Liceo de Cagayan University

College of Nursing

Individual Care Study

 Table of contents
I. Introduction
a. Overview of the Case
b. Objective of the Study
c. Scope and Limitation of the Study

II. Health History

a. Profile of patient
b. Personal Health History
c. History of Present Illness
d. Chief Complaint

III. Developmental Data

IV. Medical Management

a. Medical Orders and rationale
b. Drug study

V. Pathophysiology with Anatomy and Physiology

VI. Nursing Assessment (System Review & Nursing

Assessment II)

VII. Nursing Management

a. Ideal Nursing Management (NCP)
b. Actual Nursing Management (SOAPIE)

VIII. Referrals & Follow-up

IX. Evaluation and Implications

X. Bibliography
I. INTRODUCTION

A. Overview of the Case

Acute Glomerulonephritis is the disease of the kidney in which there is an

inflammation of the glomerular capillaries. In most cases, the stimulus of the reaction is

group A streptococcal infection, which ordinarily precedes the onset of

glomerulonephritis by 2 to 3 weeks.

B. Objective of the Study

The study generally aims to investigate the condition of an adult man and further

understand the extent of the case.

Specifically, the health care provider sought to;

 Perform Physical Assessment,

 Data Base and History taking that solidifies the present diagnosis of the client.

 Identify the development and changes encountered by the client.

 Identify the nursing problems which will be the basis of the care plan.

 Develop Plan of the Care and Implement nursing interventions relevant and

suitable for the case.

As nursing students they will be able to improve their skills in accordance to patient’s

needs and condition.

The purpose of the study is to gather significant data to broaden our knowledge with

regards to the condition of the patient and to improve our abilities as future health care

providers. Moreover, this case study will enable us to apply the acquired skills we

obtained in the classroom set-up.

C. Scope and Limitation of the Study

The study focuses only on one of the many problems of the kidney, mainly the

glomerulonephritis and its causes and effects on patients that are being diagnosed to it.

Also, the study tackles on how this problem is being acquired.

II. HEALTH HISTORY

A. Client’s Profile
Name : Lisdan, Elpedio N.
Wife : Lisdan, Jemma
Address : San Rafael, Talakag, Bukinon province
Civil Status : Married
Sex : Male
Age : 42 years old
Religion : Roman Catholic
Educational Status : Elementary level
Income : 2,000 php/month
Nationality : Filipino
Date of Admission : January 27, 2009
Time of Admission : 9:10 am
Informant : Patient
Height : 158 centimetres
Weight : 52 kg
Vital Signs during Assessment
Temperature : 36.7 °C
Pulse Rate : 55 bpm
Respiratory rate : 20 cpm
Blood Pressure : 150/110 mmHg

Admitting Diagnosis : Acute Glomerulonephritis related to nephritic

syndrome; hypertension

Attending Physician : Dr. Joseph Borong

B. Family and Personal Health

Patient’s History

Allergies:
- No known allergies on foods and drugs.

Injuries/ Accident in the past:

- Patient had not experience injuries or accident in the past.

Blood Transfusion:
- Patient didn’t receive blood in the past.

Family health history:

- Experienced Hypertension and Kidney disorder (2006)

Social History

Alcohol use:
- Patient occasionally drinks alcoholic beverages, as seldom as once in 2 months.

Tobacco use:
- Patient often smokes.

Home and Environment:

- Resides at San Rafael, Talakag
- Living status is just enough for their family needs
C. Chief Complaint and History of Present Illness

Noted to have edema; condition noted for a week – prior to admission as onset of

fever on and off associated with dysuria – tea colored urine.

III. DEVELOPMENTAL DATA

 The Developmental Stages of Erik Erickson

Middle Adulthood: 35 to 65:

Generativity vs. Self absorption or Stagnation

Now work is most crucial. Erickson observed that middle-age is when we tend to

be occupied with creative and meaningful work and with issues surrounding our family.

Also, middle adulthood is when we can expect to "be in charge," the role we've longer

envied. The significant task is to perpetuate culture and transmit values of the culture

through the family (taming the kids) and working to establish a stable environment.

Strength comes through care of others and production of something that contributes to the

betterment of society, which Erikson calls generativity, so when we're in this stage we

often fear inactivity and meaninglessness.

 Freud's Psychosexual Stages of Development

The Genital Stage

 In the genital stage, as the child's energy once again focuses on his genitals,

interest turns to heterosexual relationships. The less energy the child has left invested in

unresolved psychosexual developments, the greater his capacity will be to develop

normal relationships with the opposite sex. If, however, he remains fixated, particularly

on the phallic stage, his development will be troubled as he struggles with further

repression and defenses.

 Robert Havighurst Developmental Task Theory

Middle Adulthood (30-60 years)

Achieving adult social and civic responsibility; Reaching and maintaining

satisfactory performance in one’s occupational career; Developing adult leisure time

activities; Relating oneself to one’s spouse as a person; To accept and adjust to the

physiological changes of middle age; Adjusting to aging parents. Assisting teenage

children to become responsible and happy adults; achieving adult social and civic

responsibility.

 Piaget's Theory of Cognitive Development

Formal operational stage (Adolescence and adulthood)

In this stage, intelligence is demonstrated through the logical use of symbols

related to abstract concepts. Early in the period there is a return to egocentric thought.

Many people do not think formally during adulthood.

IV. MEDICAL MANAGEMENT

A. Medical Orders and Rationale

Doctor’s Order Rationale

01/27/09

 Please admit  To monitor patient’s medical

condition and proper management.

 TPR q 4h  To monitor any abnormal changes

in vital signs

 Full low salt, low fat diet  For proper nourishment and for
prevention of disease that may lead
to severity of the condition

 Give 1 egg white a day  To promote good nutritional status

 0.9 NaCl @ KVO rate  To monitor body fluids & prevent

dehydration
 Furosemide i amp q 12h x 3doses  For treatment of hypertension,
edema associated with CHF,
cirrhosis and renal disease

 For treatment of lower respiratory

 Cefuroxime 750 mg q 8h IVTT
infection, UTI & dermatologic
infection

 First line treatment for heartburn

 Omeprazole 20mg icap OD P.O.
and short term treatment of active
duodenal ulcer
 Captopril 25mg itab BID P.O.
 Treatment for pulmonary
tuberculosis that is not responsible
to 1st line antituberculosis
  For proper hydration of the patient
 I & O q shift and carefully monitor the fluid
losses

01/28/09

 IVF 0.9 NaCl @ KVO rate  To monitor body fluids & prevent
dehydration

 Spironolactone 50mg itab TID P.O.  To counteract potassium loss

caused by other diuretics

 Continue meds.  To treat the disease & remove the

symptoms

 Weight patient daily pre-breakfast  To monitor if the symptoms are

relieved

01/29/09

 Continue meds.  To treat the disease & remove the

symptoms
 IVF of D5nm iL @ KVO rate
 To monitor fluids
B. Drug Study
Generic Date Classi- Dose/ Mechanism of Specific Contra- Side Nursing
Name of Ordered fication Frequency/ Action Indication indication Effects/ Precaution
Ordered Route Toxic
Drug Effects

Cefuroxime 01/27/09 Antibiotic 750 mg q 8h Inhibits For lower Contra Hypersen- Assess for
(Cephalos IVTT synthesis of respiratory indicated with sitivity, hepatic or
porin – 2nd bacterial cell infection, allergy to nephrotoxi renal
generation) wall, causing UTI & cephalosporin city, pain impairment
cell death. derma or penicillins at injection
tologic site Assess for
infection skin status

Check for
sensitivity
tests
 Generic Date Classi- Dose/ Mechanism of Specific Contra- Side Nursing
Name of Ordered fication Frequency/ Action Indication indication Effects/ Precaution
Ordered Route Toxic
Drug Effects

Furosemide 01/27/09 Loop Amp of 12h Inhibits Hyperten- Contraindicates Polyuna, Assess for
Diuretic x 3 doses reabsoption of sion, allergy to Nocturia, allergy to
Na and Cl from Edema furosemide; Rash, furosemide
the proximal and associated anuria, hepatic Anemia,
distal tubules with CHF, coma Muscle Assess for
and ascending cirrhosis spasms, skin color,
limb of the loop and renal Cardiac lesions and
of Henle, disease arrythmias edema
leading to a Na- CBC,
reach diuresis serium
electrolytes
 Generic Date Classi- Dose/ Mechanism of Specific Contra- Side Nursing
Name of Ordered fication Frequency/ Action Indication indication Effects/ Precaution
Ordered Route Toxic
Drug Effects

Omeprazole 01/27/09 Antisecre 20mg icap Gastric acid First line Contra- Rash, Assess for
tory drug; OD P.O. pump inhibitor: treatment indicated with alopecia, hypersensit
Proton Supresses for hyper- nausea, ivity to
Pump gastric acid heartburn sensitivity to vomiting omeprazole
Inhibitor secretion by and short omeprazole or Epistasis,
specific term its component. fever Assess for
inhibition of treatment Use cautiously skin lesions
hydrogen- K of active pregnancy Assess for
ATPase duodenal lactation urinary
enzymes system ulcer output
at secretory
surface of the
gastric parietal
cells.
Generic Date Classi- Dose/ Mechanism of Specific Contra- Side Nursing
Name of Ordered fication Frequency/ Action Indication indication Effects/ Precaution
Ordered Route Toxic
Drug Effects

Captropil 01/27/09 ACE 25mg itab Polypeptide Treatment Contra- Polyuria, Assess for
inhibitor BID P.O. Antibactic; hyper- indicated Tachy- allergy to
against tension allergy to cardia, captropil
Mycobacterium capreomycin; proteinuria
tuberculosis pre-existing cough Assess for
auditory dry mouth skin color
impairment and lesions

For CBC
and
differential
Generic Date Classi- Dose/ Mechanism of Specific Contra- Side Nursing
Name of Ordered fication Frequency/ Action Indication indication Effects/ Precaution
Ordered Route Toxic
Drug Effects

Spirono- 01/28/09 Diuretics 50mg itab Cause loss of To Hyper- Clumsy Monitor
lactone TID P.O. sodium counteract sensitivity; Headache intake &
bicarbonate and potassium Hyperkalemia Dyscrasias output
calcium while loss
saving caused by Daily
potassium and other weight
hydrogen ions diuretics during
therapy

Monitor
BP before
adminis-
tering
V. PATHOPHYSIOLOGY

Post-streptococcal infection
(group-A, beta hemolytic)

Release of material from the organism,

into the circulation (antigen)

Formation of antibody

Immune complex reaction in the

glomerular capillary

Inflammatory response

Proliferation of epithelial cells lining

glomerolus & cells between
endothelium & epithelium of capillary
membrane

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

glomeeruli plasma flow

Retention of H2O & Na; hypovolemia;

circulatory congestion

Edema
Hypertension
↓ urinary output
Urine dark in color
Anorexia
Irritability lethargy

ACUTE
GLOMERULO-
NEPHRITIS
VI. ASSESSMENT
EENT:
GENITO URINARY and GYNE:
[ ] impaired vision [ ] blind
[x] pain [x] urine color [ ] vaginal bleeding
[ ] pain [ ] reddened [ ] drainage
[ ] hermaturia [ ] discharge [ ] nocturia
[ ] gums [ ] hard of hearing
[ ] no problem
[ ] deaf [ ] burning [x] edema

[ ] lesion [ ] teeth [ ] no problem

NEUROLOGICAL:

[ ] paralysis [ ] stuporous [ ] unsteady

RESPIRATORY:
[ ] seizures [ ] lethargic [ ] comatose
[ ] asymmetric [ ] tachypnea
[ ] vertigo [ ] tremors [ ] confused
[ ] apnea [ ] rales [x] cough
[ ] vision [ ] grip [x] no problem
[ ] barrel chest [ ] bradypnea

[ ] shallow [ ] rhonchi [x] sputum

MUSCULOSKELETAL:
[ ] diminished [ ] dyspnea
[ ] appliance [ ] stiffness [ ] itching
[ ] orthopnea [ ] labored [ ] wheezing
[ ] petechiae [ ] hot [ ] drainage
[ ] pain [ ] cyanotic [ ] no problem
[ ] prosthesis [ ] swelling [ ] lesion

[ ] poor turgor [ ] cool [ ] deformity

CARDIO VASCULAR:
[ ] wound [ ] rash [ ] skin color
[ ] arrhythmia [ ] tachycardia [ ] numbness
[ ] flushed [ ] atrophy [x] pain
[ ] diminished pulses [ ] edema [ ] fatigue
[ ] ecchymosis [ ] diaphoretic [ ] moist
[ ] irregular [ ] bradycardia [ ] murmur
[ ] no problem
[ ] tingling [ ] absent pulses [x] pain

[ ] no problem

GASTRO INTESTINAL TRACT:

[ ] obese [ ] distension [ ] mass

[ ] dysphagia [ ] rigidly [ ] pain

[x] no problem
 dysuria

Infusion site

Edema wit pain

in both
extremities
 NURSING ASSESSMENT II
SUBJECTIVE OBJECTIVE
COMMUNICATION:
[ ] Hearing Loss Comments: “wala [ ] Glasses [ ] Language
[ ] Visual Changes man – wala [ ] Contact lens [ ] Hearing Aide
[x] Denied gihapon”
As verbalized by R L
the husband Pupil Size: 3-5 mm [ ] Speech difficulties
Reaction: PERRLA
OXYGENATION:
[ ] dyspnea Comments: “Nah! Respiratory: [x] regular [ ] irregular
[ ] smoking history gapanigarilyo Describe: regular breathing but associated with
Oftentimes mana siya -giubo pain
[x] cough pd siya karon oh.’
[x] sputum As verbalized by Right: Right lung is symmetrical to left lung.
[ ] denied the wife Left: Left lung is symmetrical to right lung.
CIRCULATION: Heart Rhythm [x]regular [ ] irregular
[ ] chest pain Comments: “Sakit! Ankle Edema: present in lower extremities
[x] leg pain bug-at… Pulse Carotid Radial DP Femoral
[x] numbness of extremities nanghubag na Right: 62 65 60 not assessed
[ ] denied man gni ako Left: 62 65 60 not assessed
mga tiil” As
verbalized by Comments: Pulse sites are palpable and its rate are
the patient within normal range.
NUTRITION:
Diet: DAT but decreased fluid intake [ ] dentures [x] none
[ ]N [ ]V Comments: “Wala
Character man…perma- Full Partial With Patient
[ ] recent charge nente nay gana” Upper [√] [ ] [ ]
in weight, appetite As verbalized
[ ] swallowing by the patient Lower [√] [ ] [ ]
Difficulty
[x] denied
ELIMINATION:
Usual bowel pattern [ ] urinary frequency Comments: urinate once Bowel Sounds:
Once a day once daily daily due to pain Audible sounds
[ ] constipation [ ] urgency and excrete small Abdominal Distention:
Remedy [x] dysuria amount. Present [ ] Yes [x] No
[ ] hematuria Urine (color,
January 27, 2009 [ ] incontinence consistency, odor)
Date of last BM [ ] polyuria tea color of urine,
inconsistent
[ ] diarrhea character [ ] foly in place
[ ] denied
MANAGEMENT OF HEALTH &
ILLNESS:
[x] alcohol [ ] denied Briefly describe the patient’s ability to
(amount, frequency) follow treatments (diet, meds, etc.) for
Occasionally – once in 2 months
chronic health problems (if present):
[ ] SBE Last Pap Smear: N/A
LMP: The patient is properly following her medications
 SUBJECTIVE OBJECTIVE
SKIN INTEGRITY:
[ ] dry Comments: “ wala man [ ] dry [x] cold [ ] pale
[ ] itching - nanghupong [ ] flushed [ ] warm
[x] other - edematous lang ko” as [ ] moist [ ] cyanotic
[ ] denied verbalized by the
Patient. * rashes, ulcers, decubitus (describe size,
location, drainage): No presence of any ulcers,
decubitus or rashes.

ACTIVITY/SAFETY:
[ ] convulsions Comments: “ dili man [ ] LOC and orientation: Oriented to time and
[ ] dizziness hinuon, bug-at lang space
[ ] limited motion of joints gyud ako tiil Gait: [ ] walker [ ] cane [ ]
Kay nanghupong other
Naman – kaya
Limitation in man hinuon nako.” [x] steady [ ] unsteady
ability to as verbalized by the [ ] sensory and motor losses in face or
[ ] ambulate patient extremities
[ ] bathe self None
[ ] other
[x] denied [ ] ROM limitations: patient can performed
range
of motion
COMFORT/SLEEP/AWAKE:
[ ] pain Comments: “ok [ ] facial grimaces
(location, raman hinuon” [ ] guarding
Frequency, As verbalized [ ] other signs of pain
Remedies) by the patient. Edema on both extremities
[ ] nocturia
[ ] sleep difficulties [ ] siderail release form signed (60 + years)
[x] denied None

COPING:
Occupation : Farmer Observed non-verbal behavior
Members of household: None
6
Most supportive person: The person and his phone number that can be
Wife reached any time

SPECIAL PATIENT INFORMATION

_______________ Daily weight _______________ PT/OT _________________
_______________ BP q shift _______________ Irradiation
_______________ Neuro VS ______________ Urine test _______________
_______________ CVP/SG. Reading ________ ______________ 24 hour urine collection
Date Diagnostic/laboratory Date done Date I.V. Date disc.
Ordered exams ordered Fluids/Blood

01/27/09 CBC 01/27/09 01/27/09 0.9 Nacl iL

@ KVO rate

01/27/09 Urinalysis
VII. NURSING MANAGEMENT
A. Ideal Nursing Management
Nursing Diagnosis:
 Excessive fluid volume related to glomerulonephritis

INTERVENTIONS RATIONALE

 Monitor intake and output  To check fluid balance and prevent dehydration

 Observe for fever  To check for infection since the patient has a greater risk

 Elevate edematous extremities, change position frequently  To reduce tissue pressure and risk of skin breakdown

 After elevating, place in semi-fowlers position  To facilitate movement of diaphragm, thus improving
respiratory effort

 Provide quiet environment  To promote ventilation and limits external stimuli

 Administer furosemide I amp of 12h as prescribed by the  For the treatment for edema

physician
Nursing Diagnosis:
 Ineffective airway clearance related to productive cough

INTERVENTIONS RATIONALE

 Assess the airway patency  To check the effectivity of the airway & to plan for further

management

 Elevate the head part of the bed/change position q 2h  To enhance drainage of/ventilation to different lung

segments

 Encourage deep-breathing and coughing exercise  To mobilize secretions

 Monitored the fluid intake  To help liquefy secretions and not to severe the edema

 Instruct to have proper clothing, not too tight and not too  To provide warm body/environment

loose
Nursing Diagnosis:
 Acute pain related to edema
INTERVENTIONS RATIONALE

 Monitor vital signs  Because vital signs are altered in acute pain experienced

 Acknowledge patient’s verbalization of pain & allow him  Pain is subjective experience of a person that no other one
to describe it can felt about it

 Perform pain assessment each time occurs  To rule out worsening of underlying condition/developing
complication

 Elevate edematous extremities, change position frequently  To reduce tissue pressure and risk of skin breakdown

 Provide quiet environment  To promote ventilation and limits external stimuli

 Administer Spironolactone 50mg itab TID P.O. as  For the treatment for edema
prescribed by the physician
B. Actual Nursing Management

S “Bug-at lang akong tiil kay nanghupong naman ko.”

As verbalized by the patient

 Edema
O  Oliguria
 Restlessness

Fluid volume excess related to Glomerulonephritis

A

Long term:
At the end of 2 days, pt. will be able to lessen or diminished the
symptoms of glomerulonephritis that produces excessive fluid.
P
Short term:
At the end of 8 hours, the pt. will be able to reduce the excessive
fluid volume.

1) Monitor vital signs especially temperature

 To check & assess for infection since the pt. has a higher
risk
2) Monitor intake & output
I  To monitor & check fluid volume & prevent dehydration
3) Elevate the edematous extremities
 To reduce tissue pressure & risk in skin breakdown
4) Place in a semi-fowlers position, change position frequently
 To facilitate movement of diaphragm & improve
respiratory effort
5) Administer furosemide 1 ampule every 12h as prescribed by the
physician
 For the treatment of edema

E At the end of 8 hrs, the pt reduces the excess fluid in his body thru
excretion of stored fluids.
 HEALTH TEACHINGS

Name of Patient: Gloria Yabo

Encourage to follow the dosages and proper timing of his

MEDICATIONS meds. Such as the Furosemide 1 ampule every 12hours x
3doses, Omeprazole 20mg 1capsule once a day, Captopril
25mg 1tablet twice a day, & Spironolactone 50mg 1 tablet
thrice a day. As prescribed by his physician.

Encourage bed rest and frequent changes of position, early

EXERCISE ambulation, and deep breathing exercise.

Encourage/instruct to keep the edematous extremities to

elevate as often; limit of water intake; monitor intake and
TREATMENT output; provide warm environment; provide egg white a
day; weight the pt. daily, at the same time.

OUT-PATIENT Encourage pt. that when his discharged, he must have a

(Check-up) regular check-up to his physician until it’s needed. To
evaluate the progress of his condition.

Instruct to limit intake of salty & fatty foodsand

DIET enrich/increase the intake of foods rich in potassium such as
bananas…
VIII. REFERRALS AND FOLLOW-UP

Since the patient is suffering from Acute Glomerulonephritis, it is advised for him

to stay in the hospital for a better and thorough management regarding on her condition.

Acute Glomerulonephritis are very critical in a man’s condition that is why the patient

needs an urgent hospital service for him to be monitored every now and then.

If the doctor has already approved the release or discharge of the patient from the

hospital, the patient is highly advised to have a regular check-up on her personal

physician to take out the risk from the said ailment.

If the patient will again suffer the Acute Glomerulonephritis, it is best for him to

be admitted to a tertiary-leveled hospital for better monitoring of his critical condition,

knowing that even a single mistake worsen his condition.

IX. EVALUATION AND IMPLICATIONS

After conducting this care study, I was able to appreciate more the

essence of utilizing the nursing process in the care and management of my

patient. It was indeed a tough job on conducting this study yet, it gave me a

big impact regarding how useful it is in my chosen profession. Nursing really

demands a tender loving care attitude. It demands patience and it is calling

that cannot be merely taken for granted.

Moreover, this care study taught us to stand on our own by not depending

on others just to make this. This provides us, the students, a big learning

regarding on how well we take care of or patients in the real clinical setting.

Most of all, this study teaches the students to provide clients care more

efficiently and competently to achieve an effective and quality nursing care.

X. BIBLIOGRAPHY

 Doenges, Marilyn E. et.al Nurses Pocket Guide:

Diagnoses, Interventions and Rationale. 9th
edition pages 278-279, 472-477, 576-578 F. A
Davis Company Philadelphia, 2004.

 Lippincott Williams & Wilkins, Manual of

Nursing Practice, 8th edition, volume 1.

 Deglin, et al. Davis’s Drug Guide for nurses, 9th

edition.

 Smeltzer, Suzanne C. et al. Textbook of Medical-

Surgical Nursing, 11th edition, volume 2.