A CASE STUDY REPORT ON ACUTE GLOMERULONEPHRITIS

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 TABLE OF CONTENTS

CASE STUDY ............................................................................................................................... 1

1. HISTORY ........................................................................................................................... 1
a. Bio-data........................................................................................................................... 1
b. Present Health History ................................................................................................... 1
c. Past History .................................................................................................................... 2
d. Family History ................................................................................................................ 2
e. Socio-economic Status .................................................................................................... 2
f. Environmental Status ...................................................................................................... 2
2. PHYSICAL EXAMINATION ............................................................................................ 3
a. General Inspection .......................................................................................................... 3
b. Measurement ................................................................................................................... 3
c. Examination of Head, Face and Neck ............................................................................ 3
d. Examination of Breast..................................................................................................... 5
e. Examination of Chest ...................................................................................................... 5
f. Examination of Abdomen ................................................................................................ 5
g. Examination of Limbs ..................................................................................................... 6
h. Examination of Back ....................................................................................................... 6
i. Examination of Female Genitalia ................................................................................... 6
3. ACUTE GLOMERULONEPHRITIS ................................................................................. 7
a. Pathophysiology.............................................................................................................. 7
b. Etiology ........................................................................................................................... 7
c. Sign and Symptom ........................................................................................................... 8
d. Investigation.................................................................................................................... 8
e. Blood Test Finding.......................................................................................................... 9
f. Urine Test...................................................................................................................... 10
g. Radiological Test .......................................................................................................... 10
h. Medication .................................................................................................................... 11
i. Treatment ...................................................................................................................... 11
j. Nursing Management .................................................................................................... 12
k. Daily Progress Report .................................................................................................. 12
l. Summary of Daily Progress Report .............................................................................. 13
m. References ..................................................................................................................... 13

TABLE 1 BLOOD TEST FINDING ........................................................................................................ 9

TABLE 2 URINE TEST ..................................................................................................................... 10
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CASE STUDY

1. HISTORY

a. Bio-data
• Name:

• Age:

• Sex:

• Occupation:

• Marital Status:

• Religious:

• Educational Status:

• Address:

• Date of admission:

• Date of discharge:

• Inpatient number:

• Hospital:

• Ward:

• Bed No:

• Attending Doctor:

• Diagnosis: Glomerulonephritis

b. Present Health History

Chief complain

• Fatigue

• Less urine output

• Edema
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 • Coughing

• Joint pain

c. Past History
• Accident: No, any accident had been occurred

• Hospitalization: She was hospitalized in Baglung due to coughing, joint pain, less
urine output, edema.

• Operation: No any operation being carried out

• Allergy to drugs/food/others/: No any allergy

• Immunization: All doses were taken.

d. Family History
Family Tree

Family Medical History

• No any disease in family

e. Socio-economic Status
• Good relation with family and friends.

• Economic status is good (Middle Class Family)

f. Environmental Status
• Refuse disposal: Dumping/compost manure

• Drainage system: Safety Tank

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 • Ventilation: Proper ventilated

• Fuel used for cooking: Fire wood & LPG

2. PHYSICAL EXAMINATION

a. General Inspection
• State of consciousness: Alert

• Gait: Balanced

• Posture:

• Nutritional status: Well nourished

• General build: Good

• Facial expression: Fair

• Hygienic status: Fair

b. Measurement
• Height: 5 ft 3 inches

• Weight: 57 kg

• Body Temperature: 97·4°F

• Pulse: 80/m

• Respiration: 24/m

• Blood Pressure: 110/80 mm of Hg

c. Examination of Head, Face and Neck

Head

• Color and texture of hair: Black hair

• Cleanliness: Clean hair

• Pediculosis: No

• Abrasions/Injurious/Other: No

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Eye

• Swelling of eyelinds: Swollen

• Discharge: No

• Color of sclera/conjunctiva: White/Pink

• Corneal/lens/reaction to light: Yes

• Eye movement: Both eyes move together while following the object

• Vision problem: No

Ear

• Appearance: Top of the pinna meets the eye occiput line

• Discharge/Pain: No discharge or pain

• Wax/redness of external auditory canals

• Hearing problems: No

Nose

• Discharge: No

• Blockage: No

• Bleeding: No

• Septal defect: No septal defect, located centrally

• Problem with smelling: No

Mouth

• Color of lips/mucous membrane: Pink, moist mucous membrane

• Sores/cracks/swelling/bleeding pain of gums, tongue: No

• Dental carries/missing teeth, denture: White teeth, no carries and missing teeth.

• Cracks lips: No

• Enlargement of tonsils: Small tonsils

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 • Oral hygiene: Good

Inspect neck for

• Mobility: Full and smooth range of movement, no stiffness or tenderness

Palpate neck for

• Enlarged lymph nodes: No

• Enlarged thyroid gland: No

• Enlarged neck veins: No

d. Examination of Breast
Inspect breast for

• Condition of nipples: Good

• Discharge from nipples: No

Palpate breast for

• Abnormal masses/lymph: No

e. Examination of Chest
Inspect chest for

• Shape of the chest: Normal

• Equal movement of chest during breathing: Yes

• Difficulty in breathing: No any difficulty, respiration was normal and regular

• Chest percussion: Deep resonant sound over the lungs

Auscultate the chest for

• Breathing sounds (front and black): Breath sounds are heard in all areas of the
lungs

• Heart sounds (4 areas): Clear and regular heart beats, no heart murmur

f. Examination of Abdomen
Inspect abdomen for

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 • Shape: Rounded or uniform shape, scar was present

• Enlarged veins: No

Auscultate for

• Bowels sound: Bowel sound is present in all areas

• Abdominal percussion: Tympanic and dullness

Palpate the abdominal for

• Enlarged liver: No

• Enlarged spleen: No

• Tenderness: No

• Masses: No

g. Examination of Limbs
Inspect/Palpate limbs for

• Joint mobility/tenderness/redness/swelling: Good joint mobility and edema of legs

and of the hand

• Texture of skin: Dryness

• Color of nails: Pinkish

Palpate axillae/groins for

• Enlarged lymph nodes: Absent

h. Examination of Back
Inspect back for

• Position of spine/movement: Spine is in the midline

• Condition of skin/prone to bedsore: No

i. Examination of Female Genitalia

Inspect the female genitalia for

• Swelling of labia: No

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 • Sores: No

• Discharge from vaginal orifice: No

• Hygiene: Good hygiene was maintained

3. ACUTE GLOMERULONEPHRITIS
Acute glomerulonephritis is a disease of kidney in which there is an inflammation of the
glomerular capillaries. It is most common in child and young adults but all age groups
can be affected.

a. Pathophysiology
Antigen antibody reaction with glomerular tissue produces swelling and death of
capillary cells.

Antigen antibody reaction activates the complement pathway

Results in release of enzymes that attack the glomerular basement membrane

Responses in the membrane increase glomerulus cells.

Causing increase membrane porosity with proteinuria and haematuria

Renal function is depressed by scaring and obstruction of the circulation through the
glomerulus.

b. Etiology
According to book

• 5 – 21 days after an infection of the pharynx or skin by beta-hemolytic

streptococci.

• Antigen antibody complexes are deposited in the glomerule and activated

compliment.

• Compliment activated causes an inflammatory reaction to the injury.

According to patient

• Acute Post Sterptococcal Glomerulo Nephritits (APSGN) results deposition of

antigen antibody in the glomerular capillary membrane causing inflammatory
damage and impending glomerular function.

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c. Sign and Symptom
According to book

• General APGN begins with 1 to 3 weeks after untreated pharyngitis.

• Mild to moderate edema especially on the face and periorbital area

• Patient may have fever, headache, weakness and fatigue.

• Laboratory findings

• Azotaemia in blood (BUN and creatinine both up)

• Hematuria

• Oliguria

• Mild to severe hypertension may result from either sodium or water retention
(caused by decreased glomerular filtration rate)

• Congestive heart failure due to hyperkalaemia (as a result of NA+ and water
retention) leads to symptoms of pulmonary edema, shortness of breath, dyspnea
and orthopnea.

According to patient

• Generalised body edema

• Oliguria

• Hematuria

• Proteinuria

• Periorbital edema

• Ascitis or peripheral edema in the legs

• Respiratory tract infection

• Joint pain

d. Investigation
According to book

History
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 • Past and present illness

• Medication

• Health status

Physical Examination

Lab Test

• Urinalysis

• Serum BUN

• Urine creatinine

• Clearance test

• ESR

• Renal biopsy

According to patient

History

Physcial Examination

Lab test

• Blood test: TCDC, Blood urea, serum, Na+, K+

• Urine test: Urine R/E

Radiological test

• USG

e. Blood Test Finding

Table 1 Blood Test Finding

Blood Test Result Normal Value Remark

WBC 88000 4000 – 10000mm3

Neutrophil 59 45 – 75%

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Lymphocyte 37 20 – 45%

Eosinophil 02 1 – 6%

Monocyte 02 2 – 10%

Basophil 0 0 – 1%

Blood Urea: 29·0 (N/v 15 – 40mg/dl)

S.creatinine: 1·0 (N/v 0·4 – 1·4 mg/dl)

f. Urine Test
Table 2 Urine Test

Color Light Yellow Transparency Clear

Reaction Acidic RBC Plenty/HPF

A/b Nil Puscells 2 – 3/ HPF

Sugar Nil Crystal (Cal-oxalate) Nil/ HPF

Cast Nil/HPF

Epithelial cells Nil/HPF

g. Radiological Test
USG

• There was a 28mm cyst in left adnexal area.

• Mode rate amount of free fluid was seen in the peritoneal cavity.

• Minimal fluid was seen in the right pleural cavity.

• Mild hepatomegally, ascities, very minimal right sided pleural effusion.

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h. Medication
• Injection Taxim 500mg IV ˟ TID (A third generation cephalosporin antibiotic
having a broad spectrum of activity used to treat intra-abdominal infection, bone
and joint infection, Gonorrhea and other infection including Penicnillinase)

• Tab. Laxis 40mg 1˟morning, 1˟day

• Pentid 8 lac p/o 1˟6 hourly

• Injection Lasix IV ½ amp stat

• Tab Ofloxacin 200 mg 1˟BD

i. Treatment
According to book

• Penicillin for residual streptococcal infection

• Diuretics and anti hypertensive agents

• Corticosteroids and immune-suppressants for rapidly progressing disease.

• Plasma exchange and treatment with immune suppressant, corticosteroids and

cytotoxic drugs to reduce inflammatory response in rapid progressive disease.

• Dialysis occasionally necessary.

• Dietary protein restricted with renal insufficiency and elevated BUN.

• Sodium restricted with hypertension, edema and congestive heart failure.

• Carbohydrates for energy and to reduce protein catabolism.

• Fluids according to fluid losses and daily body weight and intake and output.

According to patient

• Complete rest was given

• Vitals was monitored timely

• Intake output was maintained strictly

• Edema was treated by restricting sodium and fluid intake and by administering
diuretics (Laxis)

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 • Protein intake was restricted.

• Persistent infection was treated.

• Antibiotics were given.

4. Nursing Management
According to book

• Review fluid and diet restrictions measure and record intake and output.

• Instruct patient to schedule follow up evaluations of blood pressure, urinalysis for

protein and BUN and creatine studies to determine if disease has worsened.

• Instruct patient to notify physician if infection or symptoms of renal failure occur:

fatigue, nausea, and vomiting, diminishing urinary output.

• Refer to home care nurse as indicated for assessment and detection of early
symptoms and follow-up evaluations.

According to patient

• Vital sign was monitored timely and was recorded in TPP chart.

• An electrolyte value was monitored.

• Renal function was assessed

• Intake and output chart was strictly maintained.

• Acute renal failure was monitored.

• Oliguria

• Azotaemia (Increased blood urea)

• Acidosis and hyperkalemia (K+ increased)

• Health education was provided about the nature of illness, diet, and medicines.

5. Daily Progress Report

2067-1-12 (Admission Day)

Patient was admitted in medical ward from OPD on 2067-1-12th. Patient was conscious
and her general condition was fair. Patient was kept in comfortable position. Her vitals

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 was stable and her vein was opened. All the prescribed medicines were given timely.
Intake and output chart was maintained strictly.

2067-1-13th (1st Day)

Patient general condition was fair. Her vital sign was stable. She was on low position
diet. All the prescribed medicines was given timely. Intake and output chart was
maintained strictly.

2067-1-14th (2nd Day)

Patient general condition was worst than first day. She was referred to Western Regional
Hospital (WRH) immediately.

6. Summary of Daily Progress Report

Patient was admitted in Medical ward from OPD on 2067-1-12th. Patient was conscious
and her general condition was fair. Her vital was stable. Investigation was carried out. All
the prescribed medicine was given timely. Intake and output was maintained strictly. She
was on low protein diet. On the 2nd day her general condition was worse than that of first
day so she was immediately referred to WRH.

7. References
• Patient

• Visitors

• Investigation

• Doctor and Staffs

• Young J, Johnson, Brunner, Sudderth. Textbook of Medical and Surgical Nursing.

11th ed. p. 386-8.

• HLMC Textbook of Adult Nursing 1st ed; 2009. p. 192-3.

• Smeltzer SC, Bare BG, Hinkle SL, Cheever KH, Brunner, Sudderth. Text book
of Medical Surgical Nursing. 11th ed. p. 1517-8.

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