CHAPTER I

INTRODUCTION

Bright initially described acute glomerulonephritis in 1927.Acute nephritic syndrome is the most serious and potentially devastating form of the various renal syndromes. Acute glomerulonephritis also known as poststreptococcal glomerulonephritis comprises 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. Acute glomerulonephritis inflammation of the blood vessels in the kidney, which causes the kidneys to malfunction. The most common cause of acute glomerulonephritis is a throat infection with the bacteria, Streptococcus and can be due to a primary renal disease or to a systemic disease. Acute GN is defined as the sudden onset of hematuria, proteinuria, and red blood cell (RBC) casts. Common symptoms of this disease include blood in the urine, fever, nausea, rash, leg swelling and high blood pressure. Treatment of AGN is mainly supportive, because there is no specific therapy for renal disease. When acute GN is associated with chronic infections, the underlying

A Case Study

infections must be treated and is usually treated with medications and a kidney diet and kidney dialysis may be necessary in some patients. There has been a significant decline in the incidence of acute glomerulonephritis in developed countries such as the US, and cases are reported only sporadically. The declining incidence rates are probably related to improved nutritional status in these countries and more liberal use of antibiotics. Developing countries, such as those in Africa and the Caribbean, appear to have a higher potential for development of streptococcal infections, and the incidence of acute glomerulonephritis is proportionally higher in these areas. Males are twice as likely to have the condition as females, and although glomerulonephritis can appear at any age, 90% of cases occur in those under 40 years. The disease most often develops in boys between 2 and 14 years (Kazzi, 2009). This case study focuses on how an individual could acquire acute glomerulonephritis; what are the causes, its signs and symptoms, its development and its treatment. The discussion are mainly centered to the certain patient we had at CRMC. All data used in this research came from the course of stay in the hospital. Moreover, with this study we also aimed to be able to gain wholistic growth and have knowledge and skills enhancement as future members of the health team. In our 3 days stay in the said hospital, we had handled various cases of patient. Among those, our selected patients condition captured our attention and we became interested with our patients diagnosis.

A Case Study

As health advocates, we should be aware and informed about the condition, how it happened, its complications and the appropriate nursing plans to be implemented in order to meet the needs of the patient. This case study provides sufficient information about a disease of the kidneys called, acute glomerulonephritis.

A Case Study CHAPTER II

OBJECTIVES

General Objectives This case study aims to conduct an extensive and comprehensive research about Acute glomerulonephritis through conducting effective gathering methods and using appropriate communication skills in conversing to our exposure in the Pedia Ward of Cotabato Regional and Medical Center. Specific Objectives In order to serve as our guide in finishing this mini case study, we have formulated the following goals: Establish a trusting relationship with our client and his family in order to gain cooperation and gather information needed for this mini case study. Assess our patient thoroughly and holistically to come up with an accurate physical assessment. Determine clients personal background as well as history and present conditions. To define Acute Glomerulonephritis. To know the clinical manifestation, nursing management and interventions for patients who have this disease.

Trace the pathophysiology of the clients condition.

A Case Study

To know the different medication for patients with AGN and know their side effects which can be harmful.

To know how AGN is diagnosed and the important laboratory examinations that will confirm AGN

Discuss the nursing interventions and the medical surgical management for the client.

To know the nursing priorities to consider when dealing with patients of AGN Formulate effective nursing care plans based on identified nursing problems. Provide information for the clients parents to broaden their knowledge, ideas and level of awareness regarding her condition.

To be able to recognize the importance of patient and familial preferences when selecting among treatment options.

A Case Study CHAPTER III

PATIENTS HISTORY

Baseline Information A. Personal Data NAME: AGE: SEX: STATUS: NATIONALITY: DATE OF BIRTH: RELIGION: B. Clinical Data ROOM: DATE OF ADMISSION: PEDIA WARD ROOM C January 19, 2013 Baby AGN 12y.o Male Child Filipino August 20, 2000 Islam

ATTENDING PHYSICIAN: Myla Faye R. Villamor, MD DIAGNOSIS: Malnutrition INITIAL VS: To consider Acute Glomerulonephritis, Severe Acute

Temperature: 36.9 Heart rate: 104bpm Respiratory rate: 36 bpm Blood pressure: 90/60mmHg

HEALTH HISTORY

A Case Study Family health history

According to the mother of the client, they dont have any history similar to the case of their son. The mother has a family history of hypertension and asthma. On the other hand, the father has a family history of arthritis and anemia. The mother was older than her husband. She also stated that she gave birth to the client at the age of 32 years and was delivered at home at exactly 7 months and 3 weeks. The client is the youngest among her 5 children. During pregnancy, the mother had complete pre-natal check-up and completely immunized with Tetanus Toxoid vaccine. Also, the mother stated that she dont usually eat salty foods but loves to drink native coffee even during pregnancy. Moreover, her children were all bottle fed. Regarding the diet of the client, he loves to eat salty foods like junk foods and carbonated drinks such as coke. Past health history According to the mother, the child has complete immunization. During childhood, the child had common colds associated with cough, sore throat and fever. Every time the child gets sick, theyre going to the nearest health center to seek for consultation and were usually given with paracetamol for fever. The child had never been admitted and it was his first hospitalization when he was diagnosed with Acute Glomerulonephritis. Present Health History A month prior to admission, the client had on and off fever with facial edema, noticed to have gradual onset of pallor and no consultation done and also no mediation given. Three days prior to admission, the client had complaints of on and off abdominal pain associated with tea-colored urine. The signs and symptoms become persistent and

A Case Study so, they prompted consultation to outpatient department of CRMC. Chest X-ray,

ultrasound and urinalysis was performed. The mother stated that the doctor suspected the child to have urinary tract infection and they were advised to admit the patient but they refused. On the day of admission, the client reported that the signs and symptoms such as abdominal pain is no longer tolerable and still with blood in the urine. The parents then decided to admit their child.

A Case Study CHAPTER IV

PHYSICAL ASSESSMENT

A. GENERAL PHYSICAL SURVEY Appearance and behaviour: 1. Age, sex & race: Female, Filipino-Asian 2. Body built: Ectomorphic 3. Posture & gait: Good posture with normal and balanced gait 4. Hygiene and grooming: poor hygienic status, untrimmed nails 5. Dress : dressed appropriately, shorts is worn for 2 days (wears loose t-shirt and shorts) 6. Odor of body and breath: no body odor, breath odor is mildly foul 7. Signs of distress: no signs of distress 8. Apparent state of health: appeared unhealthy, the child is so thin 9. Attitude: cooperative, answers questions directly 10. Affect & mood: verbal cues are congruent with the nonverbal cues 11. Speech: clear and understandable, speaks in moderate pace. 12. Thought process: logical, answers question appropriately Measurements: Height: 116 centimeters Weight:19 kilograms

A Case Study Neurologic: State of consciousness: Alert Orientation: oriented Emotional state: relaxed and calm Vital signs: Temperature: 36.9 0C Cardiac rate: 104 bpm, regular Pulse rate: 100 bpm, regular Respiratory rate: 36bpm B. CEPHALOCAUDAL ASSESSMENT a. HEAD: normocephalic b. FACIAL MOVEMENT: symmetrical c. FONTANELS: closed d. HAIR: Color: black Amount and distribution: well-distributed hair Texture: Soft Presence of parasites: none e. SCALP: Symmetry: symmetrical Texture: smooth Lesions: none f. SKULL: Rounded skull

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A Case Study g. FACE: dark brown complexion h. FOREHEAD: Smooth and firm i. EYES: Eyebrows: symmetrical in shape Position and appearance: lashes are short and evenly distributed, and curled outward; upper margins of lid cover approximately 2 mm of the iris Blinking: 13blinks per minute on both eyes Conjunctiva: Pale palpebral conjunctiva and without discharges Bulbar conjunctiva is clear with visible tiny vessels Cornea: transparent, smooth and moist cornea noted Sclera: anicteric sclera Iris and pupil: round shape, equal and with uniform color of iris Pupils reaction to light: Brisk a. EARS: Symmetry: Symmetrical ears External canal: no discharges External pinnae: normoset Hearing: normal j. NOSE: Patency: both patent Sinuses: no tenderness Smell: normal in both nose

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A Case Study k. MOUTH: Lips: symmetrical lip, without lesions Color of the lips: upper lip is dark reddish brown, lower lip is pale Gums: pale in color and dry Tongue: Furred tongue and with some lesions noted on the taste buds Pharynx: midline uvula, not inflamed, pinkish l. NECK: supple neck m. SKIN: rough and dry, warm to touch, dark brown in color n. NAIL: Color: pale nail beds Texture: nail round and soft Condition of nail bed: smooth nails Capillary refill: 2 seconds

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o. CHEST/LUNGS: Chest and lung expansion symmetry are equal, intercostals spaces are equal; respiratory rhythm and depth are even, friction rub upon auscultation p. ABDOMEN: Abdominal distention noted q. GENITO-URINARY: With minimal urine output, tea colored urine r. UPPER EXTREMITIES: Patients upper limbs, shoulders and arms were symmetrical. No deformities and swelling noted. No tenderness on the bones of the wrists and fingers and no structural deviations. s. LOWER EXTREMITIES: Lower limbs were symmetrical. Presence of edema + 1on right lower leg.

A Case Study C. Focused Assessment Abdominal Assessment A.) Inspection

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Skin: color of the abdomen is lighter than the exposed parts of the body. Umbilicus: flat, centrally located at the midline and pale in color. Contour: distended and round in contour. Symmetry: abdomen is symmetrical upon inspection. Enlarged organs: no enlarged organs based on diagnostic tests B.) Auscultation Bowel sounds: Hypoactive bowel sounds heard in all four quadrants upon auscultation. C.) Percussion Entire Abdomen: no presence of solid masses and dullness heard upon percussion D.) Palpation: no presence of tenderness, no masses and enlarged organs

A Case Study CHAPTER V

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ANATOMY AND PHYSIOLOGY

The Urinary System The Urinary System is a system of organs that produces and excretes urine from the body. Urine is a transparent yellow fluid containing unwanted wastes, mostly excess water, salts, and nitrogen compounds. The major organs of the urinary system are the kidneys, a pair of bean-shaped organs that continuously filter substances from the blood and produce urine. Urine flows from the kidneys through two long, thin tubes called

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ureters. With the aid of gravity and wavelike contractions, the ureters transport the urine to the bladder, a muscular vessel. The normal adult bladder can store up to about 0.5 liter (1 pt) of urine, which it excretes through the tube like urethra. An average adult produces about 1.5 liters (3 pt) of urine each day, and the body needs, at a minimum, to excrete about 0.5 liter (1 pint) of urine daily to get rid of its waste products. Excessive or inadequate production of urine may indicate illness and doctors often use urinalysis (examination of a patients urine) as part of diagnosing disease. For instance, the presence of glucose, or blood sugar, in the urine is a sign of diabetes mellitus; bacteria in the urine signal an infection of the urinary system; and red blood cells in the urine may indicate cancer of the urinary tract. Functions of the urinary system Excretion. The kidneys are the major excretory organs of the body. They remove waste products, many of which are toxic, from the blood. Most waste products are metabolic by products of cells and substances absorbed from the intestine. The skin, liver, lungs, and intestines eliminate some of these waste products, but they cannot compensate if the kidneys fail to function. Blood volume control. The kidneys play an essential role in controlling blood volume by regulating the volume of water removed from the blood to produce urine. Ion concentration regulation. The kidneys help regulate the concentrate of the major ion in the body fluids. pH regulation. The kidneys help regulate the pH of the body fluids. Buffers in the blood and the respiratory system also play important roles in the regulation of pH.

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Red blood cell concentration. The kidneys participate in the regulation of red blood cell production and, therefore, in controlling the concentration of red blood cells in the blood. Vitamin D synthesis. The kidneys, along with the skin and the liver, participate in the synthesis of vitamin D. Kidneys The kidneys are bean-shaped organs, each about the size of a tightly clenched fist. They lie on the posterior abdominal wall, behind the peritoneum, with one kidney on either side of the vertebral column. Structures that are behind the peritoneum are said to be retroperitoneal. The kidneys are abundantly supplied with blood vessels- they process blood the kidneys receive 20 25% of the resting cardiac output via the right and left renal arteries. In adults, blood flow through both kidneys (renal blood flow) is about 1200 ml per minute. Function of the kidneys The functions of the kidney are regulation of blood ionic composition, regulation of blood pH , regulation of blood volume, regulation of blood pressure, maintenance of blood osmolarity , production of hormones, regulation of blood glucose level , and excretion of wastes and foreign substances. Three layers of tissue surround each kidney The renal capsule. The deep layer, smooth, transparent sheet of dense irregular connective tissue. Serves as a barrier against trauma and helps maintain the shape of the kidneys. Continuous with the outer coat of the ureter.

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The adipose capsule. Middle layer, a mass of fatty tissue surrounding the renal capsule. Protects kidney from trauma and holds it firmly in place in the abdominal cavity. The renal fascia. The superficial layer, thin layer of dense irregular connective tissue. anchors the kidney to surrounding structures and to the abdominal wall. Glomerulus In the kidney, a tubular structure called the nephron filters blood to form urine. At the beginning of the nephron, the glomerulus is a network (tuft) of capillaries that performs the first step of filtering blood. The glomerulus is surrounded by Bowman's capsule. The blood is filtered through the capillaries of the glomerulus into the Bowman's capsule. The Bowman's capsule empties the filtrate into a tubule that is also part of the nephron. A glomerulus receives its blood supply from an afferent arteriole of the renal circulation. Unlike most other capillary beds, the glomerulus drains into an efferent arteriole rather than a venule. The resistance of these arterioles results in high pressure within the glomerulus, aiding the process ofultrafiltration, where fluids and soluble materials in the blood are forced out of the capillaries and into Bowman's capsule. A glomerulus and its surrounding Bowman's capsule constitute a renal corpuscle, the basic filtration unit of the kidney. The rate at which blood is filtered through all of the glomeruli, and thus the measure of the overall renal function, is the glomerular filtration rate (GFR). Afferent circulation

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The afferent arteriole that supplies the capillaries of a glomerulus branches off of an interlobular artery in the renal cortex. Glomerular capillary pressure, and thus glomerular filtration rate, can be influenced by constriction or relaxation of the afferent arteriole, resulting in decreases or increases in pressure. As an example, one study involving rats found that having narrowed afferent arterioles contributed to the development of increased blood pressure. Sympathetic nervous system action as well as hormones can also impact glomerular filtration rate by modulating afferent arteriole diameter. Layers If a substance has passed through the glomerular capillary endothelial cells, glomerular basement membrane, and podocytes, then it enters the lumen of the tubule and is known as glomerular filtrate. Otherwise, it exits the glomerulus through the efferent arteriole and continues circulation as discussed below and as shown on the picture. Endothelial cells The endothelial cells of the glomerulus contain numerous pores (fenestrae) that, unlike those of other fenestrated capillaries, are not spanned by diaphragms. The cells have fenestrations that are 70 to 100 nm in diameter. Since these pores are relatively large, they allow for the free filtration of fluid, plasma solutes and protein. However they are not large enough that red blood cells can be filtered. Glomerular basement membrane

A Case Study The glomerular endothelium sits on a very thick (250350 nm) glomerular

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basement membrane. The glomerular basement membrane (GBM) of the kidney is the basal lamina layer of the glomerulus. The glomerular capillary endothelial cells, the GBM and the filtration slits between the podocytes perform the filtration function of the glomerulus, separating the blood in the capillaries from the filtrate that forms in Bowman's capsule. The GBM is a fusion of the endothelial cell and podocyte basal laminas. Podocytes Podocytes line the other side of the glomerular basement membrane and form part of the lining of Bowman's space. Podocytes form a tight interdigitating network of foot processes (pedicels) that control the filtration of proteins from the capillary lumen into Bowman's space. The space between adjacent podocyte foot processes is spanned by a slit diaphragm formed by several proteins including podocin and nephrin. In addition, foot processes have a negatively charged coat (glycocalyx) that limits the filtration of negatively charged molecules, such as serum albumin. The podocytes are sometimes considered the "visceral layer of Bowman's capsule", rather than part of the glomerulus. Ureters The ureters are two slender tubes that run from the sides of the kidneys to the bladder. Their function is to transport urine from the kidneys to the bladder. Bladder

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The bladder is a muscular organ and serves as a reservoir for urine. Located just behind the pubic bone, it can extend well up into the abdominal cavity when full. Near the outlet of the bladder is a small muscle called the internal sphincter, which contract involuntarily to prevent the emptying of the bladder. Urethra The urethra is a tube that extends from the bladder to the outside world. It is through this tube that urine is eliminated from the body.

A Case Study CHAPTER VI

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PATHOPHYSIOLOGY

Schematic Diagram Predisposing Factors: >Child (12 y.o) >Gender (Male) Precipitating Factor: >Post-streptococcal infection (sore throat)

Release of antigen by the group a beta-hemolytic streptococci into the circulation Formation of Antibodies

Immune complex reaction in the glomerular capillary Inflammatory process Activation of complement pathways Attack glomerular basement membrane Proliferation of epithelial cells lining glomerolus and cells between endothelium and epithelium of capillary membrane. Swelling of capillary membrane and infiltration with leukocytes

Damage glomeruli Irritation on the Hematuria tissue

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Dark or tea colored urine Thickening of the glomerular filtration membrane Scarring and loss of glomerular filtration membrane

Decrease glomerular filtration rate Decrease ability to form filtrate from glomeruli plasma flow Retention of water and sodium Decrease urinary output

Fluid Shifting Facial & lower extremities edema

Increase blood volume Hypertension

Narrative Glomerulonephritis also known as glomerular nephritis (GN) or glomerular disease is a disease of the kidney, characterized by inflammation of the glomeruli. Glomeruli are very small blood vessels in the kidneys that act as tiny little filters - there are about one million glomeruli in each kidney. The disease damages the kidneys' ability to remove waste and excess fluids from the body. GN can be acute, meaning there is a sudden attack of inflammation, or chronic (long-term and coming on gradually). People can develop glomerulonephritis on its own, in which case it is called primary

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glomerulonephritis. If it is caused by another disease, such as diabetes or lupus, infection, or drugs it is called secondary glomerulonephritis (Nordqvist, 2009). Glomerulonephritis (GN) is a disease condition where immunologic mechanisms trigger inflammation of the glomerulus as well as the proliferation of glomerular tissue resulting into basement membrane, mesangium, and capillary endothelium damage (Papanagnou, 2008). Etiologies may vary, however, majority of the cases are idiopathic while one of the known causes of GN include infection such as that of streptococcal infection (Pais, Kump, & Greenbaum, 2008). Because of this, clinical manifestations of patients with GN include hematuria, proteinuria and RBC casts which may be accompanied by azotemia, oliguria, and decreased GFR (glomerular filtration rate). According to Mayo Clinic, a variety of conditions can cause glomerulonephritis, ranging from infections that affect the kidneys to diseases that affect the whole body, including the kidneys. Sometimes the cause is unknown. Here are some examples of conditions that can lead to inflammation of the kidneys' glomeruli: Infections

Post-streptococcal glomerulonephritis. Glomerulonephritis may develop a week or two after recovery from a strep throat infection or, rarely, a skin infection (impetigo). An overproduction of antibodies stimulated by the infection may eventually settle in the glomeruli, causing inflammation. Symptoms usually include swelling, reduced urine output and blood in the urine. Children are more likely to develop post-streptococcal glomerulonephritis than are adults, and they're also more likely to recover quickly.

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Bacterial endocarditis. Bacteria can occasionally spread through your bloodstream and lodge in your heart, causing an infection of one or more of your heart valves. Those at greatest risk are people with a heart defect, such as a damaged or artificial heart valve. Bacterial endocarditis is associated with glomerular disease, but the exact connection between the two is unclear.

Viral infections. Among the viral infections that may trigger glomerulonephritis are the human immunodeficiency virus (HIV), which causes AIDS, and the hepatitis B and hepatitis C viruses.

Immune diseases

Lupus. A chronic inflammatory disease, lupus can affect many parts of your body, including your skin, joints, kidneys, blood cells, heart and lungs.

Goodpasture's syndrome. A rare immunological lung disorder that may mimic pneumonia, Goodpasture's syndrome causes bleeding (hemorrhage) into your lungs as well as glomerulonephritis.

IgA nephropathy. Characterized by recurrent episodes of blood in the urine, this primary glomerular disease results from deposits of immunoglobulin A (IgA) in the glomeruli. IgA nephropathy can progress for years with no noticeable symptoms. The disorder seems to be more common in men than in women. Vasculitis

Polyarteritis. This form of vasculitis affects small and medium blood vessels in many parts of your body, such as your heart, kidneys and intestines.

Wegener's granulomatosis. This form of vasculitis affects small and medium blood vessels in your lungs, upper airways and kidneys.

A Case Study Conditions that are likely to cause scarring of the glomeruli:

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High blood pressure. Damage to your kidneys and their ability to perform their normal functions can occur as a result of high blood pressure. Glomerulonephritis can also cause high blood pressure because it reduces kidney function.

Diabetic kidney disease. Diabetic kidney disease (diabetic nephropathy) can affect anyone with diabetes. Diabetic nephropathy usually takes years to develop. Good control of blood sugar levels and blood pressure may prevent or slow kidney damage.

Focal segmental glomerulosclerosis. Characterized by scattered scarring of some of the glomeruli, this condition may result from another disease or occur for no known reason. Chronic glomerulonephritis sometimes develops after a bout of acute

glomerulonephritis. In some people there's no history of kidney disease, so the first indication of chronic glomerulonephritis is chronic kidney failure. Infrequently, chronic glomerulonephritis runs in families. One inherited form, Alport syndrome, may also involve hearing or vision impairment. Glomerular lesions in acute GN are the result of glomerular deposition or in situ formation of immune complexes. On gross appearance, the kidneys may be enlarged up to 50%. Histopathologic changes include swelling of the glomerular tufts and infiltration with polymorphonucleocytes. Immunofluorescence reveals deposition of immunoglobulins and complement. Acute GN involves both structural changes and functional changes. Structurally, cellular proliferation leads to an increase in the number of cells in the glomerular tuft because of the proliferation of endothelial, mesangial, and

A Case Study epithelial cells. The proliferation may be endocapillary (ie, within the confines of the glomerular capillary tufts) or extracapillary (ie, in the Bowman space involving the

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epithelial cells). In extracapillary proliferation, proliferation of parietal epithelial cells leads to the formation of crescents, a feature characteristic of certain forms of rapidly progressive GN. Leukocyte proliferation is indicated by the presence of neutrophils and monocytes within the glomerular capillary lumen and often accompanies cellular proliferation. Glomerular basement membrane thickening appears as thickening of capillary walls on light microscopy. On electron microscopy, this may appear as the result of thickening of basement membrane proper (eg, diabetes) or deposition of electron-dense material, either on the endothelial or epithelial side of the basement membrane. Electron-dense deposits can be subendothelial, subepithelial, intramembranous, or mesangial, and they correspond to an area of immune complex deposition. These structural changes can be focal, diffuse or segmental, or global. Functional changes include proteinuria, hematuria, reduction in GFR (ie, oligoanuria), and active urine sediment with RBCs and RBC casts. The decreased GFR and avid distal nephron salt and water retention result in expansion of intravascular volume, edema, and, frequently, systemic hypertension (Parmar, 2012). Acute poststreptococcal glomerulonephritis (APSGN) results from an antecedent infection of the skin or throat caused by nephritogenic strains of group A beta-hemolytic streptococci. The concept of nephritogenic streptococci was initially advanced by Seegal and Earl in 1941, who noted that rheumatic fever and acute poststreptococcal glomerulonephritis (both nonsuppurative complications of streptococcal infections) did not simultaneously occur in the same patient and differ in geographic location. Acute

A Case Study poststreptococcal glomerulonephritis occurs predominantly in males and often completely heals, whereas patients with rheumatic fever often experience relapsing

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attacks. Most forms of acute poststreptococcal glomerulonephritis (APSGN) are mediated by an immunologic process. Cellular and humoral immunity is important in the pathogenesis of this disease, and humoral immunity in APSGN. Nonetheless, the exact mechanism by which APSGN occur remains to be determined. The 2 most widely proposed theories include (1) glomerular trapping of circulating immune complexes and (2) in situ immune antigen-antibody complex formation resulting from antibodies reacting with either streptococcal components deposited in the glomerulus or with components of the glomerulus itself, which has been termed molecular mimicry (Bhimma, 2012). In most cases of acute glomerulonephritis, a group A betahemolytic streptococcal infection of the throat precedes the onset of glomerulonephritis by 2 to 3 weeks (Fig. 453). It may also follow impetigo (infection of the skin) and acute viral infections (upper respiratory tract infections, mumps, varicella zoster virus, Epstein-Barr virus, hepatitis B, and human immunodeficiency virus infection). In some patients, antigens outside the body (eg, medications, foreign serum) initiate the process, resulting in antigen-antibody complexes being deposited in the glomeruli. In other patients, the kidney tissue itself serves as the inciting antigen (Brunner & Suddarth, 2009).

A Case Study CHAPTER VII

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COURSE IN THE HOSPITAL DATE/TIME ORDER 1/19/13 -Admit to miscellaneous ward 3pm -secure consent to care Wt. 21kg Bp: 110/70 -VS q4 hr RATIONALE -For legal purposes; protection between the patient,health providers and the institution - Serves as baseline information for any changes in the health status of the pt. -Because sodium attracts water causing water retention -to determine abnormal values in the blood components which can help diagnose the condition of the client and to know the blood type in case blood transfusion is needed - check kidney function & help diagnose other dse., determines whether bacteria are present in the urine, strains & concentration - to assess residual renal function & the need for dialysis or transplantation -to detect presence of infection - to delineate the size, shape and position of the kidneys and to reveal urinary system abnormalities - to tx electrolytes and water imbalances

-Low salt diet

-LABS: 1. CBC, BT STAT

2. U/A

3. Serum creatinine, BUN

4. ESR 5. UTZ of KUB

-start venoclysis: D5.3 NaCl 500cc @ 60cc/hr

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-Meds: 1.Pen G 525,000 "u" IVTT q6hr ANST 2. Ranitidine 21mg IVTT q8hr

3. Furosemide 20mg IVTT q12hr

-MIO q shift & record without fail

-Monitor BP q4hr & record

-weigh pt. daily

-to treat infections - healing and/or prevention of ulcers; decreased secretion of gastric acid - Management of renal dse. ; diuresis and subsequent mobilization of excess fluid - to determine the balance in the intake & output of the pt in terms of fluids as well as to check for adequate circulation & functioning of the kidneys -Because patient may exhibit high BP due to current condition -to check if there is retention of fluids (a kilogram increase in wt is equal to a litre of fluid retention) -the previous dose is not enough to treat the infection -determines whether bacteria are present in the urine, as well as the strains and concentration . Also identify the antimicrobial therapy that is best suited for the particular strains identified

1/20/13

-Increase Pen G to 1m unit q6hr

-For urine cs

6:30

-ff-up UTZ of tom AM -cont. IVF @SR -D/c Furosemide -change IVF to D5W 1l @150cc x8hr -med revising IVF(D5.3% NaCl x 150cc) then terminate once consumed -Metoclopramide 3mg IVTT now

-therapeutic effect has been already met -can cause fluid overload -to treat electrolytes and fluid imbalances -decrease or prevention of nausea and vomiting

A Case Study -continue meds: 1. Pen G 2. Ranitidine -follow-up UTZ result -ff. CXR result -ff CBC result -for urine CS

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-determines whether bacteria are present in the urine, as well as the strains and concentration. Also identify the antimicrobial therapy that is best suited for the particular strains identified

1/22/13 10am -cont. meds -still for re-UA & urine c/s- provide request -ff-up CXR result -IVF TF: D5.3 NaCl 500cc@60cc/hr -continue monitoring -to prevent complication, aids in treating pt. 8am -ReCBC today to determine if pt is progressing or improving with his condition -cont. meds - ff-up ESR, ASO titer -ff-up CXR result -IVF tf with D5 IMB 500cc @SR -to receive 1"u" of PRBC of pt's blood type B -Transfuse 280cc in 4hr after proper -because pt's rbc decreased screening and crossmatching As well as the haemoglobin - Furosemide 10mg IVTT TID & post BT -to prevent cardiac overload post BT -Oxacillin 525mh IVTT q6 ANST -to treat infections -for serum electrolytes -to check electrolytes status of the patient -limit oral fluid intake -to prevent fluid overload -IVF Tf: D5.3 NaCl 500cc @SR -to treat electrolytes and fluid imbalances -cont. monitoring -cont. meds Pen G

1/23/13

1/24/13

1/26/13

A Case Study -still for BT follow-up of blood please -cont. IVF @SE -cont. monitoring -weigh pr. Daily before breakfast -cont. meds -reCBC 6hr post BT -IVF tf with D5IMB 500cc @SR

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1/27/13 6am ongoing BT (+) vomiting 1x yesterday 1/28/13 11am Pen G Oxacillin 1/29/13 8:15am D4 Oxacillin D8 Pen G (-) edema UO- 0.8cc/hr 1/30/13 5:30am Hgt: 141 Weak pulses

-reinserted IVF -cont. meds -cont. monitoring -cont. meds- Oxacillin and Pen G -resume Furosemide 20mg IVTT q12hr -IVF tf: D5 IMB 800cc @SR

-IV push 210cc of PNSS now -hold Furosemide temporarily -repeat serum electrolytes STAT -repeat BP after IV push

7am

-run another 210cc of PNSS now -start Dopamine 7.8 cc/hr via perfusor pump

-to prevent fluid deficit -to check electrolytes status of the patient -to check effectiveness of the therapy --adjunct to standard measures to improve blood pressure, cardiac output and improve renal blood flow

8:30am NO MIO No conscious ambulation 370 Wt 19

-close watch -pls. Wt pt now and record -continue MIO q shift and record without fail. -repeat CXR APL today without fail -cont. meds: Pen G D8-D9 Oxacillin D5D6 -IVF to KVO -limit OFI to 220cc -pls. Incorporate 10meqs KCl to present IVF regulate @SR -still for x-ray APL now(rpt) today without fail pls.

-to prevent fluid overload -to prevent fluid overload -treatment or prevention of K depletion

3pm

1/31/13

A Case Study -cont. meds -cont. IVF @SR -cont. monitoring I&O q shift; daily wt. -refer accordingly. -shift Pen G to Ceftriaxone 2.9 mg IVYT OD, +20cc D5W as side drip via soluset -D/C Pen G once @ Ceftriaxone -IVF TF: D5LR 1L @KVO -ff-up repeat CXR

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2/1/13

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CHAPTER VIII

NURSING CARE PLAN # 1

HRP NSG. DX AMB
SUBJECTIVE

PATHOPHYSIOLOGY

CLIENT OUTCOME

INTERVENTION

RATIONALE

EVALUATION

E X C H A N G I N G

Imbalance nutrition: Less than body requiremen ts related to increased metabolic needs

Medyo gumaan siya. Hind na kasi siya kumakain as verbalized by the mother.

Intestinal fluid output overwhelms the absorptive capacity of the GI tract Damage the villous brush border of the intestine malabsorption of intestinal contents Leading to an osmotic diarrhea Release of toxins that binds to a specific enterocyte receptors Release of chloride ions into the intestinal

OBJECTIVE

-Weight loss without adequate calorie intake. -slightly pallor

Within 4 days of duty, the significant others will verbalizes and demonstrates selection of food/meals that will achieve a cessation of weight loss.

INDEPENDENT -Obtain vital signs frequently.

-To monitor some complication that present in the disease process and will have baseline comparisons. -To monitor nutrional intake of the patient and body functions. -Caffeinated beverages may decrease appetite and carbonated beverages may lead to satiety. -To prevent dehydration

-Monitor Intake and out put

-Discourage to give beverages that are caffeinated and carbonated beverages.

GOAL MET. Patient verbalize Medyo kumakain na siya ng mabuti hidi tulad dati. Medyo bumabalik na din yung katawan niya; normal sin color; afebrile; capillary refill of less than 2 seconds.

-Instruct adequate hydration treatment.

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lumen, leading to secretory diarrhea -Monitor Intravenous fluid therapy. COLLABORATIVE -Administer medications as prescribed. -To ensure proper hydration.

-To treat underlying illnesss.

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NURSING CARE PLAN # 2

HRP NSG. DX AMB
SUBJECTIVE

PATHOPHYSIOLOGY

CLIENT OUTCOME

INTERVENTION

RATIONALE

EVALUATION

E X C H A N G I N G

Loose bowel movement related to Diarrhea secondary to disease process

6 na beses siyang dumumi sa ngayon tapos matubig, sa ihi naman kakaunti lang 2-3x as verbalized by the mother.

Intestinal fluid output overwhelms the absorptive capacity of the GI tract Damage the villous brush border of the intestine malabsorption of intestinal contents Leading to an osmotic diarrhea Release of toxins that binds to a specific enterocyte receptors Release of chloride ions into the intestinal lumen, leading to secretory diarrhea

Within 4 days of duty, mother of patient will report reduction in frequency of stools and return to more normal stool consistency.

INDEPENDENT: - Observe and record stool frequency, characteristics, amount, and precipitating factors. -Identify foods and fluids that precipitate diarrhea.

OBJECTIVE

-Increase bowel sounds noted -Frequent and often severe, mushy stools -decreased skin turgor -capillary refill more than 2 seconds.

-Monitor Intake and Output.

GOAL MET. Mother verbalized 4 na beses lang siya nakabawas ngayong araw. -Avoiding intestinal Mejo matubig irritants promotes pa din pero intestinal rest. hindi na gaya ng dati; capillary refill -Provides information less than 2 about aver all fluid seconds; good balance, renal function, skin turgor. and bowel disease control, as well as guidelines or fluid replacement. -Helps differentiate individual disease and assess severity of episode.

-Observe -Indicates excessive for excessively dry fluid loss/resultant skin and mucous dehydration. membranes, decreased skin turgor, slowed capillary refill COLLABORATIVE Administer parenteral

-Maintenance

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fluids, blood transfusions as indicated

of bowel rest requires alternative fluid replacement to correct losses/anemia. Note: fluids containing sodium may be restricted in presence of regional enteritis. -Reduces fluid losses from intestines.

-Administer antidiarrheal medications as prescribed.

NURSING CARE PLAN # 3

HRP NSG. DX AMB
SUBJECTIVE

A Case Study
RATIONALE

37

PATHOPHYSIOLOGY

CLIENT OUTCOME

INTERVENTION

EVALUATION

E X C H A N G I N G

Deficient fluid volume related to frequent passage of loose watery stools secondary to diarrhea

6 na beses siyang dumumi sa ngayon tapos matubig, sa ihi naman kakaunti lang 2-3x as verbalized by the mother.
OBJECTIVE

Intestinal fluid output overwhelms the absorptive capacity of the GI tract Damage the villous brush border of the intestine malabsorption of intestinal contents Leading to an osmotic diarrhea

Within 4 days of duty, the patient will maintain fluid volume as evidence by hydration status, intake is equal as output and good skin turgor.

INDEPENDENT: -Establish rapport. -Monitor I & O

-To gain parents trust -To ensure accurate picture of fluid status -To prevent dehydration and maintain hydration status -To prevent oral mucous membrane from dryness

-Increase and maintain fluid intake. -Instruct mother to provide frequent oral care.

GOAL MET. Patient has normal urine output; good skin turgor and good hydration status; afebrile; responsive

-Weight loss noted -dry mucous membranes -weakness noted -loose watery stools noted

COLLABORATIVE:

Release of toxins that binds to a specific enterocyte receptors Release of chloride ions into the intestinal lumen, leading to secretory diarrhea

-Administer intravenous fluid as prescribed. -Administer prescribed medications

-To deliver fluids accurately and at desired type and rate. -To treat underlying cause

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NURSING CARE PLAN # 4

HRP NSG. DX AMB
SUBJECTIVE

PATHOPHYSIOLOGY

CLIENT OUTCOME

INTERVENTION

RATIONALE

EVALUATION

K N O W I N G

Risk for Impaired Skin integrity related to altered fluid status

6 na beses siyang dumumi sa ngayon tapos matubig, sa ihi naman kakaunti lang 2-3x as verbalized by the mother.
OBJECTIVE

Intestinal fluid output overwhelms the absorptive capacity of the GI tract Damage the villous brush border of the intestine malabsorption of intestinal contents Leading to an osmotic diarrhea Release of toxins that binds to a specific enterocyte receptors Release of chloride ions into the intestinal lumen, leading to secretory diarrhea

Within 4 days of duty, the mother of the patient will verbalize that the childs perinea and rectal tissue remains pink and intact.

INDEPENDENT: -Assess skin of perineum and rectum for signs of skin Breakdown or irritation.

-slightly dry skin -decreased skin turgor -slightly pallor -slightly dry lips

GOAL MET. Wala man gapula-pula mga singit nya. Gina hugasan ko ko yan para hindi ma irritate as verbalized by -Instruct mother to -Minimizes skin the mother; change diapers every contact with perinea and 2 hours as needed. chemical irritants rectal tissue from stool remains pink and urine and intact; afebrile; moist -Instruct mother to -Removes traces of skin; good skin wash diaper area after stool if color and skin each soiling. Present turgor. -Early assessment and intervention can prevent worsening of the condition

COLLABORATIVE: -Notify the physician if the skin is severely broken or peeling or if a rash is present. -For early detection and treatment.

NURSING CARE PLAN # 5

HRP NSG. DX AMB SUBJECTIVE PATHOPHYSIOLOGY CLIENT OUTCOME INTERVENTION

A Case Study
RATIONALE

39

EVALUATION

F E E L I N G

Fear related to perceived threat or danger secondary to the presence of the health care provider.

Takot po talga yan siya sa naka puti as verbalized by the mother

OBJECTIVE

Intestinal fluid output overwhelms the absorptive capacity of the GI tract Damage the villous brush border of the intestine malabsorption of intestinal contents Leading to an osmotic diarrhea Release of toxins that binds to a specific enterocyte receptors Release of chloride ions into the intestinal lumen, leading to secretory diarrhea

-sweating -crying in the presence of the health care provider -dry oral mucous membranes

Within 4 days of duty, patient will show decrease or absence of fear manifested by decrease crying and smiling.

INDEPENDENT: -Establish rapport.

-To gain trust of the child and parents -The childs fear will decrease if the child will know that these instruments are not harmful -Patients feeling of stability increases in a calm and nonthreatening atmosphere. -To let the patient feel secure when interacting with the health care provider.

-Let the patient play with your instruments e.g stethoscope, thermometer etc. -Maintain calm and tolerant manner while interacting with the patient.

GOAL PARTIALLY MET. Patient is still crying in the presence of health care provider but can be stopped if the health care provider let the child play while interacting.

-Instruct the mother to stay beside the child when in the presence of the health care provider. -Encourage rest periods.

-To improve the childs ability to cope

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DRUG STUDY # 1
GENERIC NAME BRAND NAME CLASSIFICATION MODE OF ACTION INDICATION CONTRAINDICATION ACTUAL DOSE USUAL DOSE S/E NSG. INTERVENTIONS

F U R O S E M I D E

L A S I X

L O O P D I U R E T I C S

Rapidacting potent sulfonami de loop diuretic and antihyper tensive with pharmaco logic effects and uses almost identical to those of ethacryni c acid. Exact mode of action not clearly defined; decreases renal vascular

Treatment of edema associated with CHF, cirrhosis of liver, and kidney disease, including nephrotic syndrome. May be used for manageme nt of hypertensio n, alone or in combinatio n with other antihyperte nsive agents, and for treatment of hypercalce

History of hypersensitivity to furosemide or sulfonamides; increasing oliguria, anuria, fluid and electrolyte depletion states; hepatic coma; pregnancy (category C), lactation.

Furose mide 20mg IVTT q12

IV/IM 2040 mg in 1 or more divided doses up to 600 mg/dse

CV:Postural hypotension, dizziness with excessive diuresis, acute hypotensive episodes, circulatory collapse. Metabolic:Hy povolemia, dehydration, hyponatremia, hypokalemia, hypochloremi a metabolic alkalosis, hypomagnese mia, hypocalcemia (tetany), hyperglycemia , glycosuria, elevated BUN, hyperuricemia ;. GI:Nausea, vomiting, oral and gastric burning, anorexia, diarrhea,

Observe 10Rs accurately. Monitor BP during periods of dieresis. Report adverse reaction/symptoms to physician. Monitor for S&S of hypokalemia such as muscle weakness, diminished knee reflexe, biceps, etc. Monitor I&O ratio and pattern. Report decrease or unusual increase in output. Excessive diuresis can result in dehydration and hypovolemia, circulatory collapse, and

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41

resistance and may increase renal blood flow. Therapeutic effects : Inhibits reabsorption of sodium and chloride primarily in loop of Henle and also in proximal and distal renal tubules; an antihypertens ive that decreases edema and intravascular volume. Reportedly less ototoxic than ethacrynic acid.

mia. Has been used concomitan tly with mannitol for treatment of severe cerebral edema, particularly in meningitis.

constipation, abdominal cramping, acute pancreatitis, jaundice. Urogenital:Al lergic interstitial nephritis, irreversible renal failure, urinary frequency. Hematologic: Anemia, leukopenia, thrombocytop enic purpura; aplastic anemia, agranulocytosi s (rare). SpecSenses:T innitus, vertigo, feeling of fullness in ears, hearing loss (rarely permanent), blurred vision. Skin:Pruritus, urticaria

hypotension

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DRUG STUDY # 2
GENERIC NAME BRAND NAME CLASSIFICATION MODE OF ACTION INDICATION CONTRAINDICATION ACTUAL DOSE USUAL DOSE S/E NSG. INTERVENTIONS

B E N Z Y L P E N I C I L L I N N A

C R Y S T A P E N T

A N T I I N F E C T I V E S

MOA: A natural penicillin that inhibits cell wall synthesis during active multiplicat ion. Bacteria resists penicillin by producing penicillina sesenzymes that convert penicillins to inactive penicillic acid.

Moderate Hypersensitivity to severe Sodium restricted systemic patients infections, neurosyphil is

525,00 0 u IVTT q6 (ANST )

Children younger than 12yrs is 25,000 to 400,000 units/kg daily IM or IV q4 to 6hrs

CNS: neuropathy,s eizure, Lethargy,con fusion Hallucination CV:heart failure Thrombophle bitis GI: Nausea&vo miting, Enterocolitis Pseudocolitis GU:Interstiti al colitis, neuropathy Hematologic: anemia leucopenia

Observe 10Rs accurately. Assess patient for allergic reaction. Do not give PEN G with other antibiotic at the same time. Administer the drug aseptically. Administer the drug slowly. Emphasized the drugs side affect to patient. Instruct patient to report occurrence of adverse effects promptly.

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DRUG STUDY # 3
GENERIC NAME BRAND NAME CLASSIFICATION MODE OF ACTION INDICATION CONTRAINDICATION ACTUAL DOSE USUAL DOSE S/E NSG. INTERVENTIONS

R A N I T I D I N E H C L

Z A N T A C

ANTI-ULCER

Competiti vely inhibits the action of the h2 receptors of the parietal cells of the stomach, inhibiting basal gastric acid secretion that stimulates by food,insuli n,histamin e, cholinergi cagonist and gastrin.

Maintenanc e therapy for duodenal or gastric ulcer, gastroesp[h ageal reflux, erosive esophagitis

Contraindicatedwit h sinus hypersensitivity Lactation Acute porpuria Use cautiously in patients with impaired renal or hepatic faiure.

21mg one IVTT q8

110mg/kg daily given as 2 divided doses

CNS: Vertigo, malaise, headache EENT: Blurred vision Hepatic: Jaundice

Observe 10Rs accurately. .Assess patient for abdominal pain,rate, presence of blood in emesis, stool. Instruct patient to report abdominal pain Provide concurrent antacid therapy. Emphasized the side effects to patient.

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DRUG STUDY # 4
GENERIC NAME BRAND NAME CLASSIFICATION MODE OF ACTION INDICATION CONTRAINDICATION ACTUAL DOSE USUAL DOSE S/E NSG. INTERVENTIONS

C E F T R I A X O N E

R O C E P H I N

ANTIMICROBIAL ANTIPARASITIC

Inhibits bacterialce ll wall synthesis,r endering cell wallosmoti cally unstable,le ad-ing to cell death.

Treatm Hypersensitivity ent of tocephalosporins LRIT and penicillins, (e.g. lidocaineor any bronchitis, other pneumonia, localanaesthetic bronchopn productof the eumonia, amide type. emphysem a, lungabsces s), skin andsoft tissue infections. Preoperative p rophylaxis toreduce c hance of postoperativesu rgical infections

2.9mg IVTT + 20cc Distille d water

1gram BID

Phlebitis Rash Diarrhea Vomiting

Observe 10Rs accurately. Assess for allergies. Teach patient to report sore throat, bruising, bleeding and joint pain Advise patient towatch out for perineal itching,fever, malaise,redness, pain,swelling, rashdiarrhea Administer the drug slowly.

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DRUG STUDY # 5
GENERIC NAME BRAND NAME CLASSIFICATION MODE OF ACTION INDICATION CONTRAINDICATION ACTUAL DOSE USUAL DOSE S/E NSG. INTERVENTIONS

M E T O C L O P R O M I D E

P L A S I L

ANTIEMETIC S

Stimulat es motility of upper GI tract, increases lower esophag eal sphincter tone, and blocks dopamin e receptors at the chemore ceptor trigger zone.

Prevention of chemothera py-induced emesis. Tre atment of postsurgica l and diabeti c gastric stasis. Facilitation of small bowel intubation in radiogra phic procedures. Manageme nt of esophag eal reflux. Treatment and prevention of postoper ative nausea and

. Contraindicated

in: Hypersensitivit y; Possible GI obstruction or hemorrhage; History of seizure disorder s; Pheochromocytom a; Parkinsons diseas e. Use Cautiously in: History of depression; Diabetes (may alter response to insulin); Renal impairment (reduce dose in CCr <50 ml/min); OB, Lactation: Safety not established; Pedi: some syrup products contain benzoate, a metabolite of benzyl alcohol

3mg IVTT q6

1 2mg/kg q4-6hrs

CNS: drowsiness, extrapyramid al reactions, res tlessness, NEUROLEP TIC MALIGNAN T SYNDROM E, anxiety, depression, irritability, tardive dyskinesia. C V: arrhythmias (supraventric ular tachycardia, bradycardia), hypertension, hypotension. GI: constipati on, diarrhea, dry mouth, nausea. Endo

Observe 10Rs accurately Instruct patient to take metoclopramid e as directed. Take missed doses as soon as remembered if not almost time for next dose. Pedi: Unintentional overdose has been reported in infants and children with the use of metoclopramide oral solution. Teach parents how to accurately read labels and administer medicati on. May cause drowsiness. Caution patient to avoid other activities requiring alertness

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46

vomiting when nasogastric suctioning is undesirable . Unlabeled uses: Treatment of hiccups. Adjunct manageme nt of migraine headaches.

which can cause potentially fatal gasping syndrome in neonates. Prolonged clearanc e in neonates can result in high serum concentratio ns and increase the risk for methemoglobinem ia. Side effects are more common in children especially extrapyramidal reactions; Geri: More susceptible to oversedation and extrapyramidal reactions

: gynecomasti a. Hemat: methemoglo binemia, neutropenia, leukopenia, agranulocyto sis.

until response to medication is known. Advise patient to notify health care professional immediately if involuntary movement of eyes, face, or limbs occurs.

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DRUG STUDY # 6
GENERIC NAME BRAND NAME CLASSIFICATION MODE OF ACTION INDICATION CONTRAINDICATION ACTUAL DOSE USUAL DOSE S/E NSG. INTERVENTIONS

O X A C I L L I N

B A C T O C I L

ANTIINFECTIVES (PENICILLINS )

A penicillinase resistant penicillin that inhibits cell-wall synthesis during microorganis m multiplicatio n; bacteria resists penicillins by producing penicilllinase enzymes that convert penicillins to inactivate penecillic acids. Oxacillin resists these enzymes.

Systemic infections caused by penicillinas eproducing staphyloco cci

Contraindicatedwit h allergies topenicillins,cepha losporins, or other allergens. Use cautiously withrenal disorders,pregnanc y,lactation .

525mg IVTT q6IVT T

250500mg q4

CNS: Lethargy,hall ucinations, se izures GI: Glossitis, stomatitis,gas tritis, sore mouth, furryor black hairytongue, nausea,vomit ing, diarrhea,abdo minal pain, diarrhea, enterocolitis, pseudomemb ranouscolitis, nonspecifich epatitis GU:nephritis oliguria,prote inuria, hematuria,ca sts, azotemia, pyuria

Observe 10Rs accurately Side effects may beexperienced, suchas: upset stomach,nausea, diarrhea(small frequentmeals), mouthsores (performfrequent mouthcare) and pain atinjection site. Report difficulty of breathing, rashes,severe diarrhea,severe pain atinjection site,mouth sores. Finish entire courseof therapy asprescribed Give drug slowly.

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Hematologic: anemia,thro mbocytopeni a,leukopenia, neutropenia,p rolonged bleeding time(more common thanwith other penicillinaseresistant penicillins)

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CHAPTER X

LABORATORY STUDY #1
Determination Urinalysis Color Actual Value Normal Value Interpretation Deviations from normal color can be caused by certain drugs and various vegetables such as carrots, beets, and rhubarb. possibly the patient has glomerular damage Within normal value Cloudy urine may be evidence of phosphates, urates, mucus, bacteria, epithelial cells, or leukocytes. High protein diets increase acidity. Nursing Intervention Instruct the patient to void directly into a clean, dry container. Sterile, disposable containers are recommended. Women should always have a clean-catch specimen if a microscopic examination is ordered. Feces, discharges, vaginal secretions and menstrual blood will contaminate the urine specimen. Cover all specimens tightly, label properly and send immediately to the laboratory. Observe standard

Dark Yellow

Straw-yellow color

Albumin

4+

Negative

Sugar Transparency

Negative Cloudy

Negative Clear to slightly hazy

pH

Acidic

4.6 8.0

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specific gravity

1.015

1.053 1.030

Low specific gravity reflects diluted urine, Overhydration, early renal disease, and inadequate ADH secretion reduce specific gravity. Damage to glomeruli or tubules allows RBCs to enter the urine. Trauma, disease, or surgery of the lower urinary tract also causes blood to be present

precautions when handling urine specimens

RBC

Abundant

Negative

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LABORATORY STUDY #2
Determination Hematology WBC Actual Value 13.6 Normal Value 4.0-10.0x10^g/l Interpretation Nursing Intervention

RBC

4.15

4.70-6.10x10^12/L

HGB

80

130-170g/L

HCT

0.28

0.42-0.50

It is possible indicated as Explain the procedure to bacterial infections. the mother Explain the importance of It is possible indicated the procedure and why it id anemia due to decrease necessary RBC production Instruct the mother to have the proper hygiene Assist in the procedure Possible as anemeia due Instruct the mother to to decreased RBC report any signs of production infection like fever Regulate IV as ordered to provide adequate hydration Possible as anemia due to decreased RBC production Possible indicated as cachexia Possibly indicates as a iron deficiency anemia

PLT

926 100-300x10^g/L

MCV

67 86-100fL

MCH

19.3

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26-31pg MCHC 288 310-370g/l RDW 12.1 11.6-13.7%

Possibly indicated as a microcytic anemia Possibly indicated as a microcytic anemia Within normal range

Differe ntial Count Neutrophil 46.7 40-70 Within normal range Lymphocyte Monocyte 17.4 19-48 24.4 3 -9 Eosinophils Basophils 11.0 0.5 1-4% Possibly indicated as acute viral infections. Increased possible indicated as a chronic infections. Increased due to parasitic and allergic reactions. Possibly problem like blood dyscrasia

0.5-1%

LABORATORY STUDY #3
Determination BUN Actual Value 1.8lmm0l/L Normal Value 2.1-7.1 Interpretation Possibly indicated as a low protein diet or malnutrition Within normal range

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Nursing Intervention Instructed the mother to increased protein in the diet Clean the venipuncture site first with an alcohol swab and then with a providoneiodine swab, starting at the site and working outward in a circular motion. Monitor the venipuncture site for bleeding and signs of infection. Document the tentative diagnosis and current or recent antimicrobial therapy on the laboratory request.

Creatinine

60.1mm0l/L

53-97

LABORATORY STUDY #4
Determination Urinalysis Color Albumin Bilirubin Transparency pH Specific gravity Actual Value Normal Value Interpretation Within normal value Within normal value Within normal value Within normal value High protein diets increase acidity Low specific gravity reflects diluted urine, Overhydration, early renal disease, and inadequate ADH secretion reduce specific gravity. Damage to glomeruli or tubules allows RBCs to enter the urine. Trauma, disease, or surgery of the lower urinary tract also causes blood to be present

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Nursing Intervention Instruct the patient to void directly into a clean, dry container. Sterile, disposable containers are recommended. Women should always have a clean-catch specimen if a microscopic examination is ordered. Feces, discharges, vaginal secretions and menstrual blood will contaminate the urine specimen. Cover all specimens tightly, label properly and send immediately to the laboratory. Observe standard precautions when handling urine specimens

Yellow Negative Negative Clear Acidic 1.005

Straw-yellow color Negative Negative Clear 4.6 8.0 1.015-1.025

RBC

Abundant

Negative

LABORATORY STUDY #5
Determination Hematology WBC Actual Value 13.0 Normal Value 4.0-10.0x10^g/l Interpretation It is possible indicated as bacterial infections.

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Nursing Intervention

RBC

3.75

4.70-6.10x10^12/L

HGB

74

130-170g/L

HCT

0.25

0.42-0.50

Explain the procedure to the mother Explain the importance of the procedure and why it It is possible indicated id necessary anemia due to decrease Instruct the mother to have RBC production the proper hygiene Possible as anemeia due Assist in the procedure to decreased RBC Instruct the mother to production report any signs of infection like fever Regulate IV as ordered to Possible as anemia due to provide adequate decreased RBC hydration production Possible indicated as cachexia

PLT

777

100-300x10^g/L

MCV

67

86-100fL

Possibly indicates as a iron deficiency anemia Possibly indicated as a microcytic anemia Possibly indicated as a microcytic anemia

MCH

20

26-31pg

MCHC

294

310-370g/l

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Diff count Within normal range Possibly indicated as acute viral infections Within normal range Increased due to parasitic and allergic reactions. Within normal range

Neutrophil Lymphocyte

48 17

40-70 19-48

Monocyte Eosinophils Basophils

9 25 1

3 -9 1-4% 0.5-1%

LABORATORY STUDY #6
Determination Hematology WBC Actual Value 17.2 Normal Value 4.0-10.0x10^g/l Interpretation It is possible indicated as bacterial infections.

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Nursing Intervention

RBC

4.35L

4.70-6.10x10^12/L

HGB

101L 130-170g/L

HCT

0.31

PLT

680

0.42-0.50

MCV

72

100-300x10^g/L

Explain the procedure to the mother Explain the importance of It is possible indicated the procedure and why it anemia due to decrease id necessary RBC production Instruct the mother to have the proper hygiene Possible as anemeia due to Assist in the procedure decreased RBC Instruct the mother to production report any signs of infection like fever Regulate IV as ordered to Possible as anemia due to provide adequate decreased RBC hydration production Possible indicated as cachexia

MCH

23.1

86-100fL

Possibly indicates as a iron deficiency anemia Possibly indicated as a microcytic anemia

MCHC

323

26-31pg

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Diff count Neutrophil Lymphocyte Monocyte 69.9 23.0 7.1 310-370g/l 40-70 Within normal range Within normal range Within normal range

19-48

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LABORATORY STUDY #7
Determination Electrolytes Na K Ca Actual Value Normal Value Interpretation Within normal value Nursing Intervention

137.7 3.39 1.26

135-148mm0l/L 3.35-5.3mm0l/L 1.13-1.32mm0l/L

Assess specific client risk, noting chronic disease processes that may lead to Within normal value electrolyte imbalances, including kidney disease, The pt. Experiences metabolic or endocrine abdominal and muscle disorders, chronic cramps tingling of finger alcoholism, cancer or around mouth .Indicated cancer treatments, as a conditions causing hyperyhroidism,diarrhea, hemolysis such as massive vit d deficiency. trauma, multiple blood transfusions; sickle cell disease. 1. Note clients age and developmental level, which may increase risk for electrolyte imbalance 2. Monitor heart rate and rhythm by palapation and asculatation. 3. Ascultate breath sounds, assess rate and depth of respirations and ease of respiratory effort, observe color of

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nailbeds and mucous membranes, and note pulse oximetry or blood gas measurement, as indicated.

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X-RAY RESULT January 23,2013 CHEST PA There is a confluence of opacity in left upper lung field. Heart is not enlarged. Diaphragm and catosphrenic sinuses are intact. The bony thorax is unremarkable. Impression: IMPRESSION: Pneumonic consolidation January 27,2013 KUB UTZ The right kidney measures 8.8x4.0cms while left measures 9.1x4.6cms. the cortical echoes are echogenic than normal and show distinct cortico medullary junctions. The pelvo calyceal systems are intact. No ectasia nor lithiasis seen. These are no focal renal mass lesions detected. The ureters are not dilated. The urinary bladder is distended show in a irregular mucosal wall. There are no intravertical lithiasis seen Negative for ascites. IMPRESSION: Normal sized kidneys with diffuse parenchymal disease,cystitis

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DISCHARGE PLANNING

A. MEDICATIONS Instruct the client as well as the parents to report for any signs of allergic reactions. Inform and instruct the parents about the purpose, route, frequency and dose of administration of the drugs being prescribed to be taken at home. Notify the parents of the side effects and adverse effects of the drugs that are possible to occur while giving the medications. Educate the parents that medicines are prescribed to promote the recovery and healing of the patient, thus maintenance and implementation must be observed. Instruct the mother not to take unprescribed drugs by his physician to avoid ineffectiveness of the drug. Medications are being given in order to facilitate recovery and healing of the present altered condition of the patient, as well as to prevent further complications that can cause other problems. Thus, it is important to educate the patient for his to be able to know how to manage, handle and maintain compliance to medical orders. B. EXERCISE

A Case Study Explain importance of exercise in maintaining physical health.

63

Explain to the client to avoid strenuous activities, since this can aggravate proteinuria, hematuria and urine cast. Instruct patient that he can resume activities but may need close monitoring and for further follow up with his care provider for continue evaluation. Exercising is advised because it is believed that it can improve physical and psychological well-being. C. TREATMENT Encourage parents to comply with treatment regimen for their son. Explain to parents the importance of treatment regimen to be done at home. Treatment regimen will help the patient to recover within a period of time to develop physical well-being. D. HYGIENE Educate client with the importance of proper hygiene in maintaining physical well-being. Instruct client to bathe daily. Instruct the client to wash genitalia regularly specially after urinating and bowel. Observing proper hygiene can help prevent further complications to condition of the patient.

A Case Study E. OUT-PATIENT DEPARTMENT FOLLOW UP Instruct parents to refer to his physician whenever symptoms of

64

complication and/or infection on their son occur and refer to his physician for immediate management of their sons condition. Instruct parents to have their son follow-up check up with his physician in the exact day at the exact time of schedule, even if he doesnt feel better, after being discharged from the hospital. Instruct mother to seek immediate medical consultation for their son when adverse effects or the undesirable effects to drugs occurs. Following up check-ups is important in order to assess the patient's recovery status as well as to prevent any further problems. F. DIET Educate parents and the client on the importance of well-balanced diet. Instruct parents to limit the fluid intake of their son depending on the prescribed amount of fluid. Instruct the patient to avoid eating junk foods and other foods high in sodium and potassium. Instruct the parents to serve foods high in calorie. Also foods which contain complete or high quality protein which is used most efficiently by the body such as egg, meat and some dairy products. Following diet prevents alteration in nutrition and helps in healing process.

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RECOMMENDATION To the Patient and Family Since the client has prognosis, we recommend that the client should continuously comply with the treatment .We recommend to the family that they should follow health teachings taught by the health care providers such as proper stoma care, proper hygiene before and after contact with the stoma and diet appropriate with childs condition and age. To the Notre Dame University-College of Health and Sciences Our group is proud to belong to such a peace loving school. We recommend that the Notre Dame Universitys College of Health and Sciences will continue to maintain or improve their high quality of teaching not only on nursing profession but also on developing the moral aspects of the student nurses through inculcating moral values and giving high emphasis on the FIRES. Help us realize our mistakes and face our difficulties, in that way we can maximize our learning. To the Student Nurses We have also evaluated ourselves upon doing this case and we have decided to follow the recommendation of our clinical instructor. To provide tender loving care to the patient is our main goal and continuous monitoring and application of nursing interventions is compulsory for patients recovery. Careful collection of data should be observed to obtain more accurate information. To the Readers The group recommends that the readers must also visit other sources of information and not solely base everything on this case presentation alone. Use a variety of sources makes a more complete understanding of the subject matter. Everyone should consider being healthy as a priority and not a choice in life. You can prevent diseases and have a healthy lifestyle by avoiding a sedentary lifestyle and by visiting a physician 1 or 2 times a year.

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Bautista, J. (2008). Theoretical foundation of nursing (1st ed). The Philippine perspective. Brunner and Suddarth (2009). Textbook of Med-Surg Nursing 12th Edition. Halcomb, K.A (2010). Health promotion and health Education: nursing students Perspectives. Retrieved August 21, 2012 from www.aacn.nche.edu/educa tion.../baccessentials John (2010). Home remedy for kidney problems. Retrieved September 14, 2012 from http://www.drmitaljohn/best-way-home-remedy-for-gastro-problems Kozier, B. et al. (2004). Fundamentals of Nursing (7th edition). California: Addison Wesley Osney Mead (1994). Blackwells Dictionary of Nursing Ltd. 2002 Scanlon, Valerie C. Essentials of Anatomy and Physiology (5th Edition). Philadelphia; F.A Davis Company. Pelaez, M.L. & Tamse, E. (2004). Manual of basic nursing procedures (3rd ed). Cotabato City: Notre Dame University College of Health Sciences Printing Press. Potter, P. & Perry, A.G. (2007). Basic nursing: essentials for practice (6th ed). Canada: Mosby Inc., Elsivier Inc. Schueler, S. et, al. (2013) Acute Glomerulonephritis. Retrieved February 5, 2013 from http://www.freemd.com/acute-glomerulonephritis/home-care-kidney-diet.htm