Mindanao Sanitarium and Hospital College Brgy.

San Miguel, Iligan City 9200 School of Nursing AY 2009-2010

ACUTE GLOMERULONEPHRITIS (AGN)

Submitted by: Mary Lyon T. Fajardo BSN- 2A

Submitted to: Karla B. Orbeta, RN

ACUTE GLOMERULONEPHRITIS
I. INDRODUCTION

Acute glomerulonephritis (AGN) is active inflammation in the glomeruli. Each kidney is composed of about 1 million microscopic filtering "screens" known as glomeruli that selectively remove uremic waste products. The inflammatory process usually begins with an infection or injury (e.g., burn, trauma), then the protective immune system fights off the infection, scar tissue forms, and the process is complete. There are many diseases that cause an active inflammation within the glomeruli. Some of these diseases are systemic (i.e., other parts of the body are involved at the same time) and some occur solely in the glomeruli. When there is active inflammation within the kidney, scar tissue may replace normal, functional kidney tissue and cause irreversible renal impairment. The severity and extent of glomerular damagefocal (confined) or diffuse (widespread)determines how the disease is manifested. Glomerular damage can appear as subacute renal failure, progressive chronic renal failure (CRF); or simply a urinary abnormality such as hematuria (blood in the urine) or proteinuria (excess protein in the urine).

II.

PHYSICAL ASSESSMENT

System
Inspection Integumentary system Respiratory system Central Nervous System Circulatory system Gastrointestinal system Vomiting Anorexia Abdominal pain Musculoskeletal system Cardiovascular system Weakness Fatigue Skin flushing diaphoresis Tachypnea Dyspnea

Physical Assessment
Auscultation Percussion Palpitation edema

Back pain

Increase HR Increase BP

Genitourinary system

Oliguria

III.

Human Anatomy And Physiology

Diagram of the Kidney

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. 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 is 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 Henl. 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 anti-diuretic 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.

Here is a diagram of the kidney showing a nephron broken up into six parts.

Here is a diagram of a nephron

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 Don't worry about remembering the name for your GCSE biology. Jolly good though if you can. 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. Loop of Henl 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 remember the definition of osmosis, you will realise that water will pass 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.

Distal Convoluted Tubules

Don't worry too much about the name. 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. Collecting Duct

Collecting ducts run through the medulla and are surrounded by loops of Henl. 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 litre of urine.It is called a collecting duct because it collects the liquid produced by lots of nephrons. 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 con verting enzyme) secreted by the lung tissue and vascular endothelium. Angiotensin II : causes vasoconstriction

stimulates the adrenal cortex to secrete aildosterone which maintains normal blood

levels of sodium and potassium and contributes to the maintenance of normal blood

pH, blood volume, and blood pressure.

IV.

Diagnostic Tests

Urinalysis

One of the most revealing test of the kidney functions is also one of the simplest : urinalysis. For best results, specimen collected should be fresh because that stands at room temperature for any length of time changes composition. A chemical reagent strip can be used to detect glucose, protein, and occult blood and to measure pH. Patients with acute glomerulonephritis (AGN) have an active urinary sediment. This means that signs of active kidney inflammation can be detected when the urine is examined under the microscope. Such signs include red blood cells, white blood cells, proteinuria (blood proteins in the urine), and "casts" of cells that have leaked through the glomeruli and have reached the tubule, where they develop into cylindrical forms. Results: Hematuria Proteinuria Albuminuria Creatinine Clearance Rate

Glomerular Filtration Rate is the rate of which substances are filtered from the blood to the urine. It is measured by the amount creatinine (the breakdown product of creatinine from muscle contraction) excreted in 24 hours urine sample. This is known as a creatinine clearance test. A venous blood sample is taken

during the 24-hour period and compared with the urine findings. A normal creatinine clearance is 100 mL/min. a normal urine creatinine levels is 0.7 to 1.5 mg/100 mL; serum creatine rarely exceeds 1 mg/dL.

Blood Studies

A blood urea nitrogen (BUN) test measures the level of urea in blood and is used to assess glomerular function, or how well the kidneys can clear this from the blood-stream. However, this level may not increase until approximately 50% of glomerular are destroyed, because the remaining glomeruli can increase in size and function to accommodate urine production. A normal value is 5 to 20 mg/100 mL. X-Ray Studies

A plain flat-plate abdominal x-ray film can provide information about the size and contour of the kidneys. This x-ray may be referred to as a KUB (kidney, ureters, and bladder). kidney biopsy is essential to establish a diagnosis of AGN, determine the cause, and create an effective treatment plan.

V.

Pathophysiology
Precipitating Factors B- hemolytic Streptococci Post infection Poor intake of vitamin rich food

Predisposing Factors Age: 5-10 years old Gender: Male

Streptococcal Infection

Microorganism circulate in the blood stream

Deposition of antigen-antibody complex glomerulus

Acute inflammation and damage within the nephrons including the glomerulus

proliferation of the endothelial cell lining of the glomerular capillary

leukocytes infiltration of the glomerulus

thickening of the glomerular filtration membrane

scarring and loss of glomerular filtration membrane

decrease glomerular filtration rate

Signs and Symptoms

G.U. System - Oliguria - Hematuria - Proteinuria - Albuminuria Circulatory system - Decrease RBC - Increase Potassium - Increase sodium G.I. System - vomiting - abdominal pain - anorexia Musculoskeletal system - back pain - weakness - fatigue Respiratory system - Tachypnea - Dyspnea

Cardiovascular system - increase heart rate - increase blood pressure

Integumentary System - skin flushing - edema - diaphoresis

CNS - nausea - headache

VI.

Nursing Management

Review fluid and diet restrictions. Measure and record intake and output. Instruct patient to schedule follow-up evaluations of blood pressure, urinalysis for protein, and BUN and creatinine studies to determine if disease has worsened. Instruct patient to notify physician if infection or symptoms of renal failure occur: fatigue, nausea, vomiting, diminishing urinary output. Refer to home care nurse as indicated for assessment and detection of early symptoms and follow-up evaluations. Provide low salt, low sodium, low potassium and high protein diet.

The goal of treatment is to stop the ongoing inflammation and lessen the degree of
scarring that ensues. Depending on the diagnosis, there are different treatment strategies. Often the treatment warrants a regimen of immunosuppressive drugs to limit the immune systems activity. This decreases the degree of inflammation and subsequent irreversible scarring.

VII.

Nursing Care Plan

The 5 prioritized Nursing Care Plan

infection related to altered immune response Acute Pain related to inflammation of the glomerulus Fluid volume excess related to failure of regulatory mechanism risk for decreased cardiac output related to decrease peripheral vascular resistance secondary to hypertension tertiary to AGN ineffective breathing pattern related to compensatory mechanism