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STI COLLEGE STA. MARIA

A CASE PRESENTATION PRESENTED TO

MR. RONALDO V. RAYMUNDO

BY

COLLEGE OF NURSING

NCM 107

CARRIE ANN S.FERNANDEZ

ACUTE GLOMERULONEPHRITISI. INDRODUCTION

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Acute glomerulonephritis (AGN) is active inflammation in the glomeruli.

Glomerulonephritis is a type ofkidney disease that involves theglomeruli. The glomeruli are very small, important structures in thekidneys that supply blood flow to the small units in the kidneys that filterurine, called the nephrons. During glomerulonephritis, the glomerulibecome 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 thatare presented commonly with hematuria

ETIOLOGY

Streptococcal infection(The most common infectious cause of acute GN is infection byStreptococcus 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

http://www.localhealth.com/article/kidney-diseasehttp://www.localhealth.com/article/kidney-disease

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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

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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 theacute 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

http://www.freemd.com/kidney-disease/home-care-diet.htmhttp://www.freemd.com/swelling/home-care-low-salt-diet.htmhttp://www.freemd.com/hypokalemia/overview.htmhttp://www.freemd.com/acute-glomerulonephritis/treatment.htm#/ed/calcium-supplements.htmhttp://www.freemd.com/kidney-disease/home-care-diet.htmhttp://www.freemd.com/swelling/home-care-low-salt-diet.htmhttp://www.freemd.com/hypokalemia/overview.htmhttp://www.freemd.com/acute-glomerulonephritis/treatment.htm#/ed/calcium-supplements.htm

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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

http://www.freemd.com/acute-glomerulonephritis/treatment.htm#/ed/corticosteroid-medications.htmhttp://www.freemd.com/acute-glomerulonephritis/treatment.htm#/ed/prednisone.htmhttp://www.freemd.com/acute-glomerulonephritis/treatment.htm#/ed/methylprednisolone.htmhttp://www.freemd.com/acute-glomerulonephritis/treatment.htm#/ed/medrol.htmhttp://www.freemd.com/acute-glomerulonephritis/treatment.htm#/ed/diuretic-medications.htmhttp://www.freemd.com/acute-glomerulonephritis/treatment.htm#/ed/furosemide.htmhttp://www.freemd.com/acute-glomerulonephritis/treatment.htm#/ed/lasix.htmhttp://www.freemd.com/acute-glomerulonephritis/treatment.htm#/ed/cyclophosphamide.htmhttp://www.freemd.com/acute-glomerulonephritis/treatment.htm#/ed/cytoxan.htmhttp://www.freemd.com/acute-glomerulonephritis/treatment.htm#/ed/neosar.htmhttp://www.freemd.com/acute-glomerulonephritis/treatment.htm#/ed/procytox.htmhttp://www.freemd.com/acute-glomerulonephritis/treatment.htm#/ed/corticosteroid-medications.htmhttp://www.freemd.com/acute-glomerulonephritis/treatment.htm#/ed/prednisone.htmhttp://www.freemd.com/acute-glomerulonephritis/treatment.htm#/ed/methylprednisolone.htmhttp://www.freemd.com/acute-glomerulonephritis/treatment.htm#/ed/medrol.htmhttp://www.freemd.com/acute-glomerulonephritis/treatment.htm#/ed/diuretic-medications.htmhttp://www.freemd.com/acute-glomerulonephritis/treatment.htm#/ed/furosemide.htmhttp://www.freemd.com/acute-glomerulonephritis/treatment.htm#/ed/lasix.htmhttp://www.freemd.com/acute-glomerulonephritis/treatment.htm#/ed/cyclophosphamide.htmhttp://www.freemd.com/acute-glomerulonephritis/treatment.htm#/ed/cytoxan.htmhttp://www.freemd.com/acute-glomerulonephritis/treatment.htm#/ed/neosar.htmhttp://www.freemd.com/acute-glomerulonephritis/treatment.htm#/ed/procytox.htm

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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, tubularstructures that stretch across both regions perpendicular to the surface of thekidney. 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

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one end, has two twisted regions interspaced with a long hairpin loop, ends in along 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 islocated in the cortex.

Proximal convoluted tubule or proximal tubule - The first twisted regionafter the Bowman's capsule; it's in the cortex.

Loop of Henle - A long, hairpin loop after the proximal tubule, it extendsfrom the cortex down into the medulla and back.

Distal convoluted tubule or distal tubule - This second twisted portion ofthe nephron after the loop of Henle is located in the cortex.

Collecting duct - This long straight portion after the distal tubule that is theopen end of the nephron extends from the cortex down through the medulla.

Each part of the nephron has different types ofcells with different properties -- this

is important in understanding how the kidney regulates the composition of theblood.

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 aconstant blood flow through and around the nephron despite fluctuations insystemic blood pressure.

Regulating the composition of the blood involves the following:

Keeping the concentrations of various ions and other important substancesconstant

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 intothe inside of the nephron (the lumen).

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It reabsorbs the components that the body needs from the lumen back intothe blood.

It secretes some unwanted components from the blood into the lumen of thenephron.

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 theseprocesses, the blood is maintained with the proper composition, and excess orunwanted substances are removed from the blood into the urine.

PATHOPHYSIOLOGY:

Immunologic Response

Antigen(group A beta-hemolytic

Antigen-antibody product

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GENERAL DATA

Name: Mr. N.M.DC

Age: 7 years old

Address: 947 Baloongan

Pantoc, Meycauayan, Bulacan

Date of Admission: November 25, 2012

Occupation: None

Religion: Roman Catholic

Deposition of antigen-antibody

complex in glomerulus

Increased production of epithelialcells lining the glomerulus

Leukocytes infiltrate the glomerulus

Thickening of the glomerular filtration

membrane

Scarring and loss of glomerular

filtration

Decreased glomerular filtration rate

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Birthday: November 07,

2005

Status: Child

Chief Complaint: Bloody urine/ edema

Final Diagnosis: Acute

Glomerulonephritis

Attending Physician: Cusay, M.D; Federico

D.

Pertinent Physical Finding:

Vital Signs:

T -------------------- 36.20C

PR -------------------- 90bpm

RR -------------------- 20cpm

BP -------------------- 130/70mmHg

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.

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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 inMeycauayan 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

LABORATORY EXAMINATION

URINALYSIS

(November 30,2012)

INSPECTION PALPATION PERCUSSION

AUSCULTATION

General Weak inappearance

- - -

Skin Pale in color Dry skin - -Head Eyes PERRLA - - -

Ears - - - -Nose - - - -

Throat - - - -Neck - - - -

Chest - - - - Increase heartrate and

increase BPAbdomen - Flank pain,

hematuria- - -

Extremities - With edemaat lower

extremities

- - -

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RESULT

NORMAL VALUES

Color yellow

pale yellow to amber

Specific gravity 1.010

1.010-1.025

WBC TNTC

0-5/hpf

Transparency turbid

transparent

pH 6.0

4.5-8.0

CHON +3

negative

Leukocytes +4

negative

RBC TNTC

0-2/hpf

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

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BLOOD CHEMISTRY

November 26, 2012

TEST NORMAL VALUES RESULTS

BUN

7-18mg/dL 9.3mg/dL

CREATININE

0.4-1.4mg/dL 0.6mg/dL

Interpretation:

Increased BUN levels suggest impaired kidney function. This may be due to

acute or chronickidney 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

http://labtestsonline.org/glossary/acutehttp://labtestsonline.org/glossary/chronichttp://labtestsonline.org/understanding/conditions/kidneyhttp://labtestsonline.org/glossary/acutehttp://labtestsonline.org/glossary/chronichttp://labtestsonline.org/understanding/conditions/kidney

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ASO TITER

November 30,2012

Remarks:

Result Normal Values

ASO=400

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DISCHARGE PLANNING

Discharge: November 10, 2012

Final Diagnosis: Acute

Glomerulonephritis

Condition upon Discharge: Improved

Final Disposition: May go home with

medications

MInstruct 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.

EEncourage early ambulation if not contraindicated or promote exercise to the

client especially ROM, and advise patient to have adequate rest and sleep.

TExplain the need of treatment after discharge and must take it seriously so as to

prevent such complications to the patient.

HEncourage patient to perform proper personal hygiene to promote comfort and

cleanliness which is very much needed in the therapeutic process.

OInform the patient that follow-up check-up is important to have continuous

monitoring and care.

DLow salt, low protein and fluid restriction

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Medication: Paracetamol 250 mg

oral AS NEEDED

Cefuroxime 250/5ml

1tsp. TID