, “sa ngayon yung exercise ko lang eh yung pagtayo tayo ko mga dalawang minuto din dito sa loob ng kwarto tsaka paglakad lakad papunta ng CR tapos uupo ulet ako sa may kama. “ Interpretation and analysis: Based on the client’s data before hospitalization his way of exercise is playing basketball which is considered to be normal. The client although has experiencing weakness, he is trying to do some walking. Factors that may affect his limited movements could be some minimal pain still experiencing and the IV fluid attached which might get tangle to him. A person must have at least 30mins of exercise per day. Regular exercise can improves appetite and increases gastrointestinal tract tone. Activities such as walking can help relieve constipation. Exercise also increases muscle tone, mass, strength and maintain joint flexibility and circulation. Reference: Kozier and Erb’s Fundamentals of Nursing, 8th Edition Volume 2
Before hospitalization, according to the client before he was admitted he used to take a bath at least 4 times a day and brushes his teeth after having each meal. He also added that he uses deodorant and perfumes for additional hygienic purposes. During hospitalization, the client verbalized “once nalang ako naliligo ngayon kase dahil nga dito (IV) pero yung sa pag totoothbrush ganon pa rin tuwing pagkatapos kong kumain.” Interpretation and analysis: Based on the data above the client practice a good hygiene. Bathing also produces a sense of well being. It is refreshing and relaxing and frequently improves morale, appearance and self respect. These are more evident when a person is ill. It is uncommon for clients who have had a restless or sleepless night to feel relax, comfortable and sleepy after a morning bath. Reference: Kozier and Erb’s Fundamentals of Nursing 8th Edition Volume 1 page 748
Before hospitalization, the client verbalized “wala po akong bisyo, hindi po ako umiinom or naninigarilyo. Yung sa gamot naman po, nagvivitamins lang ako.” During hospitalization, the client said that he is taking some medications as maintenance for his hypertension. Interpretation and analysis: Based on the data of the client he doesn’t have any vices and he only take medicines prescribed by his physician during hospitalization. Alcohol can bring about feelings of well being that may be highly valued by people with adjustment problem. Prolonged use can lead to physical and psychologic dependency and subsequent health problems. Addiction, or physical and psychologic dependence on substance, is related to properties of the substance, the individual user and the social network of the individual. Prolonged use of alcohol can lead to such diseases as cirrhosis of the liver and cancer of the esophagus. Smoking is another type of drug abuse that can lead to disease such as lung cancer and cardiovascular disease. Reference: Kozier and Erb’s Fundamentals of Nursing 8th Edition Volume 1 page 396
Sleep and Rest
Before hospitalization, according to Mr. L.R. he usually sleeps around 1am and wakes up at 9am with satisfied and uninterrupted sleep except when he feels an urge to void. The client verbalized “nanonood kase ako ng dvd kaya 1am na ko nakakatulog.” He also added that he usually takes a nap in the afternoon for at least 4 hours. During hospitalization, Mr. L.R. said that since the day he was admitted in the hospital he sleeps at 9pm and wakes up at 5am. The client verbalized “mababaw lang yung tulog ko, masakit pa sa ulo.” He said that he takes a nap for 30 minutes.” Interpretation and analysis: Based on the data, the client has adequate sleep and rest before hospitalization. Normally an adult person should sleep at least 8hours a day. Sleep should be complete, without interruption and with a satisfied feeling after waking up. Reference: Kozier and Erb’s Fundamentals of Nursing 8th Edition Volume 2
Before hospitalization, the client said that he was sexuality active. According to the Mr. L.R. they are using safety methods such as withdrawal and calendar method in engaging in sexual intercourse. During hospitalization, the client’s sexual activity had stopped since he was staying in the hospital and because of his condition.
Analysis and interpretation: Based on the data the client uses only the natural contraceptives. Even though the patient’s sexual activity had stopped because she is hospitalized, it doesn’t have any bad effect to her health. Responsible sexual behaviour involves the prevention of sexually transmitted diseases, the prevention of unwanted pregnancy, and the avoidance of sexual harassment or abuse. TSE is a simple technique that men can use to assess for changes in their testicles that may signal a testicular cancer. The risk is highest in adolescent and in men under 35 years old. Reference: Black and Hawks Medical Surgical Nursing 8th edition p. 858
Physical Assessment (See attached paper) Course in the Ward 1. Diagnostics and Laboratories (See attached paper) 2. Medications/Drug Study (See attached paper)
Infections: (Post-streptococcal infection, Viral infections) Auto-Immune Diseases: (Lupus, Goodpasture's syndrome, IgA nephropathy) Conditions that cause scarring of the glomeruli: (High blood pressure, Diabetic kidney disease, Focal segmental glomerulosclerosis)
Antigen (group A beta-hemolytic streptococcus
Deposition of antigen antibody complex in the glomerulus Increased production of epithelial cell lining the glomerulus
Leukocytes infiltrate the glomerulus
Thickening of the glomerular filtration membrane (INFLAMMATION) Scarring and loss of glumerular filtration membrane
Decreased filtration rate
VIII. IX. X.
Ecologic Model (See attached paper) Problems Identified (See attached paper) Nursing Care Plan (See attached paper)
Medicine: a.) Encouraged client to take medications as prescribed by his physician, if any. b.) Teach patient or the significant others of the different side and adverse effects of the drugs. c.) Report any adverse effect when taking the prescribed drug such as nausea and vomiting or skin allergies. d.) Instruct him and significant others not to take other medications without consulting with the physician to prevent any harmful drug-drug interactions. Exercise: a.) Encouraged the patient to engage in at least 30 minutes of moderatelevel activity on most, and preferably all, days of the week, this can lower or reduced blood pressure. b.) Encouraged patient to have adequate rest periods and sleep to promote faster recovery. Treatment: a.) Encouraged to decrease fluid intake b.) Encouraged the patient to comply with the medication as ordered by his physician. c.) Explain the importance of adhering to his treatment regimen. Health Teaching: a.) Encouraged to elevate the part where there is edema b.) Tell the patient to notify the physician immediately if there are unusualities. c.) Teach the client to follow all the instructions including medications, diet regimen and do’s and don'ts that was instructed to him by the physician. d.) Teach the patient to ensure rest for himself as much as possible. Out- patient referral: a.) Inform the patient to have follow-up check-ups to prevent further complications and to update the medical team concerning the progress of the patient’s condition and to promote continuity of care. c.) Encourage him to comply with all the modifications and instructions given to him. Diet: a.) Limit fluid intake, Do not consume more than 48 oz. b.) encouraged Low calorie diet , Low protein , Low sodium diet , Low potassium diet , Low phosphorus diet , Calcium supplements , Vitamin B supplements.