Case Study On Acute Glomerulonephritis 2e3h3i

I. INTRODUCTION

Acute glomerulonephritis 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. Acute nephritic syndrome is a group of disorders that cause inflammation of the internal kidney structures (specifically, the glomeruli). In acute glomerulonephritis, the kidneys are normal in size or enlarged and edematous, and the surface of the kidney may show punctate hemorrhages. With the development of the microscope, Langhans was later able to describe these pathophysiologic glomerular changes. 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. As will be discussed, acute glomerulonephritis can be due to a primary renal or systemic disease. Symptoms of acute glomerulonephritis include the following:Hematuria is a universal finding, even if it is microscopic. Gross hematuria is reported in 30% of pediatric patients. Edema (peripheral or periorbital) is reported in approximately 85% of pediatric patients; edema may be mild (involving only the face) to severe, bordering on a nephrotic appearance.Headache may occur secondary to hypertension; confusion secondary to malignant hypertension may be seen in as many as 5% of patients.Shortness of breath or dyspnea on exertion secondary toheart failure or pulmonary edema; usually uncommon, particularly in children.Possible flank pain secondary to stretching of the renal capsule. Hypertension is seen in as many as 80% of affected patients. Hematuria, either macroscopic (gross) or microscopic, may be

noted. Skin rashes (ie, malar rash frequently seen with lupus nephritis) may be observed. Abnormal neurologic examination or altered level of consciousness occurring because of malignant hypertension or hypertensive encephalopathy. Arthritis may be noted. The most common cause is postinfectious Streptococcus species (ie, group A, beta-hemolytic). Two types have been described as (1) attributed to serotype 12, poststreptococcal nephritis due to an upper respiratory infection occurring primarily in the winter months, and (2) attributed to serotype 49, poststreptococcal nephritis due to a skin infection usually observed in the summer and fall and more prevalent in southern regions of the United States. With some exceptions, a reduction in the incidence of poststreptococcal 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. In Port Harcourt, Nigeria, the incidence of acute glomerulonephritis in children aged 3-16 years was 15.5 cases per year, with a male-tofemale ratio of 1.1:1; the current incidence has not changed much over the past 14 years.(http://emedicine.medscape.com/article/777272-overview; http://www.total-healthcare.com/illness/acute-glomerulonephritis.htm) Sporadic cases of acute nephritis often progress to a chronic form. This progression occurs in as many as 30% of adult patients and 10% of pediatric patients.Glomerulonephritis is the most common cause of chronic renal failure (25%).The mortality rate of acute glomerulonephritis in the most commonly affected age group, pediatric patients, has been reported at 0-7%. A male-to-female ratio of 2:1 has been reported. 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.

On the other hand, a urinary tract infection (UTI) is a bacterial infection that affects any part of the urinary tract. The main etiologic agent is Escherichia coli. Although urine contains a variety of fluids, salts, and waste products, it does not usually have bacteria in it.[1] When bacteria gets into the bladder or kidney and multiply in the urine, they may cause a UTI. Infections of the urinary tract are the second most common type of infection in the body. Urinary tract infections (UTIs) for about 8.3 million doctor visits each year. Women are especially prone to UTIs for reasons that are not yet well understood. One woman in five develops a UTI during her lifetime. UTIs in men are not as common as in women but can be very serious when they do occur. The most common type of UTI is acute cystitis often referred to as a bladder infection. An infection of the upper urinary tract or kidney is known aspyelonephritis, and is potentially more serious. Although they cause discomfort, urinary tract infections can usually be easily treated with a short course of antibiotics. Symptoms include frequent feeling and/or need to urinate, pain during urination, and cloudy urine. UTIs in men are often a result of an obstruction—for example, a urinary stone or enlarged prostate—or from a medical procedure involving a catheter. The first step is to identify the infecting organism and the drugs to which it is sensitive. Usually, doctors recommend lengthier therapy in men than in women, in part to prevent infections of the prostate gland. As a group, we decided to study this kind of disease for us to know more about the complications. As a nursing students, we must not only focus to one corner or merely by just taking care of our patients but to know their underlying condition as well for the better and good nursing intervention done to promote maximum living ability. Furthermore, we have chosen this case study in order to identify and determine the general health problems and needs of the patient with an itting diagnosis of acute glomerulonephritis. This study also intends to help patient as well as its significant others to promote health and medical understanding of such condition through the application of the nursing theories and nursing skills.

II. Clients Profile A. Socio-demographic data Patient X is a 13 year old male, Roman Catholic; a resident of Esperanza Agusan del Sur. Patient X was itted for the first time at Northern Mindanao Medical Center on July 31, 2010 at 5:30 pm. due to facial edema. He arrived at the hospital awake, conscious and coherent with a chief complaint of facial edema. B. Vital Signs The patient’s vital signs are essential because it provides a baseline data in determining alteration in the patient’s body that may suggest underlying disease. Any changes from the normal are considered to be an indication of the person’s state of health and provide cues to the physiological functioning of the client. The patient had the following vital signs: blood pressure: 100/70 mmHg, pulse rate: 104 bpm, respiratory rate: 32 m, temperature: 36.9ºC. He currently weighs 35 kilograms from the previous weight of 32 kilograms and he is 4’6 tall. C. Health Patterns Assessment 1. History of Present Illness The client was brought to the hospital due to anemia anasarca. Six months prior to ission, onset of edema with no other associated symptoms noted. Three months prior to ission, persistence of facial edema associated with pallor. A month prior to ission, enlarging abdomen and pallor and decreased urine output (1 time per day) was noted which prompted patient to seek medical consultation. Patient has no previous hospitalization and surgeries. Client has no family history of kidney-related diseases. Patient X was not taking any medication. He’s a non tobacco and a non alcoholic drinker. He has no known food and drug allergies. Patient X has an abdominal girth 77cm and weighs 35 kg.

2. Nutrition

During pre-hospitalization, the client used to eat junk foods which are high sodium and almost always eat “guinamos” as their viand. During hospitalization, Patient X was on a low salt, low fat diet. He consumed whole share with good appetite. The client seldom drinks water and was not taking in any vitamins. The client is not hooked in any intravenous fluid.

3. Elimination Pattern Pre-hospitalization, Patient X defecates once to twice daily with formed, brownish stool and soft in consistency. No discomfort felt during defecation but during hospitalization, the client has difficulty in defecating, thus, making him at risk to have constipation. While confined, the client defecates after 2-3 days. Pre-hospitalization, a month before the ission to the hospital, client has difficulty urinating thus, decreasing the urinary frequency from 68 times to 1 time per day. It’s yellowish in color and clear.

4. Activity -Exercise Pattern (pre – hospitalization)

Patient X is incorporating his exercise when walking going to school every morning and he’s going home from the school. Playing is his leisure activity together with few of his friends but mostly, he loves to play with his other siblings. A. Activity-Exercise Pattern (while confined) Describe the patient’s functional abilities a. Feeding: independent b. Bathing: independent c. Toileting: independent d. Bed mobility: independent e. Dressing: independent f. Grooming: dependent

g. General mobility: independent h. ROM: independent i. Ambulation: independent

The patient can do independently all activity- exercise but then, it is limited and controlled due to disease condition and client prefer to stay in the bed than ambulating. Toileting was done in the bedside only like urinating except defecating and don’t take a bath during hospitalization rather, his mother cleans wipe out dirt in the body which made him dependent in Grooming.

5. Cognitive-Perceptual Pattern

Patient X understands and speaks Visayan language and he didn’t have any speech deficit. Patient is an elementary student without any learning difficulties. There is pain felt in the right costovertebral angle and patient usually guards the location of pain.

6. Sleep -Rest Pattern Pre-hospitalization, Patient X usually sleeps for 11 hours. He doesn’t have any sleep disturbances but while confine, he verbalized problem of sleeping disturbances at night. Imagery is one of the effective tool for him in order to sleep at night.

7. Self-perception and Self-concept Pattern

Patient X says that he is handsome and he is a good as well as responsible student because he usually gets an award after each school year. He feels that he was weak and fear to be behind in their classroom lessons and scared not to get an award this school year due to the series of absences because of his hospitalization.

8. Role-Relationship Pattern His family specifically his mother and grandmother who helped him during hospitalization. His father and other in the family ar not around because they can’t visit for they are very far from the city thus, it requires money in order for them to visit at the hospital. Other than that, Philhealth is also their financial system.

9. Coping -stress Tolerance Pattern Patient X seldom experience any stress, but whenever he has, he subject his self in sleeping.

10. Value -Belief Pattern

Patient X is a Roman Catholic. To him it is important as it had helped him when he has a problem. He goes to church 3 times a month because the church is far away from their home and they nees to spent a lot of time walking because they have financial constraints as well. The client also prays frequently as part of his religious practices.

D. Physical Assessment

1. Neurologic Assessment Level of consciousness

Conscious

Orientation

Oriented

Emotional state

Worried/anxious (sometimes)

2. Head Head

Normocephalic

Facial movement

Symmetrical

(sometimes);

restless

Fontanels

Closed

Hair

Fine

Scalp

Clean

3. Eyes Lids

Symmetrical

Periorbital region

Edema

Conjunctiva

Pale

Cornea & lens

Opacity R/L

Sclera

Anicteric

Pupils

Equal in size

Reaction to l ight

Brisk R/L

Reaction to accommodation

Uinform to constriction

Visual acuity

Grossly normal

Peripheral vision

Intact/full

4. Ears

External pinnae

Normoset

External canal

No discharge

Tympanic membrane

Intact

Gross hearing

normal

5. Nose Mucosa

Pinkish

Patency

Both patent

Gross smell

Normal/symmetrical

Sinuses

No tenderness presence

6. Mouth

Lips

Pallor

Mucosa

Pinkish

Tongue

Midline

Teeth

Complete

Gums

pinkish

7. Pharynx Uvula

Midline

Tonsils

Not inflamed

Posterior pharynx

No inflame presence

8. Neck Trachea

Midline

Thyroids

non-palpable

9. Skin General color

Pallor

Texture

Rough

Turgor

Firm

Tempareture

warm

10.

Abdomen

Configuration

Globular

Bowel sound

Hypoactive (3 counts)

Percussion

Tympanitic

11.

Cardiovascular Status

Precordial area

Flat

Point of maximal impulse(PMI)

5th intercostal

Apical & rhythm

normal(108bpm)

Heart sound

Regular

Peripheral pulse

Symmetrical & regular but weak

Calillary refill

2 second

12. Respiratory Status Breathing pattern

Irregular (tachypneic)

Shape of chest

AP2:L1

Lung expasion

Symmetrical

Percussion

Resonant

Breath sound

Vesicular

Cough

non-productive

III. ANATOMY AND PHYSIOLOGY The Kidney

The main functional unit of the kidney is the nephron. There are approximately one million nephrons per kidney. The role of nephrons is to make urine by: •

Filtering blood of small molecules and ions such as water, salt, glucose and other solutes including urea. Large “macromolecules” like proteins are untouched.

•

Recycling the required quantities of useful solutes which then re-enter the bloodstream. (A process called reabsorption)

•

Allowing surplus or waste molecules/ions to flow from the tubules/ureter as urine.

Nephrons are the basic structural and functional units of the kidney. They consist of a network of tubules and canals specialized in filtration.

The kidney is responsible for maintaining fluid balance within the body. The basic structural and functional units of the kidneys are the nephrons. Each nephron is made of intricately interwoven capillaries and drainage canals to filter wastes, macromolecules, and ions from the blood to urine. The approximately 1 million nephrons in each human kidney form 10-20 cone-shaped tissue units called renal pyramids that span both the inner and outer portions of the kidney, the renal medulla and renal cortex. A. Renal Vein This has a large diameter and a thin wall. It carries blood away from the kidney and back to the right hand side of the heart. Blood in the kidney has had all its urea removed. Urea is produced by your liver to get rid of excess amino-acids. Blood in the

renal vein also has exactly the right amount of water and salts. This is because the kidney gets rid of excess water and salts. The kidney is controlled by the brain. A hormone in our blood called Anti-Diuretic Hormone (ADH for short) is used to control exactly how much water is excreted. This blood vessel supplies blood to the kidney from the left hand side of the heart. This blood must contain glucose and oxygen because the kidney has to work hard producing urine. Blood in the renal artery must have sufficient pressure or the kidney will not be able to filter the blood. Blood supplied to the kidney contains a toxic product called urea which must be removed from the blood. It may have too much salt and too much water. The kidney removes these excess materials; that is its function. B. Renal Artery This blood vessel supplies blood to the kidney from the left hand side of the heart. This blood must contain glucose and oxygen because the kidney has to work hard producing urine. Blood in the renal artery must have sufficient pressure or the kidney will not be able to filter the blood. Blood supplied to the kidney contains a toxic product called urea which must be removed from the blood. It may have too much salt and too much water. The kidney removes these excess materials; that are its function. C. Pelvis This is the region of the kidney where urine collects. If you are very unlucky, you may develop kidney stones. Sometimes the salts in the urine crystallise in the pelvis and form a solid mass which prevents urine from draining out of the medulla of the kidney. You will need treatment: see your doctor. D. Ureter This one is easy peasy: the ureter carries the urine down to the bladder. It does this 24 hours per day, but fortunately the urine can be stored in a bladder so that it is not necessary to wear a nappy! E. Medulla The medulla is the inside part of the kidney. It is shown in green in the diagram, but in real life it is a very dark red colour. This is where the amount of salt and water in your urine is controlled. It consists of billions of loops of Henlé. These work very hard pumping sodium ions. ADH makes the loops work harder to pump more sodium ions. The result of this is that very concentrated urine is produced.The opposite of an antidiuretic is a "diuretic". Alcohol and tea are diuretics.

F. Cortex The cortex is the outer part of the kidney. This is where blood is filtered. We call this process "ultra-filtration" or "high pressure filtration" because it only works if the blood entering the kidney in the renal artery is at high pressure. Billions of glomeruli are found in the cortex. A glomerulus is a tiny ball of capillaries. Each glomerulus is surrounded by a "Bowman's Capsule". Glomeruli leak. Things like red blood cells, white blood cells, platelets and fibrinogen stay in the blood vessels. Most of the plasma leaks out into the Bowman's capsules. This is about 160 litres of liquid every 24 hours.Most of this liquid, which we call "ultra-filtrate" is re-absorbed in the medulla and put back into the blood. G. Glomerulus and Bowman's Capsule This is where ultra-filtration takes place. Blood from the renal artery is forced into the glomerulus under high pressure. Most of the liquid is forced out of the glomerulus into the Bowman's capsule which surrounds it. This does not work properly in people who have very low blood pressure. Proximal Convoluted Tubules Proximal means "near to" and convoluted means "coiled up" so this is the coiled up tube near to the Bowman's capsule. This is the place where all that useful glucose is re-absorbed from the ultrafiltrate and put back into the blood. If the glucose was not absorbed it would end up in your urine. This happens in people who are suffering from diabetes. H. Loop of Henlé This part of the nephron is where water is reabsorbed. Kidney cells in this region spend all their time pumping sodium ions. This makes the medulla very salty; you could say that this is a region of very low water concentration. If you the definition of osmosis, you will realise that water will from a region of high water concentration (the ultra-filtrate and urine) into a region of low water concentration (the medulla) through cell membranes which are semi-permeable. I. Distal Convoluted Tubules Distal means "distant" so it is at the other end of the nephron from the Bowman's capsule. This is where most of the salts in the ultra-filtrate are re-absorbed. J. Collecting Duct Collecting ducts run through the medulla and are surrounded by loops of Henlé. The liquid in the collecting ducts (ultra-filtrate) is turned into urine as water and salts are removed from it. Although our kidneys make about 160 litres of urine every 24 hours,

we only produce about ½ litre of urine.It is called a collecting duct because it collects the liquid produced by lots of nephrons. Nephron Function The blood is filtered and urine formed by the actions of the nephrons. In each nephron, high pressure in the glomerulus pushes water and small dissolved materials into the extravascular space of the Bowman’s capsule and into the tubule. The proximal tubule reabsorbs water, salts, glucose, and amino acids to maintain electrolyte levels in the body. The interstitium of, that is the tissue space surrounding, the loop of Henle concentrates salts that will be excreted in the urine, creating a concentration gradient in the medulla. The limbs of Henle’s loop are permeable to particular ions (descending, water and some urea; thin ascending, general ions; medullary thick ascending – sodium, potassium, chloride), with the cortical thick ascending limb draining into the distal convoluted tubule. The distal tubule contains cells specialized in active transport and maintains urine and blood pH levels, particularly through the regulation of sodium and potassium. Fluid then es from the distal tubule to the collecting ducts, a tubule system that can become permeable or impermeable to water depending on the body’s needs. Ultrafiltration also occurs in the cortex in the cortical collecting ducts, which is regarded by some anatomy references as not being a portion of the nephron, and by others as being the final portion of the nephron. The urine then es from the collecting ducts through the drainage system of the kidney to the ureters and bladder for urination. Tubular Secretion in the Kidneys Another, less familiar, mechanism for urine production in the kidneys is tubular secretion. Specialised cells move solutes directly from the blood into the tubular fluid. For example, hydrogen and potassium ions are secreted directly into the tubular fluid. This process is “coupled” or balanced by the re-uptake of sodium ions back into the blood. Tubular secretion of hydrogen ions, augmented by control of bicarbonate levels, is important in maintaining correct blood pH. When the blood is too acidic (acidosis) more hydrogen ions are secreted. If the blood becomes too alkaline (alkalosis), hydrogen secretion is reduced. In maintaining blood pH within normal limits (about 7.35–7.45) the kidney can produce urine with pH as low as that of acid rain or as alkaline as baking soda!

The Kidney as an Endocrine Gland In addition to its excretory and homeostatic roles, the kidneys also release two important hormones into the blood. These are: •

Erythropoietin which acts on bone marrow to increase the production of red blood cells

•

Calcitriol which promotes the absorption of calcium from food in the intestine and acts directly on bones to shift calcium into the bloodstream.

Finally the kidney produces the enzyme renin, an important regulator of blood pressure. THE RENIN ±ANGIOTENSIN MECHANISM  Decreased blood pressure stimulates the kidney to stimulates the kidney to secrete renin.  Renin splits the plasma protein angiotensinogen (synthesized by the liver) to angiotensin I.  Angiotensin I is converted to angiotensin II by an enzyme (called converting

enzyme)  Secreted by the lung tissue and vascular endothelium.

Angiotensin II : - causes vasoconstriction - stimulates the adrenal cortex to secrete aldosterone which maintains normal blood levels of sodium and potassium and contributes to the maintenance of normal blood pH, blood volume, and blood pressure.

VIII. DISCHARGE PLANNING/ HEALTH TEACHINGS

MEDICATIONS •

Explain to the patient and family the importance of taking medicines.

•

Discuss to the patient and family the dosage, frequency and adverse effects of the drugs.

•

Encourage to follow the dosages and proper timing of his meds. Such as the Furosemide 1 ampule every 12hours x3doses, Omeprazole 20mg 1capsule once a day, Captopril25mg 1tablet twice a day, & Spironolactone 50mg 1 tabletthrice a day. As prescribed by his physician .

Economic status •

Explain to significant others that the rehabilitation may be prolonged to be able for the family to prepare financial needs

•

Have occupational therapist to help re- learn everyday activities or ADL

•

Inform the patient to avail to some government programs such as Philhealth.

Treatment •

Tell the patient that she should have self-monitoring by checking his vital signs and weighing regularly.

•

. Encourage/instruct to keep the edematous extremities to elevate as often

•

Limit of water intake; monitor intake and output

•

Provide warm environment

•

Provide egg white a day

•

Weight the pt. daily, at the same time.

HEALTH TEACHINGS •

Instruct the patient to take medications religiously.

•

Improve nutritional status.

•

Importance of proper hygiene for comfort.

OUT-PATIENT •

The patient could avail his medication from government hospitals that he could get some benefits.

•

He will also be able to avail the services offered by the barangay health center and and at the “Botika ng barangay”.

•

Instruct patient to seek regular medical check-up

DIET •

Eat five or more servings of vegetables and fruit daily.

•

Intake of fluids 8-10 glasses a day to avoid constipation and to maintain skin turgor.

•

Instruct patient to eat low fat and low sodium foods that will help not worsen her condition that is ordered by the physician.

IX. RELATED LEARNING EXPERIENCE We were assigned in the Reverse Isolation Ward for almost 4 weeks. We have encountered several restraints with regards to the implementation. It was not easy that we are dealing with our patients lives. But we did not loose hope because it’s our responsibility to care and to address the patient’s needs. We spent three nights of multi-tasking and time management even though we are busy in our major subject, we tried our best to do this case study correctly and to avoid corrections about this work but then again caring patient in reverse isolation ward is challenging task for us because this is our first time to be exposed in this ward with different kind of diseases that some are not easy to handle and should be closely monitored. Moreover, some of the significant others are uncooperative but as student nurses we are responsible in understanding their situation. Hence, it is imperative that we should establish rapport towards them. However, it was a wonderful experience since we have handled different patients with different disease condition which enable us to apply our knowledge and performed some procedures in the care of our client. We are fortunate enough, that we have our clinical instructor and our PCI who persistently supervised us and assisted us to avoid errors. Although, this is our 4th time to manage group case study in different setting, we are still up for improvement especially in assessing our patient thoroughly. Also we have acquired ourselves with regards to establish rapport with our patient to have trusting relationship. But enjoy with other people helps you identify your strength and weakness, and it aids in modifying what is somehow negative in our attitude. Most and for all we thank to god for the guidance always and for giving wisdom and knowledge to do this case study successful.

X. SOURCES: WEB:

http://generalmedicine.suite101.com/article.cfm/the_human_kidney_structure_and_func tion#ixzz0wIXUzTtr http://cellstissuesmembranes.suite101.com/article.cfm/nephron_structure_and_fu nction http://emedicine.medscape.com/article/777272-overview; http://www.total-health-care.com/illness/acute-glomerulonephritis.htm)

BOOKS: Nurse’s Pocket Guide 11th edition (Diagnoses, Prioritized interventions, and Rationales) By: Marilyn E. Doenges Mary s Moorhouse Alice C. Murr

Nursing 2003 Drug Handbook 23rd edition By: Springhouse Lippincott Williams and Wilkins