BSN IV-CEFI GROUP 4

INTRODUCTION
A.

Background of the study

During our 1st & 2rd week of hospital exposure at Quezon Medical Center Pedia Ward, we encountered a patient with Acute Glomerulonephritis VS Nephrotic Syndrome, Urinary Tract Infection. Mr. x, 15 years old, was admitted with the chief complaint of abdominal pain, fever & edema last July 21, 2010.

Acute glomerulonephritis refers to 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. 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. When there is active inflammation within the kidney, scar tissue may replace normal, functional kidney tissue and cause irreversible renal impairment.

Most original research focuses on the post streptococcal patient. Acute glomerulonephritis is defined as the sudden onset of hematuria, proteinuria,and red blood cell casts. This clinical picture is often accompanied by hypertension, edema, and impaired renal function. Although this is primarily a disease of children, with ages 4-12 being at high risk, it can occur at almost any age. Males are more susceptible than females, with a ratio of 1.7-2:1. No specific race is considered at high risk of acquiring this illness, though those in lower socioeconomic brackets are more prone to this due to environmental and sanitary conditions

Nephrotic syndrome is a group of symptoms including protein in the urine (more than 3.5 grams per day), low blood protein levels, high cholesterol levels, high triglyceride levels, and swelling. Autoimmune process leading to structural alteration of glomerular membrane that results in increased permeability to plasma proteins, particulary albumin. Nephrotic syndrome is a disorder of the glomeruli (clusters of microscopic blood vessels in the kidneys that have small pores through which blood is filtered) in which excessive amounts of protein are excreted in the urine. This typically leads to accumulation of fluid in the body (edema) and low levels of the protein albumin and high levels of fats in the blood. Nephrotic syndrome is not a specific glomerular disease but a cluster of clinical findings, including:Marked increase in protein (particularly albumin) in the urine (proteinuria), Decrease in albumin in the blood (hypoalbuminemia), Edema, High serum cholesterol and low-density lipoproteins (hyperlipidemia).

This clinical picture is often accompanied by Albuminuria (s1), Edema(s2), Hyperlipidemia(s3) & Hypoalbuminemia(s4) Although this is primarily a disease of children,with 1 12 and 4 yr at high risk, it can occur at almost any age. Males are more susceptible than females, with a ratio of 1.7-2:1. No specific race is considered at high risk of acquiring this illness, though those in lower socioeconomic brackets are more prone to this due to environmental and sanitary conditions. People with family history of nephrotic syndrome increases likelihood of developing nephrotic syndrome.

Urinary tract infection (UTI) is a bacterial

infection that affects any part of the urinary tract. Although urine contains a variety of fluids, salts, and waste products, it usually does not have bacteria in it. When bacteria get into the bladder or kidney and multiply in the urine, they cause a UTI. The most common type of UTI is a bladder infection which is also often called cystitis. Another kind of UTI is a kidney infection, known as pyelonphritis, and is much more serious. The major problem here is that urinary tract infection causes discomfort and pain on urination.

Incidence: Most common renal disease in children. Almost 10 times more common in females than in males, except in the neonatal period. Bladder is the most common site of infection 25% of all women (cystitis) Men before the age of 50 years Risk Factors:
y y y

Location of the female meatus Sexual intercourse Urinary stasis and reflux in pregnant women caused by pressure on the ureters and hormonal changes. Tight and synthetic clothing (causes irritation) Presence of an indwelling catheter.

B. Objectives of the Study

General The general objective of this case presentation is to foster and develop knowledge and skills in providing care and management for a patient with acute glomerulonephritis vs nephrotic syndrome, urinary tract infection Specific KNOWLEDGE


To define acute glomerulonephritis, nephrotic syndrome,

urinary tract infection

 To know the clinical manifestations, nursing

management and interventions for patients who have this disease.  To know the different medications that needs to be taken including its side effects which can be harmful to the patient

SKILLS To be able to obtain, document, and present a comprehensive medical history. To perform initial physical examination such as general assessment of the patients appearance, position and degree of comfort. To apply necessary skills in providing care for a client with acute glomerulonephritis VS nephrotic syndrome, UTI ATTITUDES To learn how to establish rapport with the client and significant others. to be able to recognize the importance of patient and familial preferences when selecting among treatment options

C. Scope and Limitation of the Study

The scope of the study encompasses the anatomy, physiology, and pathophysiology of the disease acute glomerulonephritis VS nephrotic syndrome, UTI. While dealing with Mr. xcase, we are subjected with the following limitations of our study: The group only had 2 days (July 2010) of actual interaction with the patient at Quezon Medical Center, Lucena City. The group credited the study on the references prior to books, researches in the internet and data collected from the interview with the client/family members, physical assessment and the patients chart.

CLINICAL SUMMARY

A. GeneralData
Case # 10071323 Name Address Age Religion Civil Status Nationality Date of Birth Date of Admission Ward and Room AdmittingDiagnosis Attending Physician :Mr. x :Brgy. Poblacion, L.C. :15 y/o :Roman catholic :Child :Filipino :July 21, 1995 :July 21,2010 :PAW 04 :AGN VS. NS, UTI :Dra Tagle

B. CHIEF COMPLAINT

abdominal pain, fever & edema last July 21, 2010.

C. History of Present Illness

D. PAST MEDICAL HISTORY

E. FAMILY HISTORY

F. Physical Assessment


General Appearance Presence of edema on both extremities The client looks weak and pale. He sleeps a lot and talks only when asked. The client experiences cold and clammy perspiration.

Head to Toe Assessment

Head - normocephalic

no presence of lumps Eye - no abnormal eye discharge PERRLA (+) Nose - symmetric Without nasal discharge Lips - slightly dry and pale uvula and tongue centrally located

Ears equal size no swelling upper pinna is in line with outer cantus Neck able to move freely no lumps upon palpation Chest symmetrical expansion with clear breath sound on both lung field upon auscultation Abdomen with tender abdomen upon palpation

G. Laboratory/Diagnostic Exams

ANATOMY

2 kidneys a pair of purplishbrown organs located below the ribs toward the middle of the back. Their function is to: >remove liquid waste from the blood in the form of urine. >keep a stable balance of salts and other substances in the blood. >produce erythropoietin, a hormone that aids the formation of red blood cells.

The kidneys remove urea from the blood through tiny filtering units called nephrons. Each nephron consists of a ball formed of small blood capillaries, called a glomerulus, and a small tube called a renal tubule. Urea, together with water and other waste substances, forms the urine as it passes through the nephrons and down the renal tubules of the kidney.

The Nephron Is the basic structural and functional unit of the kidney. Its chief function is to regulate the concentration of water and soluble substances like sodium salts by filtering the blood, reabsorbing what is needed and excreting the rest as urine. A nephron eliminates wastes from the body, regulates blood volume and blood pressure, controls levels of electrolytes and metabolites, and regulates blood pH. Its functions are vital to life and are regulated by the endocrine system by hormones such as antidiuretic hormone, aldosterone, and parathyroid hormone. In humans, a normal kidney contains 800,000 to one million nephrons.

The Glomerulus
The glomerulus is themain filter of the nephron and is located within the Bowman's capsule.The glomerulus resembles a twisted mass of tiny tubes through which the blood passes.The glomerulus is semipermeable, allowing water and soluble wastes to pass through and be excreted out of the Bowman's capsule as urine.The filtered blood passes out of the glomerulus into the efferent arteriole to be returned through the medullary plexus to the intralobular vein

Bowman'sCapsule
The Bowman's capsule contains the primary filtering device of the nephron, the glomerulus. Blood is transported into the Bowman's capsule from the afferent arteriole (branching off of the interlobular artery). Within the capsule, the blood is filtered through the glomerulus and then passes out via the efferent arteriole. Meanwhile, the filtered water and aqueous wastes are passed out of the Bowman's capsule into the proximal convoluted tubule

PATHOPHYSIOLOGY

UTI

Post-streptococcal infection (group-A, beta hemolytic)

Release of material from the organism, into the circulation (antigen)

Formation of antibody

Immune complex reaction in the glomerular capillary

Inflammatory response
Proliferation of epithelial cells lining glomerolus & cells between endothelium & epithelium of capillary membrane

Swelling capillary membrane & infiltration with leukocytes

Permeability of base membrane

Glomerular filtration rate

Occlusion of the capillaries of the glomeruli vasospasm of afferent ventrioles

Ability to form filtrate from glomeruli plasma flow

Retention of H2O & Na; hypovolemia; circulatory congestion

NEPHROTIC SYNDROME

Renal injury

Excessive lost of protein in urination

Common manifestations of the syndrome are: Proteinuria, hypoalbumenia,hypercoagulability,hypoalbuminemia, hyperlipideminemia,hypercoagulability Edema Hypertension urinary output Urine dark in color Anorexia Irritability lethargy

ACUTE GLOMERULO-NEPHRITIS GLOMERULO-

CLINICAL MANIFESTATIONS

Oliguria/anuria, due to decreased glomerular filtration rate (GFR) Elevated BUN and serum creatinine, due to decreased urine output Hematuria (microscopic or gross), occurs in approximately 30% of cases; urine may appear dark, cola-colored or tea-like Proteinuria, primarily albumin, due to increased permeability of glomerular membrane Edema (facial, periorbital and/or pedal), hypertension, anemia, increased ICP, pulmonary edema, all related to increased circulating blood volume/excess extracellular fluid (ECF) Tenderness over the costo-vertebral angle ( + kidney punch), due to swelling of kidneys

ASSESSMENT AND DIAGNOSTICS

History taking; 1-3 weeks poststreptococcal infection (1-2 weeks postpharyngitis) Urinalysis; dark urine, (+) RBC, albumin, casts; specific gravity > 1.020 CBC; decreased Hgb, Hct Blood chemistry; elevated BUN and serum creatinine Kidney biopsy, electron microscopy and immunofluorescent analysis Antistreptolysin O; increased in 60-80% of patients KUB; enlarged kidneys

POSSIBLE NURSING DIAGNOSIS

Fluid volume excessrelated to decreased glomerular filtration rate as evidenced by decreased urine output, edema and hypertension Imbalanced body temperature related to unknown etiology (possible infection) as evidenced by Temp=38.4 C Imbalanced nutrition: less than body requirementsrelated to increased glomerular permeability as evidenced by proteinuria Knowledge deficitrelated to medical management of the disease as evidenced by questioning attitude by the mother Anxietyrelated to outcome of treatment Impaired parent-child interactionrelated to irritability of child Risk for impaired skin integrityrelated to edema/altered skin turgor Risk for infectionrelated ongoing disease process (immunocompromised)

DRUG STUDY

Ranitidine

Therapeutic Classification y Antiulcer Drug Action y Reduces gastric secretion and increases gastric mucus and bicarbonate production, creating a protective coating on gastric mucosa Contraindication y Hypersensitivity to drug and its component Toxic/Side Effects y Nausea, vomiting, diarrhea, constipation, abdominal discomfort or pain. Indications y To maintain healing of duodenal and gastric ulcers Safety y Renal or hepatic impairment, heart rhythm disturbances

FUROSEMIDE

Therapeutic Classification y Diuretic Action y Increases potassium excretion and plasma volume, promoting renal excretion of water. Contraindications y Hypersensitivity to drug or other sulfonamides Toxic/Side effects y Nausea, vomiting, diarrhea, constipation, dyspepsia, oral and gastric irritation, cramping, anorexia, dry mouth. Indications y For hypertension. Safety y Diabetes melitus, severe hepatic disease, neonates

Asessment

Nursing Diagnosis

Planning

Interventio n INDEPEND ENT reinstructed patient on NPO -monitor intake and ouput -elevate edematous extremities -Provide adequate activity or position changes

Rati onal e -to avoi d exce ssive fluid reten tion -to mea sure the intak e and outp ut -to incre ase veno

Evaluation

S> Fluid volume Namamana excess related s na ang to renal failure kamay at paa ko as verbalized by the patient O> -fluppy face -edema on both lower and upper extremities -tender abdomen -pale in appearance -body malaise

After 8 hours of nursing intervention patient can demonstrate behaviors to monitor fluid stasus and reduce recurrence of fluid excess

Goal partially met seen patient elevating both legs using pillow

Asessment

Nursing Diagnosis

Planning

Interventio n

Rati onal e

Evaluation

-DEPENDE NT -Administer diuretic as ordered

us diuresis retur n -to prev ent fluid accu mula tion in depe nden t area s -to prom ote of fluid