NURSING PROCESS I. PATIENT ASSESSMENT DATA BASE A. GENERAL DATA 1. Patients name: Ms. AF 2.

Address: Libueg Camiling, Tarlac 3. Age: 14 years old 4. Sex: Male 5. Birthdate: August 1, 1997 6. Rank in the family: 3rd child 7. Nationality: Filipino 8. Civil Status: Child 9. Date of Admission: September 12, 2011 10. Order of Admission: > Please admit to peadia ward under Dr. Gerardo Tamayo > Low salt, low fat diet > Please insert heplock > Monitor urine output > Monitor vital signs and record 11. Attending Physician: Dr Gerardo Tamayo B. CHIEF COMPLAINT: Bipedal Edema C. HISTORY OF PRESENT ILLNESS: > 4 days prior to admission patient ha abdominal pain accompanied by decreased urine output and tea-colored urine. No consultation done, no medication given > 3 days prior to admission due to above symptoms with bipedal edema consult was done at health center, no medicine given, advice for admission but patient did not comply. > Few hours prior to admission persistent of above symptoms prompted consult at TPH and was subsequently admitted. D. PAST HEALTH HISTORY/STATUS 1. Childhood Illnesses: mumps, sore eyes, chicken pox, measles 2. Immunization: Hepa1, Hepa2, BCG, OPV, DPT 3. Major Illnesses: Glomerulonephritis 4. Current medications: Penicillin, Furosemide, Nifedipine, Cloxacillin 5.Allergies: no know allergies

E. FAMILY ASSESMENT Name Mr. ROS Mrs. MYS Ms. APS Mr. CHS Mr. RES

Relation

Age 39 42 22 18 9

Sex Male Female Female Male Male

Occupation Tricycle driver Housewife

Educl Attainment High school graduate High school graduate High school graduate High school undergraduate Grade 4 student

Father Mother Sister Brother Brother

Student

F. SYSTEM REVIEW- GORDONS 11 FUNCTIONAL HEALTH PATTERNS ASSESMENT 1. Health perception Health Management Pattern > Patient RMS believes that he could achieve health by taking care of himself. Illnesses occurs when you forgot to give importance to your body. If ever patient RMS is sick his mother gave him medicine, but ever it become worst they would admit him to the hospital. 2. Nutritional Metabolic Pattern > Mr. RMS eats 3x a day and usually eats snacks > Usual Daily Menu > Food rice, meats, vegetables and fish > Water drinks 5 glasses of water a day > Beverages softdrinks, juice

3. Elimination Patterns > Bowel habits: patient RMS usually defecates once a day. > Color: Brownish in color and semi formed > Odor: Foul in odor > Consistency: soft > Laxative use if any: Patient RMS is not using any laxatives > Bladder: Patient RMS usually urinate 5x a day. > Color: Tea- colored Urine > Odor: Aromatic > Alteration if any: 4. Activity Exercise Pattern O Feeding O Bathing O Bed mobility Legend: O I II III IV -Full care -Requires use of equipment -Requires assistance of supervision of others -Requires assistance or supervision of others, and equipment and a device -Dependent; doesnt participate

O Dressing O Toileting O Home maintenance

O Grooming O Cooking

5. Cognitive Perceptual Pattern > Hearing: Patient RMS perceives sounds. > Vision: Patient RMS can see clearly > Sensory Perception: Patient RMS > Learning Style: Patient RMS can supervise his learning abilities and level of understanding through reading books, going to school and watching television. 6. Sleep Rest Pattern > Patient RMS usually sleep 11 oclock in the evening then wake up 8 in the morning. He says that he has no difficulty in sleeping. He watch television or stare at a blank things to make himself asleep.

7. Self- Perception and Self concept Pattern > Our patient accepts his present health status, through he know the complications of the disease in his body. He sees himself as a brave man and feels like he can survive the crisis that his going through even though he was a little bit afraid of injection. 8. Role Relationship Pattern > Patient RMS is a responsible son in his family because he usually help their mother in preparing their food and sometimes he cook for them.

9. Coping Stress Tolerance Pattern > Whenever Mr. RMS got bull by his classmates, he would cry and tell it to his mother. If ever he was scolded by his parents he take their word as a motivation to do good. 10. Value Belief Pattern > Patient RMS is a Roman Catholic who usually goes to church together with his family every Sunday. He truly believes in God as the Father and our Creator.

G. HEREDO FAMILIAL ILLNESS MATERNAL unremarkable PATERNAL unremarkable

I. PHYSICAL ASSESSMENT A. General Survey > Patient is well groomed and appropriately dress. He has an actual height of 115 cm and a weight of 35 kg. he is a little bit worried in his condition but has a moderately good mood. He is also alert upon interviewing. B. Vital Signs: > BP 120/90 mmHg > CR 88 beats per minute > RR 22 breath per minute > Temp 37.2 Degrees Celsius

C. Regional Exam: 1. Hair, head and face - Thick evenly distributed hair - normocephalic with a symmetrical facial movement 2. Eyes - presence of pustule in his lower left eye, edema 3. Nose - Normal nasal congestion 4. Ears - Normal hearing acuity 5. Mouth and Throat - Dry mouth, free from lesion 6. Neck and Lymph nodes - can move his neck freely and not tender 7. Skin - Light deep brown, moist due to warm room 8. Nails - Intact epidermis 9. Thorax and Lungs - Normal breath sound 10. Cardiovascular - rhythmic pattern 11. Breast and Axilla - symmetrical, non tender 12. Abdomen - Symmetrical, Umbilicus inverted 13. Genitals - Not assess 14. Rectum and Anus - Not assess 15. Neurological/Cranial nerves - patient is alert, oriented to time and place and he has an appropriate behavior.

II. PERSONAL/ SOCIAL HISTORY A. HABITS/VICES a. Caffeine not drinking b. Smoking not drinking c. Alcohol not drinking d. Tea not dringking e. Drugs not using drugs B. LIFESTYLE > Go to school and playing around with friends. C. RANK IN THE FAMILY > 3rd Child D. EDUCATIONAL ATTAINMENT > Second year high school

III. ENVIRONMENT HISTORY > Living in a concrete house along the hi-way

XII. DISCHARGE PLAN Medications > Nifedipine 10 mg PO TID > Furosemide 20 mg x 1 tab PO OD Exercise > Advise client to have a non-strenous and non jarring exercise such as walking. > Tell client to initiate exercise through repetitive low intensity exercise first. > As time and experiences increases the client can move to higher intensity exercise. Treatment > Ensure follow up and self care. > Advice client or significant others to take in time prescribe medicines specially high blood pressures. > Ensure dietary restrictions and salt, fluids protein and other substances max be recommended. > Tell significant others to closely watched and monitor for signs of developing kidney failure. Diet > Assure a low sodium, low protein diet. > Limitation of fluid and salt intake to minimize vascular overload and hypertension.

V. INTRODUCTION Glomerulonephritis is a condition where the small structures inside the kidneys, known as glomeruli, become inflamed. There are two kidneys in the body. These organs have a very important function. They remove waste products from the blood, which are then passed out of the body in urine. In each kidney, there are about one million tiny filters called glomeruli. Glomerulonephritis occurs when the glomeruli become inflamed (swollen). If the kidneys become inflamed, they are unable to work properly. Salt and excess fluid can build up, leading to complications, such as high blood pressure (hypertension). In some cases, kidney disease or kidney failure can occur. Glomerulonephritis is the name given to a range of conditions that affect the kidneys. There are a number of different types of glomerulonephritis. However, the condition can be broadly categorised into two main types: primary glomerulonephritis and secondary glomerulonephritis. Primary glomerulonephritis: where the condition develops on its own, and is not related to another pre-existing condition.Secondary glomerulonephritis: where the condition develops as a result of another, pre-existing condition such as Hodgkin's disease, or Goodpasture's syndrome (an autoimmune disorder that affects the lungs and kidneys). Glomerulonephritis can vary in severity. It can be short-lived (acute) and need minimal treatment or be more serious and last for a long time (chronic). VI. ANATOMY AND PHYSIOLOGY

1. 2. 3. 4. 5. 6. 7.

Renal pyramid- are cone-shaped tissues of the kidney. Interlobular artery- The first set of renal bloodvessels Renal artery - normally arise off the side of the abdominal aorta, immediately below the superior mesenteric artery, and supply the kidneys with blood. Renal vein - The renal veins are veins that drain the kidney. They connect the kidney to the inferior vena cava. Renal hilum - or renal pedicle of the kidney is the recessed central fissure. Renal pelvis - The renal pelvis or pyelum is the funnel-like dilated proximal part of the ureter in the kidney. Ureter - are muscular tubes that propel urine from the kidneys to the urinary bladder.

8. Minor calyx - n the kidney, surrounds the apex of the renal pyramids. Urine formed in the kidney passes through a papilla at the apex into the minor calyx then into the major calyx. 9. Renal capsule - is a tough fibrous layer surrounding the kidney and covered in a thick layer of perinephric adipose tissue. It provides some protection from trauma and damage. 10. Inferior renal capsule 11. Superior renal capsule 12. Interlobular vein - veins that drain the arcuate veins, pass down between the renal pyramids, and unite to form the renal vein. 13. Nephron - is the basic structural and functional unit of the kidney. Its chief function is to regulate the concentration of water and soluble substances like sodium salts by filtering the blood, reabsorbing what is needed and excreting the rest as urine. 14. Minor calyx 15. Major calyx - in the kidney, surrounds the apex of the renal pyramids. 16. Renal papilla - is the location where the medullary pyramids empty urine into the minor calyx. 17. Renal column- is a medullary extension of the renal cortex in between the renal pyramids. It allows the cortex to be better anchored.

VII. PATHOPHYSIOLOGY The initial reaction is usually either an upper respiratory infection or skin infection due to group A beta-hemolytic streptococcus. This leads to the formation of an antigen-antibody reaction. It is followed by the release of a membrane-like material from the organism into the bodys circulation. Antibodies produced to fight the invading organism also react against the glomerular tissue, thus forming immune complexes. The immune complexes become trapped in the glomerular loop and cause an inflammatory reaction in the affected glomeruli. Changes in the glomerular capillaries reduce the amount of the glomerular filtrate, thereby allowing passage of blood cells and protein into the infiltrate, and reducing the amount of sodium and water that is passed into the tubules for reabsorption. This affects the vascular tone and permeability of the kidney, resulting to tissue injury.

VIII. LABORATORY AND DIAGNOSTIC EXAMINATIONS TYPE OF EXAMINATION: COMPLETE BLOOD COUNT RESULTS RBC Count: 4.03 NORMAL VALUES Male:4.7 to 6.1 million cells/mcL SIGNIFICANCE -The cells that carry oxygen to the body. Low results can indicate blood loss, problems with the bone narrow, leukemia and malnutrition. High results can indicate heart problems, kidney disease, over transfusion and dehydration. -This cells are the infection fighting portion of the blood and play a role in inflammation. A low count can indicate bone narrow problems, chemical exposure, autoimmune disease, and problem with the liver or spleen. High level can indicate the presence of tissue damage(burn), leukemia and infection disease. -This is the percentage of the blood that is composed of red blood cells, low hematocrit level can indicate anemia, blood loss, bone marrow problems, malnutrition and more. -Hemoglobin is a protein on red blood cells that carries oxygen. Low levels may indicate blood loss or anemia. -The MCV shows the size of the red blood cells. The MCV value is the amount of hemoglobin in an average red blood cell. -Mean corpuscular hemoglobin (MCH) is a calculation of the
average amount of oxygen-carrying hemoglobin inside a red blood cell.

WBC Count: 11.

44,500 to 10,000 cells/mcL

Hematocrit: .318

Male: 40.7 to 50.3 %

Hemoglobin: .112 MCV: 78.9 fL

Male: 13.8 to 17.2 gm/Dl 80 to 95 femtoliter

MCH: 27.8 pg

27 to 31 pg/cell

MCHC: 35.2

32 TO 36 GM/Dl

-The MCHC measures the concentration of hemoglobin in an average red blood cell. These numbers help in the diagnosis of different types of anemia. -The platelet count is the number of platelets in a given volume
of blood. Both increases and decreases can point to abnormal conditions of excess bleeding or clotting.

PLATELET: 368.

150,000 TO 400,000 per mm3

TYPE OF EXAMINATION: URINALYSIS RESULTS COLOR: Yellow APPEARANCE: Cloudy pH: 5.0 Specific gravity: 1.026 NORMAL VALUES Pale yellow Clear 4.6 to 8.0 1.003 to 1.030 SIGNIFICANCE -color is influence by urine concentration and ingredients. -Bacteria, excessive crystals, or cells cause cloudiness. -Urine becomes alkaline(pH more than 7) with urinary tract infection or severe alkalosis. -Specific gravity is elevated in dehydration as kidney try to conserve fluid, and decreased in over hydration as they try to rid the body of fluid. -Due to inflammation, protein molecules pass into urine. -Glucose in urine occurs most frequently as a symptom of diabetes mellitus.

PROTEIN: +2 GLUCOSE: Negative

0 0

TYPE OF EXAMINATION: BLOOD CHEMISTRY(ELECTROLYTES) RESULTS SODIUM: 139.6 NORMAL VALUES 135 TO 145 mEq/L SIGNIFICANCE -plays a major role in regulating the amount of water in the body. Also, the passage of sodium in and out of cells is necessary for many body functions, like transmitting electrical signals in the brain and in the muscles. The sodium levels are measured to detect whether there's the right balance of sodium and liquid in the blood to carry out those functions. -is essential to regulate how the heart beats. Potassium levels that are too high or too low can increase the risk of an abnormal heartbeat. Low potassium levels are also associated with muscle weakness. - Like sodium, helps maintain a balance of fluids in the body. If there's a large loss of chloride, the blood may become more acidic and prevent certain chemical reactions from occurring in the body that are necessary it to keep working properly.

POTASSIUM: 4.53

3.5 to 5 mEq/L

CHLORIDE: 108.7

100 TO 106 mEq/L

X. LIST OF IDENTIFIED PROBLEMS 1. Excess fluid volume related to compromised regulatory mechanism as manifested by AGN. 2. Imbalanced nutrition: less than body requirements related to increased glomerular fermeability as evidenced by proteinuria. XI. NURSING CARE PLAN ASSESSMENT SO Periorbital and pedal edema Irritable when awake NURSING DIAGNOSIS Excess fluid volume related to compromised regulatory mechanism as manifested by AGN. GOALS After nursing intervention, the patient will: Display appropriate urinary output with normal specific gravity and laboratory status within normal range Minimize presence of edema Achieve stable weight and vital sigs. INTERVENTION Record accurate intake and output(I&O) RATIONALE EVALUATION After nursing intervention, Low output(less the patient has: than 400 ml/24 Displayed hr) is the first indicator of appropriate urinary acute renal output with normal failure. specific gravity and laboratory status To measure the within normal kidneys ability to range. concentrate Absence of edema urine and body weight Daily body returns to normal weight is best monitor of fluid Vital signs within status. A weight normal range. gain of more than 0.5 kg/day siggest fluid retention. Tachycardia and hypertension can occur because of failure of the kidney to excrete urine To promote venous return

VS: T- 37.2 degrees Celsius P-88 R- 22 BP- 120/90

Monitor urine specific gravity

Weigh daily at the same time of the day

Monitor heart rate and BP.

Elevate edematous body part.

ASSESSMENT S- andaming bawal ipakain sa kanya as verbalized by the mother. O- Protein = +2

NURSING DIAGNOSIS Imbalanced nutrition: less than body requirements related to increased glomerular fermeability as evidenced by proteinuria.

GOALS INTERVENTION RATIONALE After nursing Assess Obtain baseline for intervention, the nutritional comparison. patient will: status. Assess Comply with body weight dietary and lab values( restrictions UA protein) Have increased Promote a diet Reduces the sources energy levels based on of restricted foods, and appetite current at the same time nutritional provides the calorie Prevent status. and nutritional symptoms Promote a needs of the client associated low-sodium, and spares protein. with protein low-potassium, deficiency. high-calorie, protein restricted but albumin-rich diet. Assist client Understanding and and the family comforts promotes to cope with compliance and also the discomfort increases appetite. caused by restrictions in the diet. Explain the rationale To evaluate behind dietary progress and to restriction. detect Monitor and complications early. record clients progress, weigh patient daily.

EVALUATION After nursing intervention, the patient had: Observably increased energy levels. Consumed high-calorie food within restrictions. Reported increase appetite Complied and actively participated in the interventions presented.

PANPACIFIC UNIVERSITY NORTH PHILIPPINES

(Urdaneta City)

CASE STUDY
(PEDIA WARD)
SUBMITTED BY:

RUSSEL M. TALIO ROBIN M. UMIPIG

SUBMITTED TO:

Mr. ALVIN BERNARDO