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, a 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 affect-
ed 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 "anti-
donor" 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 that’s why she
doesn’t 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 doesn’t 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 family’s 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 Mother side

Grandfather Grandmother Grandfather Grandmother

Uncle Uncle Father Aunt Aunt

(Mr. AGN) 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 doesn’t
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 didn’t 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 doesn’t
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 AGN’s mother, she had a complete immunization during her infancy stage at
their Health center in Baliti, Arayat.

Frued’s Personal Development: Preschooler: Phallic stage

• Child’s 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 child’s genital area.

Erickson’s 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.
Piaget’s 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.

Kohlberg’s 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 wasn’t diagnose and didn’t 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 AGN’s 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 didn’t do any treatment
because they can no longer handle the condition of Baby AGN (we don’t know the
specific medications but according to our informant, they gave some medications.
But our informant was not there so she can’t 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: doesn’t have difficulty in urination and defecation.

Genitalia: no lesions and no pubic hair noted.

7. Diagnostic and Laboratory Procedure

Diagnostic/ Date Indications Results Normal Analysis

Laboratory Ordered or Purpose Values and
Procedure Date Result Interpretati
on

1.)CBC
A. D.O: 06-20- The amount 118.9 125-155 g/L Indication of
Diagnostic/ Date Indications Results Normal Analysis
Laboratory Ordered or Purpose Values and
Procedure Date Result Interpretati
on

Hemoglobin 08 of hgb anemia due

(hgb) D.R: 06-20- determines to hematuria
08 how much because of
oxygen the decrease
RBC's are erythropoieti
capable of n
carrying to leads to
other cells. damage in
the kidney.
B. D.O: 06-20- The hct 0.35 M: 0.40-0.52 Indication of
Hematocrit 08 shows the F: 0.38-0.48 anemia due
(hct) D.R: 06-20- oxygen- to hematuria
08 carrying because of
capacity of decrease
the blood. erythropoieti
This value n
also tells leads to
whether the damage in
blood is too the kidney.
thick or too
thin.
C. D.O: 06-20- WBC count is 10.20 6-10 g/L More than
White Blood 08 the count of required
Cells (WBC) D.R: 06-20- the so-called WBC count.
08 leukocytes. Indicates
WBC's infection.
defend the
body against
infection and
make up part
of the
immune
system.
Diagnostic/ Date Indications Results Normal Analysis
Laboratory Ordered or Purpose Values and
Procedure Date Result Interpretati
on

D. D.O: 06-20- The second 0.41 0.20-0.60 Range is

Lymphocytes 08 most type, within
D.R: 06-20- are cells that normal
08 produce range.
antibodies, Indicative of
regulate the antibody
immune production.
system and
fight viruses.

E. D.O: 06-20- Responsible 358 150-400 x Range is

Platelet 08 for blood 108L within
D.R: 06-20- coagulation normal
08 and range.
determines Indicative of
bleeding coagulation.
tendencies.

F. D.O: 06-20- 0.57 .55-.70 Range is

Segmenters 08 within
D.R: 06-20- normal
08 range.
G. D.O: 06-20- Eosinophils 0.02 0 – 0.02 Range is
Eosinophils 08 become within
D.R: 06-20- active when normal
08 you have range. Fights
certain parasitic and
allergic allergic
diseases, reaction.
infections,
and other
medical
conditions.
Diagnostic/ Date Indications Results Normal Analysis
Laboratory Ordered or Purpose Values and
Procedure Date Result Interpretati
on

CBC

A. D.O: 06-24- The amount 10.0 12-16 Indication of

Hemoglobin 08 of hgb anemia due
(hgb) D.R: 06-24- determines to hematuria
08 how much because of
oxygen the decrease
RBC's are erythropoieti
capable of n
carrying to leads to
other cells. damage in
the kidney.
B. D.O: 06-24- The hct 0.32 M: 0.40-0.52 Indication of
Hematocrit 08 shows the F: 0.38-0.48 anemia due
(hct) D.R: 06-24- oxygen- to hematuria
08 carrying because of
capacity of decrease
the blood. erythropoieti
This value n
also tells leads to
whether the damage in
blood is too the kidney.
thick or too
thin.
C. D.O: 06-24- WBC count is 4,000 5-10x 10 to Indicates
White Blood 08 the count of the 3rd power infection.
Cells (WBC) D.R: 06-24- the so-called
08 leukocytes.
WBC's
defend the
body against
infection and
make up part
of the
immune
system.
Diagnostic/ Date Indications Results Normal Analysis
Laboratory Ordered or Purpose Values and
Procedure Date Result Interpretati
on

D. D.O: 06-24- The second 54 25-40 Body have

Lymphocytes 08 most type, adequate
D.R: 06-24- are cells that amt. of
08 produce lymphocytes
antibodies, to produce
regulate the antibodies,
immune regulate the
system and immune
fight viruses. system and
fight viruses.

E. D.O: 06-24- Responsible 218 150-450 x Range is

Platelet 08 for blood 108L within
D.R: 06-24- coagulation normal
08 and range.
determines Indicative of
bleeding coagulation.
tendencies.

F. D.O: 06-24- 40 50-70

Segmenters 08
D.R: 06-24-
08
G. D.O: 06-24- Eosinophils 6 1-4 Active.
Eosinophils 08 become Indicative of
D.R: 06-24- active when certain
08 you have allergic
certain diseases,
allergic infections,
diseases, and other
infections, medical
and other conditions.
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/ Date Indications Results Normal Analysis

Laboratory Ordered or Purpose Values and
Procedure Date Interpretati
Result on

2) Serum
Creatinin
e
A. D.O: 06-20- To evaluate .86 .3-.7 g/dl Result is
Creatinine 08 any type of within
D.R: 06-20- renal normal
08 dysfunctions values.
. Indicative of
(+)renal
dysfunction.

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 Results Normal Analysis

Laboratory Ordered or Purpose Values and
Procedure Date Interpretati
Result on

3) Blood
Chemistry

A. D.O:06-21- To 69.0 Range is

64-83 gm/L
Total Protein 08 determine within
D.R: 06-21- nutritional normal
08 status or to range.
screen for
certain liver
and kidney
disorders as
well as
other
diseases. To
determine
the extent
of protein
loss.
B. D.O:06-21- Albumin 34.0 35—50 g/L Range is
Albumin 08 maintains below the
D.R: 06-21- the amount normal
08 of blood in range.
the veins Indicative of
and arteries. proteinuria
When and edema.
albumin
levels
become
very low,
fluid can
leak out
from the
blood
vessels into
nearby
tissues,
causing
swelling in
the feet and
 ankles. Very
low levels of
albumin
may
indicate
liver
damage.
C. D.O:06-21- Globulin is 35.0 20-35 g/L Range is
Globulin 08 carrier of within
D.R: 06-21- some normal
08 hormones, range.
lipids, metal
&
antibodies.
D. D.O:06-21- 1.5-1 0.8-2.0 Result is
A/G Ratio 08 within
D.R: 06-21- normal
08 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/ Date Indications Results Normal Analysis

Laboratory Ordered or Purpose Values and
Procedure Date Interpretati
Result on

4) Serum
Electrolyte
A. Na D.O:06-21- Sodium is 162.0 136–145 Solutes
08 both an
D.R: 06-21- electrolyte milliequivale absorbed by
 08 and mineral. nts per liter the kidney
It helps results to
keep the (mEq/L) or
damage
water (the 136–145 and
amount of
millimoles decrease
fluid inside
and outside
reabsorptio
per liter n
the body's
cells) and (mmol/L)
electrolyte
balance of
the body.
Sodium is
also
important in
how nerves
and muscles
work.
B. K D.O:06-21- It helps 4.0 3.4–4.7 Result is
08 keep the within
D.R: 06-21- water (the mEq/L or normal
08 amount of 3.4–4.7 values.
fluid inside
and outside mmol/L
the body's (in children)
cells) and
electrolyte
balance of
the body.

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 Results Normal Analysis
Laboratory Ordered or Purpose Values and
Procedure Date Result Interpretati
on

5) Routine D.O: 06-23- Urinalysis Color: yellow Color: light Color:

Urinalysis 08 was ordered yellow to Normal
D.R: 06-23- for Baby AGN Transparenc dark amber
08 to determine y: sl. Tubid Transparanc
whether the y:Normal
urine Sugar: Sugar:
contains negative negative Sugar:
substances Normal
indicative or Albumin: +1 Albumin:
normally negative Microalbimin
absent from Reaction: uria. It
urine and acidic Reaction: indicates
detected by acidic spillage of
urinalysis are Specific
Specific protein from
proteins,
gravity: the damaged
glucose,
1.000 gravity: glumerulus.
acetone,
1.001-1.035 Normal.
blood, pus
Pus cells:4-6 Reaction
and casts.
Pus cells: 0-3 Normal.
Bacteria:
negative Bacteria: Gravity
none slightly lower
than normal.

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 12th 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 Modifiable Factors

1.) Female 1.) Streptococcal infections (URTI)
2.) Age (5 years old) 2.) Skin infections (presence of lesions)
3.) Familial history of kidney disease 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 destruction and inflammation of kidneys inflammatory

depressed. Response of the body.
(hyperthermia)
(Date: reported by
S.O; occurred prior
admission)

Decreased in circulating lysosomes released during

plasma the inflammatory response

triggered stimulation damage top glomerular basement membrane Presence of

pus is
of renin may be due to
presence of
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

` Hematuria Volume Signs

&
increased
Sumptoms of
circulating fluid serum albumin is
Anemia
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 transient in

workload uremic &
fluid shifted from intravascular +3 RBC in urine
into interstitial spaces (UA Dated:06-23-
08)
decrease osmotic pressure

Elevated Blood pressure

(Date: upon admission) Tea-colored
edema (+ facial edema) urine (UA Dated:06-
23-08)
(Date: apparent upon admission June 20&
still slight apparent until discharge June 26,2008)
IV. Patient’s 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 CHON’s 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 Indication(s) Client’s Client’s
Management ordered Description Or initial rxn to response to
Date
Purposes treatment the treatment
Performe
d
Date
Changed
Hypertonic solution To replace fluid loss and Patient cried Patient was able
DO: 06-20- which causes “cell serve as a vehicle for when IV to maintain
D5 0.3 NaCl 08 shrinkage”
administration of drugs. insertion is hydration status.
500 cc x KVO DP: 06-20-
08 done. KVO: To not
DC: 06-26- aggravate fluid
08 retention.

Nursing Responsibilities in IVF insertion:
• Wash hands before preparing the equipment.
• Check the health practitioner’s order for the
type and amount of solution.
• Check integrity of the IV solution and
equipment.
• Prepare IV solution label with client’s name,
date, time, additives, and initial of the
administering nurse.
• Explain to the client what you are doing before
taking the equipment into the client’s room.
• 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 Route of General Initial reaction Client’s

ordered/Date administration/dos action/Function response to
taken age and frequency al the medication
of administration classification/
Mechanism of
Action
GN: Penicillin G. DO: 06-20-08 IV 375,000 U every 6 To treat Patient dislikes Patient’s WBC
Sodium DP: 06-20-08 hours moderate to the feeling of IV count decreased
D/ C: 06-26-08 severe systemic administration of
infections caused drugs
by penicillin-
sensitive
microorganisms
GN: DO: 06-20-08 IV 200 mg every 4 Antipyretic Patient dislikes Patient’s
Paracetamol DP: 06-20-08 hours the feeling of IV temperature
D/C: 06-24-08 administration of decreased
drugs
GN: DO: 06-20-08 IV ½ amp now Increases Patient dislikes Patient did not
Metoclopramide DP: 06-20-08 sensitivity to the feeling of IV vomit.
D/C: 06-21-08 acetylcholine; administration of
re- drugs
sults
in increased
motility of the
upper GI tract
and relaxation of
the pyloric
sphincter and
duodenal bulb.
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 Date ordered General Indication(s) Specific foods Client’s
Date Performed Description Or taken response
Date Changed Purposes and/or rxn to
the diet
Low salt, Low fat DO: 06-20-08 A type of diet To prevent fluid Rice, fish Development of
(Patient was wherein foods retention, further edema
advised to provided to the decrease was prevented.
maintain this patient are low in metabolic
type of diet even fat and sodium demand and help
after discharge) content. decrease blood
pressure
 Low Protein DO: 06-26-08 A type of diet To allow kidney Bread, chocolate Development of
(Patient was wherein foods function to rest. further edema
advised to provided to the kidney
maintain this patient are low in disfunction will be
type of diet after protein content. prevented.
discharge)

High Protein DO: 06-26-08 A type of diet To allow tissue Fish, cheese Stronger and
(Patient was wherein foods repair. healthier body
advised to provided to the will be achieved.
maintain this patient are high
type of diet after in protein
discharge) content.

Nursing Responsibilities:
• Explain the reason for suggested diet and exercise
• Monitor foods taken by the patient
D. Activity/Exercise
Date ordered General Indication(s) Client’s
Date Description Or response to the
Type of Performed activity/exercise
exercise Date Changed Purposes
Bed rest DO: 06-20-08 A type of To reduce oxygen demand Patient shows
(Patient was activity wherein and prevent fatigue gradual increase in
advised to the patient is strength.
maintain this kept on bed with
type of exercise limitations to
even after activity
discharge)
Nursing Responsibilities:
• Explain the reason for suggested exercise
C. Nursing Management
 1. Nursing Care Plan
Assessme Nursing Scientific Objectives Interventi Rationale Expected
nt diagnosis explanation on Outcome
S= Hyperthermia People suffer heat- SHORT TERM: - Monitor - To have a SHORT TERM:
O= patient related illness when After 4º of NI, VS and baseline Patient’s body
manifests: the body's patient’s boby note level data and to temperature
temperature control temp. will of reveal shall have
system is overloaded. decrease rom consciousn alteration decreased
-body
0 0
The body normally 38.4 C to 37 C. ess from 38.40C to
malaise
cools itself by 370C
-pale
sweating. But under - to
palpebral - performed
some conditions, promote
conjunctiva TSB (tepid
sweating just isn't LONG TERM: wellness
-pale skin sponge
enough. In such After 8 days of LONG TERM:
-activity bath)
cases, a person's NI, patient’s SO patient’s SO
intoleran
body temperature verbalize shall have
ce -instructed
rises rapidly. Very understanding verbalized
patient - to
high body o the underlying understanding
VS as increase promote
temperatures can cause factors o the
follows: fluid intake wellness
damage the brain or and importance underlying
T - 38.40C
other vital organs. of treatment cause factors
PR – -Instruct
84bpm, RR and
patient to
– 22 bpm importance of
avoid -To
treatment
strenuous conserve
activity energy

-Provide
foods rich
in Iron and
Vitamin C - To
promote
-Encourage wellness
use of
relaxation
techniques

-To avoid
fatigue
Assessme Nursing Scientific Objectives Interventi Rationale Expected
nt diagnosis explanation on Outcome
S= Activity intolerance The kidneys are re- SHORT TERM: - adjust - to prevent SHORT TERM:
O= patient markable in their Ater 4º o NI the activities overexertio the pt’s SO
manifests: ability to compensate pt’s SO will use n shall have used
for problems in their identified identified
- encourage
function. That is why techniques to - to reduce techniques to
-appears rest periods
chronic kidney dis- enhance activity fatigue enhance
weak
ease may progress tolerance activity
-body -promote
without symptoms for - to tolerance
malaise comfort
a long time until only enhance
-pale measures
very minimal kidney ability to
palpebral
function is left. participate
conjunctiva
-pale skin LONG TERM: in activities LONG TERM:
Because the kidneys
-activity After 5 days of pt. shall have
perform so many -assist
intoleran NI the pt. will - to prevent actively or
functions for the client in
ce actively or injuries willingly
body, kidney disease learning
willingly participated in
can affect the body in safety
participate in necessary
a large number of dif- measures
necessary activities
ferent ways. Symp-
activities -To avoid
toms vary greatly. -Encourage
Several different fatigue
use of
body systems may be relaxation
 techniques
affected.

-plan
maximal
activity - to
within the promote
client’s wellness
ability
Assessme Nursing Scientific Objectives Interventi Rationale Expected
nt diagnosis explanation on Outcome
S= Poor personal It is generally known SHORT TERM: - instruct - to SHORT TERM:
O= patient hygiene that unclean After 4º the pt.’s proper promote the pt’s SO
manifests: conditions and poor SO will verbalize bathing wellness shall have
hygiene are the main understanding verbalized
-implement
promoters of of proper -to assist in understanding
-appears proper
bacterial growth. hygiene correcting of proper
weak bowel/
situations hygiene
-body bladder
malaise training
-pale LONG TERM:

palpebral LONG TERM: pt. shall have

- instruct performed self-
conjunctiva After 3-4 days of
proper care activities
-pale skin NI the pt. will - to
handwashin within level of
-with facial perform self- promote
g own ability
edema care activities wellness
within level of
own ability - encourage
food and
fluids
choices that -to assist in
meets correcting

nutritional situations
needs

-make
home visit

- to assess
environmen
tal needs
Assessme Nursing Scientific Objectives Interventi Rationale Expected
nt diagnosis explanation on Outcome
S= Fluid volume The inflammation SHORT TERM: - Establish - To gain SHORT TERM:
O= patient excess r/t disrupts the After 4º the pt.’s rapport the trust of the pt’s SO
manifests: disruption of functioning of the SO will verbalize the client shall have
regulatory glomerulus, which is understanding verbalized
mechanism the part of the kidney of individual - Monitor - To have a understanding
-body
that controls filtering fluid restrictions VS and baseline of individual
malaise
and excretion. This note level data and to fluid
-pale
disruption results in of reveal restrictions
palpebral
blood and protein LONG TERM: consciousn alteration
conjunctiva
appearing in the After 3-4 days of ess
-pale skin
urine, and the build NI the pt. will
-with facial
up of excess fluid in stabilized fluid - To reveal
edema -Monitor I &
the body. volume as alteration in
O LONG TERM:
evidenced by fluid status pt. shall have
balance I&O stabilized fluid
volume as
-To reduce evidenced by
- Restrict
further balance I&O
fluid/sodiu
edema
m intake as
indicated
-Administer -To
diuretics as promote
ordered fluid
excretion
Assessmen Nursing diagnosis Scientific Objectives Interventio Rationale Expected
t explanation n Outcome
S= Altered tissue Patients with SHORT TERM: -Establish -To gain SHORT TERM:
O= patient perfusion related to kidney problems After 6º of NI, rapport trust of the Patient’s SO
manifested: decreased manifest anemia patient’s SO will client was able to
hemoglobin due to the be able to - Monitor VS verbalize
level/concentration interruption in verbalize and - To have a understanding
-body
in the blood the release of understanding note level of baseline of condition
malaise
erythropoietin, an of condition and consciousnes data and to and therapy
-pale skin
enzyme therapy s reveal regimen
-activity
responsible for regimen alteration
intolerance
RBC production
-decreased -Elevate HOB
and presence of -To increase
performanc
hematuria. LONG TERM: gravitationa
e
-with After 8 days of l blood flow LONG TERM:
-Check for
periorbital NI, patient will - May Patient was
calf
edema be able to indicate able to
tenderness
-vital signs demonstrate thrombus demonstrate
taken as increased formation increased
follows: perfusion as perfusion as
-Provide
T:36.10C individually -To promote individually
quiet, restful
PR:97 appropriate relaxation appropriate
environment
RR:18
BP: 90/60
-Instruct
-To
 patient to conserve
The patient avoid energy
may strenuous
manifest: activity
- -Provide
dehydration foods rich in - To
-inappropri- Iron and promote
ate urine Vitamin C RBC
output for production
intake -Encourage
use of -To avoid
relaxation fatigue
techniques
Assessme Nursing Scientific explanation Objectives Interventio Rationale Expected
nt diagnosis n Outcome
S= Fatigue Patients with anemia SHORT TERM: - Establish - To gain SHORT TERM:
O= patient related to experience fatigue which is After 6º of NI, rapport the trust of Patient was
manifest: increased due to increased oxygen patient will be the client able to report
-body metabolic demand caused by decreased able to report an improved
malaise demands ability of the blood to provide an improved - Monitor VS - To have a sense of
-pale skin and adequate tissue perfusion. sense of and baseline energy
-activity anemia Moreover, presence of edema energy note level of data and
intolerance may increase level of fatigue consciousnes to reveal
-decreased due to hematuria which s alteration
performanc decreases oxygen and leads LONG TERM:
e to a decrease in cerebral LONG TERM: - For Patient was
-Accept
-with tissue perfusion. After 8 days of proper able to report
reality of
periorbital NI, patient will assessmen improved
patient’s
edema be able to t sense of
report of
-vital signs report energy
fatigue
taken as improved
follows: sense of
0 - Provide
T:36.1 C energy
supplementa
PR:97
l oxygen as
RR:18
indicated -To
BP: 90/60
support
-Provide oxygen
The patient
demand
 may environment
manifest: conducive to
- relief of -To reduce
dehydratio fatigue exhaustion
n And to
-inappropri- -Assist promote
ate urine patient with comfort
output for activity
intake -For safety
-Assist measures
patient to
identify - To
appropriate promote
coping sense of
behaviors control

Assessme Nursing Scientific explanation Objectives Interventio Rationale Expected

 nt diagnosis n Outcome

S= Decreased The excessive urine output of SHORT TERM: - Establish - To gain SHORT TERM:
O= patient cardiac the patient is due to failure of After 6º of NI, rapport the trust of After 6º of NI,
the client
manifested: output regulatory mechanism patient will be patient was
related to resulted to altered circulation/ able to display - Monitor VS - To have a able to
altered increased in blood pressure hemodynamic baseline display
-with
data and
blood due to albuminuria which stability hemodynamic
history of to reveal
pressure causes edema and leads to an alteration stability
hematuria
increase in blood volume that
-with
-Promote - To
triggered the stimulation of
history of maximize
adequate
renin, to angiotensin I LONG TERM:
frequent sleep
rest by
converted by Angiotensin After 3-4 days periods LONG TERM:
urination
decreasing
Converting Enzyme to of NI, patient After 3-4 days
but small
stimuli,
Angiotensin II that acts on will be to of NI, patient
amount of
providing
adrenal cortex causing demonstrate was able to
urine in
quiet
secretion of aldosterone. an increase in demonstrate
yellow color
environment
Increased in aldosterone activity an increase in
-appears
. Schedule
promoted renal retention of tolerance activity
weak
activities
Na and H2O which means that tolerance
-with good
and
there would be increased in
skin turgor
assessments
circulating fluid that would
-decreased
increase the heart's workload
food intake
-To
resulting to increased blood
-VS taken increase
pressure. - Provide
as follows: oxygen
supplementa
T:36.80C l oxygen as available
PR:72 indicated to the
tissues
RR: 19
BP: 80/72 -Encourage -To reduce
relaxation anxiety

The patient techniques

may
manifest: -To
-Provide for
- maintain
diet
dehydratio adequate
restrictions
n nutrition
(e.g. low
- and fluid
sodium,
inappropria valance
bland, soft,
te urine low calorie/
output for residue/ fat
intake diet, with
frequent
small
feedings as
indicated

Assessm Nursing Scientific Objectives Interventio Rationale Expected

ent diagnosis explanation n Outcome
S= Risk for The presence of SHORT TERM: - Establish - To gain the SHORT TERM:
O= patient impaired edema interferes After 6º of NI, rapport trust of the client Patient was able
manifeste Skin with cellular patient will to demonstrate
d: Integrity 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
--with
to skin breakdown. breakdown note level of and to reveal
history of
hematuria consciousne alteration
-with ss
history of
frequent - To reveal LONG TERM:
-Assess skin
urination abnormality/skin Patient’s edema
condition
but small LONG TERM: disruption was able to
amount of After 6 days of NI, decrease/subsid
urine in patient’s edema e
- Monitor
yellow will -To monitor
weight daily
color decrease/subside presence of
-appears edema
weak
-with good
skin turgor -Provide
-To prevent skin
- meticulous
breakdown
decreased skin care
food
intake -Keep bed
-To prevent
-VS taken
as follows: linens dry moisture which
T:36.80C may promote
PR:72 skin breakdown
RR: 19
BP: 80/72 -Frequently -To promote

change proper circulation

The patient’s and prevent
patient position excessive
may pressure on skin
manifest:
-
dehydratio
n
-
inappropri-
ate urine
output for
intake
Assessme Nursing Scientific Objectives Interventi Rationale Expected
nt diagnosis explanation on Outcome
S= Risk for spread of Viruses and bacteria SHORT TERM: - instruct - to reduce SHORT TERM:
O= patient infection both enter your body After 4º the pt.’s proper existing risk the pt’s SO
manifests: through your mouth SO will identify hygiene factors shall have
or nose — either interventions to identified
because you breathe reduce spread interventions
-appears
in particles that are of infection - instruct - to reduce to reduce
weak
released into the air proper existing risk spread of
-body
when someone handwashin factors infection
malaise
coughs or sneezes, or g
-pale
because you have LONG TERM:
palpebral
hand-to-hand contact After 3-4 days of - promote LONG TERM:
conjunctiva - to prevent
with an infected NI the pt.’s SO clean pt. shall have
-pale skin inection
person or use shared will demonstrate environmen demonstrated
-with facial
objects such as techniques, t techniques,
edema
utensils, towels, toys, lifestyles lifestyles
- to correct
doorknobs or a changes to changes to
- change existing risk
telephone. promote safe promote safe
linens an factors
environment dressings environment

as needed

- to
-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 SOAPIER’S)

June 24, 2008 (Tuesday)

A.1)

S>Ø

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: T-

36.80C 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>Ø

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: T-

36.80C 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 patient’s capability to identify

negative factors affecting activity tolerance and eliminate or reduce their effects

when possible

June 25, 2008 (Wednesday)

B.1)

S>Ø

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>Ø

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. Client’s Daily Progress in the Hospital

1. Client’s Daily Progress Chart

Client’s daily Progress

Nursing Problems Admission 06-21-08 06-22-08 06-23- 06-24-08 06-25-08 Discharge
(06-20-08) 08
Hyperthermia √

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

Vital Signs
Temperature 38.4ºC 37.3 37 36.8ºC 36.1ºC
 Pulse rate 84 72 97
Respiratory rate 22 19 18
Blood Pressure 90/60 80/60 70/60 80/72 90/60

*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 √ √ √ √ √ √ √

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>Ø
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 patient’s SO to provide foods that are low in salt and fat.
E > Goal met as evidenced by patient’s 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 patient’s 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
 Nurse’s Pocket Guide
 http://en.wikibooks.org/wiki/Human_Physiology/The_Urinary_
System#Urethra