Case Presentation

Acute Glomerulo Nephritis

Submitted By:
Section 2 Group 5
Abdullah, Samad
Abduljalil, Janima
Abellera, Gerlie
Advincula, Mark Jim
Agustin, Jenilyn
Aranda, Jeanette
Bares, Catherine

Submitted To:Mr. Rowel Lucina

THEORETICAL FRAMEWORK

We have chosen Florence Nightingale’s environment theory because it is much related

to the case of our patient. According to the mother of the patient they are using

unsanitary water supply, they are using it in cooking noodles, drinking and in everyday

life. In order to be healthy or have an easier recovery from any disease, we must

consider our environment as a factor in achieving wellness; clean water supply and

proper sanitation are just some in basic things we must consider. Like what had happen

to our patient the disease maybe prevented only if they had taken into consideration

that clean water supply is very important in the health of their family.

The factors posed great significance during nightingale’s time when health institution

had poor sanitation and health workers had little education and training were frequently

incompetent and unreliable in attending to the needs of the patient. Also emphasized

theory is the provision of quiet noise free and warm environment to patient dietary

needs by assessment, documentation of time of food intake, and evaluating it’s effect

on the patient. Nightingale’s theory was shown to be applicable during the Carmen War

when she along with other nurses she had trained took care of injured soldier’s

attending to their immediate needs when communicable disease and rapid spread of

infections where rampart in the early in period in the development of disease capable

medicine.
 Nursing History

A.Biographical Data
Name: Patient X
Age: 5 years old
Birthday: July 23,2005
Gender: Female
Address: Maseilan St., Mandaluyong City
Civil Status: Single
Religion: Roman Catholic
Admitting Diagnosis: Acute Glumerulonephritis
Date of admission: Jan. 19,2011

B.Reason for seeking Admission

Patient X was admitted in the institution (MCMC) with the chief complaint of

periorbital edema on both right and left eye.

C.History of Present Illness

Three days prior to admission , Patient X experienced periorbital edema on both

right and left eye. This is accompanied by hematuria and abdominal enlargement. No

associated signs and symptoms noted such as fever, vomitting, dificulty of breathing

and abdominal pain. Resistance of above signs and symptoms experienced. Consulted

at the doctor and recommended for admission and hence admitted.

D.History of Past Illness

Patient X has no hospitalization before, no surgical procedure done, no known

allergies to drugs and food. Patient X has no history of asthma, hypertension, DM, and

cancer. With complete dose of immunization of Hepa B, OPV, BCG,DPT and Measles.

E.Family History
 Patient X has no hereditary disease noted such as Asthma, Heart Disease,

Diabetes Mellitus, Hypertension and Cancer.

Gordon’s Functional Pattern

Health Perception Pattern

When she experienced pain or suffering from illness, she always inform her

mother or her father.

Nutritional/ Metabolic Pattern

Before, she is very choosy on the food that she eat. She do not want to eat

“lugaw”. But when she was hospitalized, she now eat all foods they give to her.

Elimination Pattern

She always urinate but in small amount of urine. She urinatefour to six times a

day and two times she defecate. Her urine was yellowish in color and no excessive

odor. Her stool was formed and not watery. There is no blood in the urine before, this

time when she was hopitalized every time she urinate there’s a blood in her urine. And

because of this she is now seldome to urinate.

Activity/ Exercise Pattern

She likes playing with her friends, but when she was hopitalizes she became

weak and she cannot play. She always lie on bed everyday.

Sleep/ Rest Pattern

She always sleep eight to ten hours a day. From eight in the evening until six or

seven in the morning.

Cognitive Perception Pattern

She likes fantasy and have magical thinking. She like that she was the only

center of attraction on their family.

Self perception/ Self-Concept Pattern

Role-Relationship Pattern
 She has initiative to do things in her own like dressing up herself, toothbrushing,

bathing and eating with her own self. She always ask questions.

Sexuality Reproductive Pattern

She is always make their family happy. She was exhibitionist, she sing and

dance when they are watching her.

Coping- stress Tolerance

When she was borede, she watch TV or eat foods. She give her attention to TV

so that she would not be overstressed.

Values/ Beliefs Pattern

They always go to church every Sunday with the complete family members.
 Physical Assessment

Appearance and Mental Status

The state of consciousness of the patient is alert. The body build, height and
weight are proportion to his age. Posture and gait, standing sitting and walking are
relaxed, erect posture and coordinated movements. There is no body and breath odor.
The client’s attitude is cooperative. The mood of the client is appropriate to situation.

Skin

Skin color varies from light to deep brown; the skin is uniform except areas
exposed to the sun. It has good skin turgor, no lesion, and no rashes.

Hair

The hair is thin and evenly distributed. There is no infection and infestation
present. No abrasions and injuries seen.

Ear

The top of the pinna meets the eye occiput line, no discharge or pain and no
hearing problem.

Nose and Sinuses

The external nose has no discharge or flaring, not tender and no lesions. The
patency of both nasal cavities is moves freely as the client breathes through the nares.
The mucosa of the nasal cavities is pink. The nasal septum is intact and in midline.

Mouth and Oropharynx

The outer lips are uniform in pink color, soft and moist texture. The teeth and
gums are smooth, with pink gums. The surface of the tongue is pink in color. The
tongue moves freely, no tenderness. Tonsil is no discharge. Gag reflex is present.

Neck

Neck muscle is equal in size; head centered. Neck movement is coordinated,

smooth movements with no discomfort. The trachea is in central placement in midline of
neck.
Chest/Lungs

The chest and lungs are symmetrical chest expansion, no retraction, no

wheezes, and no crackles.

Breast

There is no mass and discharge from the breast.

Abdomen

The abdominal contour and symmetry are flat, rounded (convex) or scaphoid
(concave). No evidence of enlargement of liver or spleen. The glomerular capillaries are
inflamed so there is a presence of blood in the urine of the patient.

The movement of the abdomen is symmetric caused by respiration. No visible vascular

pattern.

Back

The spine is in midline portion. There is no bedsore presence.

Muskuloskeletal

The muscle sizes are both equal on both sides of the body. There are no
contractures on muscles and tendons. No muscle fasciculation or tremors.
 Pathophysiology
Precipitating Factor Predisposing Factor
Age: 5-10 y/o B-hemolytic Streptococci
Gender: Male Post Infection

Antigen(Group A beta-hemolytic streptococcus)

Antigen-antibody product

Deposition of antigen-antibody complex in glomerulus

Increased production of epithelial cells lining the glomerulus

Leukocyte infiltration of the glomerulus

Thickening of the glomerular filtration membrane

Scarring and loss of glomerular filtration membrane

Decreased glomerular filtration rate (GFR)

Sign and Symptoms

G.U System
- Oliguria
- Hematuria
- Proteinuria
 ANATOMY AND PHYSIOLOGY

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

interwovencapillaries 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 therenal 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.

G. Glomerulus and Bowman's Capsule

This is where ultra-filtration takes place. Blood from the renal artery is forced into the

glomerulus under high pressure. Most of the liquid is forced out of the glomerulus into the Bowman's

capsule which surrounds it. This does not work properly in people who have very low blood

pressure. Proximal Convoluted Tubules Proximal means "near to" and convoluted means "coiled up"

so this is the coiled up tube near to the Bowman's capsule.

 This is the place where all that useful glucose is re-absorbed from the ultra- filtrate and put

back into the blood. If the glucose was not absorbed it would end up in your urine. This happens in

people who are suffering from diabetes.

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.

I. Distal Convoluted Tubules

Distal means "distant" so it is at the other end of the nephron from the Bowman's

capsule. This is where most of the salts in the ultra-filtrate are re-absorbed.

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.

Tubular Secretion in the Kidneys

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.

Tubular secretion of hydrogen ions, augmented by control of bicarbonate levels, is important

in maintaining correct blood pH. When the blood is too acidic (acidosis) more hydrogen ions are

secreted. If the blood becomes too alkaline (alkalosis), hydrogen secretion is reduced. In maintaining

blood pH within normal limits (about 7.35–7.45) the kidney can produce urine with pH as low as that

of acid rain or as alkaline as baking soda!

The Kidney as an Endocrine Gland

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.

THE RENIN ±ANGIOTENSIN MECHANISM

 Decreased blood pressure stimulates the kidney to stimulates the kidney to

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

- stimulates the adrenal cortex to secrete aldosterone which maintains normal blood levels of sodium

and potassium and contributes to the maintenance of normal blood pH, blood volume, and blood

pressure.
          

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

         

Subjective Ineffective After 8 hours -Monitor After 8 hours of

airway of using respiration and nursing
‘’NAHIHIRAPANG clearance nursing breathe sounds, intervention the
HUMINGA ANG related to intervention noting rate and patient was
ANAK KO’’ as possibly the patient sounds. able to
verbalized by the evidenced by will be able Indicative of maintain airway
mother of the verbal reports to maintain respiratory patency.
patient. and airway distress and/or
autonomic patency. accumulation of
  responses secretion.
(changes in  
  vital signs) -elevate head of
  bed/change
Objective position every 2
hours and prn.
-crackles breath To take
sounds advantage of
gravity
-restlessness decreasing
pressure on the
diaphragm and
enhancing
drainage
of/ventilation of
different lung
segment.

-Encourage
deep-breathing
and coughing
exercises. To
maximize effort.

-Position
appropriately and
discourage use
of oil-based
products around
nose. To
prevent
vomiting with
aspiration into
lungs.

-Monitor vital
signs, noting
blood pressure/
pulse changes.

-Demonstrate SO
 in performing
specific airway
clearance
techniques.

-Encourage/
provide
opportunities for
rest, limit
activities to level
of respiratory
tolerance.

 
 

         

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

         

Subjective Excess fluid After 8 hours -Measure After 8 hours of

volume related of using abdominal girth. using nursing
“namamaga to nursing For changes that intervention the
yung dalawang compromised intervention may indicate patient was
mata nya” as regulatory the patient increasing fluid able to
verbalized by mechanism will be able retention/edema. stabilized fluid
the mother of manifested by to stabilized volume as
the patient. PE. fluid volume -Note for fever. evidenced by
as evidenced Client could be balanced intake
  by balanced at risk for and output, vital
intake and infection. signs within
  output, vital normal limits.
signs within -Restrict sodium
  normal limits. and fluid intake,
as indicated.
Objective
-Set an
- (+) per orbital appropriate rate of
edema in right fluid
and left eye. intake/infusion
throughout 24
- (+) hematuria hours period. To
prevent
-look`s bloated peaks/valleys in
fluid level and
  thirst.

-Elevate
edematous
extremities,
change position
frequently. To
reduce tissue
pressure and
risk for skin
breakdown.

-Provide quiet
environment.

-Used safety
precautions if
confused.