STI COLLEGE STA.

MARIA

A CASE PRESENTATION PRESENTED TO MR. RONALDO V. RAYMUNDO

BY COLLEGE OF NURSING

NCM 107

CARRIE ANN S.FERNANDEZ

ACUTE GLOMERULONEPHRITIS I. INDRODUCTION

Acute glomerulonephritis (AGN) is active inflammation in the glomeruli. Glomerulonephritis is a type of kidney disease that involves the glomeruli. The glomeruli are very small, important structures in the kidneys that supply blood flow to the small units in the kidneys that filter urine, called the nephrons. During glomerulonephritis, the glomeruli become inflamed and impair the kidney's ability to filter urine. There are many diseases that cause an active inflammation within the glomeruli. Some of these diseases are systemic and some occur solely in the glomeruli. This is a common disease in children and it is one of the diseases that are presented commonly with hematuria

ETIOLOGY Streptococcal infection(The most common infectious cause of acute GN is infection by Streptococcus species (ie, group A, beta-hemolytic). Two types have been described, involving different serotypes:

Serotype 12 - Poststreptococcal nephritis due to an upper respiratory infection, occurring primarily in the winter months Serotype 49 - Poststreptococcal nephritis due to a skin infection, usually observed in the summer and fall) Impetigo Acute viral infection Medications Foreign serum Immunologic problem

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

Precipitating Factors: B-hemolytic Streptococci Post infection Poor intake of vitamin rich foods

SIGNS AND SYMPTOMS

H-hematuria H-hypertension E-edema(due to increase salt and water retention, and decrease oncotic pressure) P-proteinuria A-azotemia

Other: Headache Malaise Flank pain Tenderness over the CVA area Circulatory overload Confusion Somnolence Seizures

DIAGNOSTIC TEST

Urine test Blood tests Imaging tests Electron microscopy and immunoflorescence Kidney biopsy ASO or anti Dnase B titer

COMPLICATIONS:
Hypertensive encephalopathy Heart failure Pulmonary edema

NURSING DIAGNOSIS

Acute Pain Fluid volume excess

NURSING MANAGEMENT
Assessment patient pertaining to his condition. Check the patients vital signs and electrolyte values. Monitor intake and output and daily weight. Instruct for fluid and diet restrictions. 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. Allow the patient to resume normal activities gradually as symptoms subside.

Provide low salt, low sodium, low potassium and high protein diet. Explain the prescribe medication to the patient. Provide best rest during the acute phase. Perform passive range of motion exercises for the patient on bed rest. 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.

MEDICAL MANAGEMENT
Kidney disease diet:

Low calorie diet Low protein Low sodium diet Low potassium diet Low phosphorus diet Calcium supplements Vitamin B supplements

 Fluid restriction:

Limiting the amount of fluid in the diet

Oral corticosteroid medications:

Prednisone Methylprednisolone (Medrol)

Diuretic medications:

Furosemide (Lasix)

Medications that suppress the immune system:

Cyclophosphamide (Cytoxan, Neosar, Procytox)

OBJECTIVES
General Objectives Enable for us, nursing students, to have an enhanced understanding of the condition, AGN. Specific Objectives To determine the kidneys anatomy and its normal function. To gain knowledge about the causes and risk factors of AGN. To elaborate the different nursing and medical interventions that can be rendered to clients with AGN. T o explain the different laboratory data and the pertinent findings about the clients condition. To provide health teachings to the client and family members on how they can manage and prevent the occurrence of AGN

ANATOMY AND PHYSIOLOGY

If you were to cut a kidney in half, you would see the following parts:

Renal capsule - a thin, outer membrane that helps protect the kidney Cortex - a lightly colored outer region Medulla - a darker, reddish-brown, inner region Renal pelvis - a flat, funnel-shaped cavity that collects the urine into the ureters

If you look closely at the cortex and medulla, you can see many tiny, tubular structures that stretch across both regions perpendicular to the surface of the kidney. In each kidney, there are one million of these structures, called nephrons. The nephron is the basic unit of the kidney. It's a long, thin tube that is closed at

one end, has two twisted regions interspaced with a long hairpin loop, ends in a long straight portion and is surrounded by capillaries. The parts of the nephron are as follows:

Bowman's capsule - This closed end at the beginning of the nephron is located in the cortex. Proximal convoluted tubule or proximal tubule - The first twisted region after the Bowman's capsule; it's in the cortex. Loop of Henle - A long, hairpin loop after the proximal tubule, it extends from the cortex down into the medulla and back. Distal convoluted tubule or distal tubule - This second twisted portion of the nephron after the loop of Henle is located in the cortex. Collecting duct - This long straight portion after the distal tubule that is the open end of the nephron extends from the cortex down through the medulla.

Each part of the nephron has different types of cells with different properties -- this is important in understanding how the kidney regulates the composition of the blood. The nephron has a unique blood supply compared to other organs:

Afferent arteriole - connects the renal artery with the glomerular capillaries Glomerular capillaries - coiled capillaries that are inside the Bowman's capsule Efferent arteriole - connects the glomerular capillaries with the peritubular capillaries Peritubular capillaries - located after the glomerular capillaries and surrounding the proximal tubule, loop of Henle, and distal tubule Interlobular veins - drain the peritubular capillaries into the renal vein

The kidney is the only organ of the body in which two capillary beds, in series, connect arteries with veins. This arrangement is important for maintaining a constant blood flow through and around the nephron despite fluctuations in systemic blood pressure. Regulating the composition of the blood involves the following:

Keeping the concentrations of various ions and other important substances constant Keeping the volume of water in your body constant Removing wastes from your body Keeping the acid/base concentration of your blood constant

The kidney does this by a combination of three processes:

It filters 20 percent of the plasma and non-cell elements from the blood into the inside of the nephron (the lumen).

It reabsorbs the components that the body needs from the lumen back into the blood. It secretes some unwanted components from the blood into the lumen of the nephron.

Anything (fluid, ions, small molecules) that has not been reabsorbed from the lumen gets swept away to form the urine, which ultimately leaves the body. Through these processes, the blood is maintained with the proper composition, and excess or unwanted substances are removed from the blood into the urine.

PATHOPHYSIOLOGY: Immunologic Response

Antigen(group A beta-hemolytic streptococcus)

Antigen-antibody product

Deposition of antigen-antibody complex in glomerulus

Increased production of epithelial cells lining the glomerulus

Leukocytes infiltrate the glomerulus

Thickening of the glomerular filtration membrane

Scarring and loss of glomerular filtration

Decreased glomerular filtration rate

GENERAL DATA Name: Age: Address: Pantoc, Meycauayan, Bulacan Date of Admission: Occupation: Religion: None Roman Catholic Mr. N.M.DC 7 years old 947 Baloongan November 25, 2012

Birthday: 2005 Status: Chief Complaint: Final Diagnosis: Glomerulonephritis Attending Physician: D. Pertinent Physical Finding: Vital Signs: T --------------------

November 07, Child Bloody urine/ edema Acute Cusay, M.D; Federico

36.20C 90bpm 20cpm 130/70mmHg

PR -------------------RR -------------------BP --------------------

HISTORY OF PRESENT ILLNESS:

November of 2012, one week prior to admission, the patient experienced of generalized edema. No consultation was done. Until the client complained of bloody urine and Mr. N.M.DC a 7 years old male was admitted at Rogaciano M. Mercado Memorial Hospital on November 25, 2012 with a chief complain of generalized edema and bloody urine.

PAST MEDICAL HISTORY:

Before admission, Mr. N.M.DCs relative stated that he has never been hospitalized before. Also, theyre unable to go to the nearby barangay center/clinic for consultation about his condition due to financial constraints.

FAMILY HISTORY:
Mr. N.M.DC relative stated that the clients grandmother died because of cardiac problems.Other than that, there is no related history of kidney diseases that runs in their family.

SOCIAL HISTORY:
Patient N.M.DC is the youngest among 6 siblings,a Grade I student in a public school and he stated that during their break time he prefer to eat some street foods such as fish ball,kikiam and also junk foods to somehow relieve his hunger; drinking of palamig to relieve his thirst. Mr. N.M.DC and his family live in Meycauayan for 10 years alongside of many industrial unit where pollution and other polluted chemicals are profound.

LIFESTYLE:
Patient N.M.DC prefer to play in a unoccupied area beside a plastic factory.

PHYSICAL ASSESSMENT
INSPECTION General Skin Head Eyes Ears Nose Throat Neck Weak in appearance Pale in color PERRLA Flank pain, hematuria With edema at lower extremities PALPATION Dry skin PERCUSSIO N AUSCULTATIO N Increase heart rate and increase BP -

Chest Abdomen Extremities

LABORATORY EXAMINATION URINALYSIS (November 30,2012)

RESULT NORMAL VALUES Color pale yellow to amber Specific gravity 1.010-1.025 WBC 0-5/hpf Transparency transparent pH 4.5-8.0 CHON negative Leukocytes negative RBC 0-2/hpf yellow 1.010 TNTC turbid 6.0 +3 +4 TNTC

Interpretaion: Significant numbers typically indicate the presence of infection. Excess turbidity results from the presence of suspended particles in the urine. Finding protein in the urine is not a normal finding. Seriously elevated levels may indicate that there is a problem with kidney function. Leukocytes in the urine typically indicate a past or current infection in the urinary tract. The presence of abnormal numbers of red cells in urine due to any of several possible causes, e.g. glomerular damage

BLOOD CHEMISTRY

November 26, 2012

TEST BUN

NORMAL VALUES

RESULTS

7-18mg/dL CREATININE

9.3mg/dL

0.4-1.4mg/dL

0.6mg/dL

Interpretation:
Increased BUN levels suggest impaired kidney function. This may be due to acute or chronic kidney disease, damage, or failure. It may also be due to a condition that results in decreased blood flow to the kidneys Elevated serum creatinine levels are most often seen in patients with renal disease that has seriously damaged 50% or more of the nephrons of the kidneys.

HEMATOLOGY

TEST Hematocrit To identify the percentage of the blood volume occupied by red blood cells. Decreased hematocrit indicates blood loss, anemia, blood replacement therapy and fluid balance. WBC Count To determine infection or inflammation in the body and monitor its responses to specific therapies. Differential Count Segmenters Lymphocytes To identify if there is an abnormal amount of lymphocyte that may indicate viral infection. Monocytes Monocytes are a type of leukocyte or white blood cell which play a role in immune system function.

NORMAL VALUES

RESULTS September 19, 2012

M: 0.40 0.48

0.31

4.0 11.0 x 109/ L

11.6 x 109/ L

0.55 0.65

0.70

0.25 0.40

0.22

0.02-0.06

0.08

ASO TITER November 30,2012 Remarks: Result ASO=400 Interpretation: If the ASO level is high or is rising, then it is likely that a recent strep infection has occurred. ASO levels that are initially high and then decline suggest that an infection has occurred and may be resolving. Normal Values <200 IU/

M E T H O D

Instruct the patient and family to follow the home medications as prescribed by the physician regarding proper administration, dosage, time, frequency and to take medications with food if not contraindicated. Encourage early ambulation if not contraindicated or promote exercise to the client especially ROM, and advise patient to have adequate rest and sleep.

Explain the need of treatment after discharge and must take it seriously so as to prevent such complications to the patient. Encourage patient to perform proper personal hygiene to promote comfort and cleanliness which is very much needed in the therapeutic process.

Inform the patient that follow-up check-up is important to have continuous monitoring and care.

Low salt, low protein and fluid restriction

DISCHARGE PLANNING

Discharge: Final Diagnosis: Glomerulonephritis Condition upon Discharge: Final Disposition: medications

November 10, 2012 Acute Improved May go home with

Medication: oral AS NEEDED 1tsp. TID

Paracetamol 250 mg Cefuroxime 250/5ml