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INTRODUCTION
Infections of the urinary tract are the second most common type of infection in
the body. Urinary tract infections (UTIs) account for about 8.3 million doctor visits each
year. Women are especially prone to UTIs for reasons that are not yet well understood.
One woman in five develops a UTI during her lifetime. UTIs in men are not as common
as in women but can be very serious when they do occur.
The most common type of UTI is acute cystitis often referred to as a bladder
infection. An infection of the upper urinary tract or kidney is known aspyelonephritis, and
is potentially more serious. Although they cause discomfort, urinary tract infections can
usually be easily treated with a short course of antibiotics. Symptoms include frequent
feeling and/or need to urinate, pain during urination, and cloudy urine.
As a group, we decided to study this kind of disease for us to know more about
the complications. As a nursing students, we must not only focus to one corner or
merely by just taking care of our patients but to know their underlying condition as well
for the better and good nursing intervention done to promote maximum living ability.
Furthermore, we have chosen this case study in order to identify and determine
the general health problems and needs of the patient with an admitting diagnosis of
acute glomerulonephritis. This study also intends to help patient as well as its significant
others to promote health and medical understanding of such condition through the
application of the nursing theories and nursing skills.
II. Clients Profile
A. Socio-demographic data
B. Vital Signs
The patient’s vital signs are essential because it provides a baseline data in
determining alteration in the patient’s body that may suggest underlying disease. Any
changes from the normal are considered to be an indication of the person’s state of
health and provide cues to the physiological functioning of the client.
The patient had the following vital signs: blood pressure: 100/70 mmHg, pulse
rate: 104 bpm, respiratory rate: 32 cpm, temperature: 36.9ºC. He currently weighs 35
kilograms from the previous weight of 32 kilograms and he is 4’6 tall.
The client was brought to the hospital due to anemia anasarca. Six
months prior to admission, onset of edema with no other associated
symptoms noted.
2. Nutrition
During pre-hospitalization, the client used to eat junk foods which
are high sodium and almost always eat “guinamos” as their viand.
3. Elimination Pattern
b. Bathing: independent
c. Toileting: independent
e. Dressing: independent
f. Grooming: dependent
g. General mobility: independent
h. ROM: independent
i. Ambulation: independent
5. Cognitive-Perceptual Pattern
His family specifically his mother and grandmother who helped him
during hospitalization. His father and other members in the family ar not
around because they can’t visit for they are very far from the city thus, it
requires money in order for them to visit at the hospital. Other than that,
Philhealth is also their financial support system.
D. Physical Assessment
1. Neurologic Assessment
2. Head
Head Normocephalic
Facial movement Symmetrical
Fontanels Closed
Hair Fine
Scalp Clean
3. Eyes
Lids Symmetrical
Periorbital region Edema
Conjunctiva Pale
Cornea & lens Opacity R/L
Sclera Anicteric
Pupils Equal in size
Reaction to l ight Brisk R/L
Reaction to accommodation Uinform to constriction
Visual acuity Grossly normal
Peripheral vision Intact/full
4. Ears
5. Nose
Mucosa Pinkish
Patency Both patent
Gross smell Normal/symmetrical
Sinuses No tenderness presence
6. Mouth
Lips Pallor
Mucosa Pinkish
Tongue Midline
Teeth Complete
Gums pinkish
7. Pharynx
Uvula Midline
Tonsils Not inflamed
Posterior pharynx No inflame presence
8. Neck
Trachea Midline
Thyroids non-palpable
9. Skin
10. Abdomen
Configuration Globular
Bowel sound Hypoactive (3 counts)
Percussion Tympanitic
The Kidney
The main functional unit of the kidney is the nephron. There are approximately one
million nephrons per kidney. The role of nephrons is to make urine by:
• Filtering blood of small molecules and ions such as water, salt, glucose and other
solutes including urea. Large “macromolecules” like proteins are untouched.
• Recycling the required quantities of useful solutes which then re-enter the
bloodstream. (A process called reabsorption)
• Allowing surplus or waste molecules/ions to flow from the tubules/ureter as urine.
Nephrons are the basic structural and functional units of the kidney. They consist
of a network of tubules and canals specialized in filtration.
The kidney is responsible for maintaining fluid balance within the body. The basic
structural and functional units of the kidneys are the nephrons. Each nephron is made of
intricately interwoven capillaries and drainage canals to filter wastes, macromolecules,
and ions from the blood to urine. The approximately 1 million nephrons in each human
kidney form 10-20 cone-shaped tissue units called renal pyramids that span both the
inner and outer portions of the kidney, the renal medulla and renal cortex.
A. Renal Vein
This has a large diameter and a thin wall. It carries blood away from the kidney
and back to the right hand side of the heart. Blood in the kidney has had all its urea
removed. Urea is produced by your liver to get rid of excess amino-acids. Blood in the
renal vein also has exactly the right amount of water and salts. This is because the
kidney gets rid of excess water and salts. The kidney is controlled by the brain. A
hormone in our blood called Anti-Diuretic Hormone (ADH for short) is used to control
exactly how much water is excreted. This blood vessel supplies blood to the kidney from
the left hand side of the heart. This blood must contain glucose and oxygen because the
kidney has to work hard producing urine. Blood in the renal artery must have sufficient
pressure or the kidney will not be able to filter the blood. Blood supplied to the kidney
contains a toxic product called urea which must be removed from the blood. It may have
too much salt and too much water. The kidney removes these excess materials; that is
its function.
B. Renal Artery
This blood vessel supplies blood to the kidney from the left hand side of the
heart. This blood must contain glucose and oxygen because the kidney has to work
hard producing urine. Blood in the renal artery must have sufficient pressure or the
kidney will not be able to filter the blood. Blood supplied to the kidney contains a toxic
product called urea which must be removed from the blood. It may have too much salt
and too much water. The kidney removes these excess materials; that are its function.
C. Pelvis
This is the region of the kidney where urine collects. If you are very unlucky, you
may develop kidney stones. Sometimes the salts in the urine crystallise in the pelvis
and form a solid mass which prevents urine from draining out of the medulla of the
kidney. You will need treatment: see your doctor.
D. Ureter
This one is easy peasy: the ureter carries the urine down to the bladder. It does
this 24 hours per day, but fortunately the urine can be stored in a bladder so that it is not
necessary to wear a nappy!
E. Medulla
The medulla is the inside part of the kidney. It is shown in green in the diagram,
but in real life it is a very dark red colour. This is where the amount of salt and water in
your urine is controlled. It consists of billions of loops of Henlé. These work very hard
pumping sodium ions. ADH makes the loops work harder to pump more sodium ions.
The result of this is that very concentrated urine is produced.The opposite of an anti-
diuretic is a "diuretic". Alcohol and tea are diuretics.
F. Cortex
The cortex is the outer part of the kidney. This is where blood is filtered. We call
this process "ultra-filtration" or "high pressure filtration" because it only works if the
blood entering the kidney in the renal artery is at high pressure. Billions of glomeruli are
found in the cortex. A glomerulus is a tiny ball of capillaries. Each glomerulus is
surrounded by a "Bowman's Capsule". Glomeruli leak. Things like red blood cells, white
blood cells, platelets and fibrinogen stay in the blood vessels. Most of the plasma leaks
out into the Bowman's capsules. This is about 160 litres of liquid every 24 hours.Most of
this liquid, which we call "ultra-filtrate" is re-absorbed in the medulla and put back into
the blood.
H. Loop of Henlé
This part of the nephron is where water is reabsorbed. Kidney cells in this region
spend all their time pumping sodium ions. This makes the medulla very salty; you could
say that this is a region of very low water concentration. If you remember the definition
of osmosis, you will realise that water will pass from a region of high water
concentration (the ultra-filtrate and urine) into a region of low water concentration (the
medulla) through cell membranes which are semi-permeable.
J. Collecting Duct
Collecting ducts run through the medulla and are surrounded by loops of Henlé.
The liquid in the collecting ducts (ultra-filtrate) is turned into urine as water and salts are
removed from it. Although our kidneys make about 160 litres of urine every 24 hours,
we only produce about ½ litre of urine.It is called a collecting duct because it collects the
liquid produced by lots of nephrons.
Nephron Function
The blood is filtered and urine formed by the actions of the nephrons. In each
nephron, high pressure in the glomerulus pushes water and small dissolved materials
into the extravascular space of the Bowman’s capsule and into the tubule. The proximal
tubule reabsorbs water, salts, glucose, and amino acids to maintain electrolyte levels in
the body. The interstitium of, that is the tissue space surrounding, the loop of Henle
concentrates salts that will be excreted in the urine, creating a concentration gradient in
the medulla. The limbs of Henle’s loop are permeable to particular ions (descending,
water and some urea; thin ascending, general ions; medullary thick ascending –
sodium, potassium, chloride), with the cortical thick ascending limb draining into the
distal convoluted tubule. The distal tubule contains cells specialized in active transport
and maintains urine and blood pH levels, particularly through the regulation of sodium
and potassium.
Fluid then passes from the distal tubule to the collecting ducts, a tubule system that can
become permeable or impermeable to water depending on the body’s needs.
Ultrafiltration also occurs in the cortex in the cortical collecting ducts, which is regarded
by some anatomy references as not being a portion of the nephron, and by others as
being the final portion of the nephron. The urine then passes from the collecting ducts
through the drainage system of the kidney to the ureters and bladder for urination.
Another, less familiar, mechanism for urine production in the kidneys is tubular
secretion. Specialised cells move solutes directly from the blood into the tubular fluid.
For example, hydrogen and potassium ions are secreted directly into the tubular fluid.
This process is “coupled” or balanced by the re-uptake of sodium ions back into the
blood.
In addition to its excretory and homeostatic roles, the kidneys also release two
important hormones into the blood. These are:
• Erythropoietin which acts on bone marrow to increase the production of red blood
cells
• Calcitriol which promotes the absorption of calcium from food in the intestine and
acts directly on bones to shift calcium into the bloodstream.
Finally the kidney produces the enzyme renin, an important regulator of blood
pressure.
secrete renin.
Renin splits the plasma protein angiotensinogen (synthesized by the liver) to
angiotensin I.
Angiotensin I is converted to angiotensin II by an enzyme (called converting
enzyme)
Secreted by the lung tissue and vascular endothelium.
Angiotensin II :
- causes vasoconstriction
MEDICATIONS
• Explain to the patient and family members the importance of taking medicines.
• Discuss to the patient and family the dosage, frequency and adverse effects of
the drugs.
• Encourage to follow the dosages and proper timing of his meds. Such as the
Furosemide 1 ampule every 12hours x3doses, Omeprazole 20mg 1capsule
once a day, Captopril25mg 1tablet twice a day, & Spironolactone 50mg 1
tabletthrice a day. As prescribed by his physician
Economic status
Treatment
• Tell the patient that she should have self-monitoring by checking his vital signs
and weighing regularly.
HEALTH TEACHINGS
OUT-PATIENT
• The patient could avail his medication from government hospitals that he could
get some benefits.
• He will also be able to avail the services offered by the barangay health center
and and at the “Botika ng barangay”.
DIET
• Intake of fluids 8-10 glasses a day to avoid constipation and to maintain skin
turgor.
• Instruct patient to eat low fat and low sodium foods that will help not worsen her
condition that is ordered by the physician.
IX. RELATED LEARNING EXPERIENCE
We were assigned in the Reverse Isolation Ward for almost 4 weeks. We have
encountered several restraints with regards to the implementation. It was not easy that
we are dealing with our patients lives. But we did not loose hope because it’s our
responsibility to care and to address the patient’s needs.
We spent three nights of multi-tasking and time management even though we are
busy in our major subject, we tried our best to do this case study correctly and to avoid
corrections about this work but then again caring patient in reverse isolation ward is
challenging task for us because this is our first time to be exposed in this ward with
different kind of diseases that some are not easy to handle and should be closely
monitored. Moreover, some of the significant others are uncooperative but as student
nurses we are responsible in understanding their situation. Hence, it is imperative that
we should establish rapport towards them. However, it was a wonderful experience
since we have handled different patients with different disease condition which enable
us to apply our knowledge and performed some procedures in the care of our client. We
are fortunate enough, that we have our clinical instructor and our PCI who persistently
supervised us and assisted us to avoid errors.
Although, this is our 4th time to manage group case study in different setting, we are
still up for improvement especially in assessing our patient thoroughly. Also we have
acquired ourselves with regards to establish rapport with our patient to have trusting
relationship. But enjoy with other people helps you identify your strength and weakness,
and it aids in modifying what is somehow negative in our attitude. Most and for all we
thank to god for the guidance always and for giving wisdom and knowledge to do this
case study successful.
X. SOURCES:
WEB:
http://generalmedicine.suite101.com/article.cfm/the_human_kidney_structure_and_func
tion#ixzz0wIXUzTtr
http://cellstissuesmembranes.suite101.com/article.cfm/nephron_structure_and_fu
nction
http://emedicine.medscape.com/article/777272-overview;
http://www.total-health-care.com/illness/acute-glomerulonephritis.htm)
BOOKS:
By:
Marilyn E. Doenges
Alice C. Murr