UNIVERSITY OF BAGUIO School of Nursing

A Case Study on Acute Glomerulonephritis

Presented to: THE FACULTY OF SCHOOL OF NURSING University of Baguio

In Partial Fulfillment Of the Requirements of the Subject NCENL06

Submitted by: Ambrocio, Jayson Basilio, Zorenne Cruz, Nestoria Dion, Junelle Marie Genetiano, Wenette Hipona, Marie Jo Mahey, Crislyn Paculan, Marjorie Ann Romero, Nelmie Supnet, Marvin

October 2011

TABLE OF CONTENTS

TABLE OF CONTENTS

I. II.

INTRODUCTION 3-6 PATIENTS PROFILE 7

III. PHYSICAL ASSESSMENT 8-11 IV. V. VI. LABORATORY RESULTS 11-13 ANATOMY AND PHYSIOLOGY 13- 16 PATHOPHYSIOLOGY 17-19

VII. NURSING CARE PLAN 20 VIII. IX. X. XI. DRUG STUDY.21 SUMMARY OF FINDINGS 21 CONCLUSION 22 RECOMMENDATION 23

XII. APPENDICES 24

I. INTRODUCTION 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. Acute nephritic syndrome is a group of disorders that cause inflammation of the internal kidney structures (specifically, the glomeruli). In acute glomerulonephritis, the kidneys are normal in size or enlarged and edematous, and the surface of the kidney may show punctate hemorrhages. With the development of the microscope, Langhans was later able to describe these

pathophysiologic glomerular changes. Acute glomerulonephritis is defined as the sudden onset of hematuria, proteinuria, and red blood cell casts. This clinical picture impaired is often accompanied function. As by hypertension, be edema, and acute

renal

will

discussed,

glomerulonephritis can be due to a primary renal or systemic disease. Symptoms of acute glomerulonephritis include the following: Hematuria is a universal finding, even if it is microscopic. Gross hematuria is reported in 30% of pediatric patients. Edema (peripheral or periorbital) is reported in approximately 85% of pediatric patients; edema may be mild (involving only the face) to severe, bordering on a nephrotic appearance. Headache may occur secondary to hypertension; confusion secondary to

malignant hypertension may be seen in as many as 5% of patients. Shortness of breath or dyspnea on exertion secondary to heart failure or pulmonary edema; usually uncommon, particularly in children. Possible flank pain secondary to stretching of the renal capsule. Hypertension is seen in as many as 80%of affected patients. Hematuria, either macroscopic (gross) or microscopic, may be noted. Skin rashes (ie, malar rash frequently seen with
3

lupus

nephritis)

may

be

observed.

Abnormal

neurologic

examination or altered level of consciousness occurring because of malignant hypertension or hypertensive encephalopathy.

Arthritis may be noted. The most common cause is post infectious Two types serotype respiratory and (2)

Streptococcus species (ie, group have been described as (1)

A,beta-hemolytic). attributed to an to

12,poststreptococcal

nephritis

due

upper

infection occurring primarily in

the winter months,

attributed to serotype 49, post streptococcal nephritis due to a skin infection usually observed in the summer and fall and more prevalent in southern regions of the United States. With some exceptions, a reduction in the incidence of post streptococcal glomerulonephritis has occurred in most western countries. Africa, Guinea, It remains Caribbean, South acute much more common in regions such as

the and of

India, In

Pakistan, Port

Malaysia,

PapuaNew the 3-16

America.

Harcourt, in

Nigeria, aged

incidence

glomerulonephritis

children

years was 15.5 cases per year, with a male-to-female ratio of 1.1:1; the current incidence has not changed much over the past 14years. Sporadic cases of acute nephritis often progress to a

chronic form. This progression occurs in as many as 30% of adult patients and 10% of pediatric patients. Glomerulonephritis is the most common cause of chronic renal failure(25%).The

mortality rate of acute glomerulonephritis in the most commonly affected age group, pediatric patients, has been reported at 07%. A male-to-female ratio of 2:1 has been reported. Most cases occur in patients aged 5-15 years. Only 10% occur in patients older than 40 years. Acute nephritis may occur at any age, including infancy.

GN represents 10-15% of glomerular diseases. Variable incidence has been reported, in part because of the subclinical nature of the disease in more than half the affected population. Despite sporadic outbreaks, the incidence of GN has fallen over the past few decades. Factors responsible for this decline may include better health care delivery and improved socioeconomic

conditions.

GN comprises 25-30% of all cases of end-stage renal disease (ESRD). About one fourth of patients present with acute

nephritic syndrome. Most cases that progress do so relatively quickly, and end-stage renal failure may occur within weeks or months of the onset of acute nephritic syndrome. Asymptomatic episodes of PSGN exceed symptomatic episodes by a ratio of 34:1.

Worldwide, Berger disease is the most common cause of GN.

With some exceptions, the incidence of PSGN has fallen in most Western countries. PSGN remains much more common in regions such as Africa, the Caribbean, India, Pakistan, Malaysia, Papua New Guinea, and South America. In Port Harcourt, Nigeria, the

incidence of acute GN in children aged 3-16 years was 15.5 cases per year, with a male-to-female ratio of 1.1:1; the current incidence is not much different.

Geographic and seasonal variations in the prevalence of GN are more marked for pharyngeally associated GN than for cutaneously associated disease.

Postinfectious GN can occur at any age but usually develops in children. Most cases occur in patients aged 5-15 years; only 10% occur in patients older than 40 years. Outbreaks of GN are

common in children aged 6-10 years. Acute nephritis may occur at any age, including infancy.

Acute GN predominantly affects males (2:1 male-to-female ratio). Postinfectious GN has no predilection for any racial or ethnic group. A higher incidence (related to poor hygiene) may be

observed in some socioeconomic groups.

The exposure started within our clinical duty at Abatan Emergency Hospital all wards including special areas under the supervision of our clinical instructor Maam Froilaline Villanueva within this exposure, the patient was handled for a day. Assessments were done with the patients significant other

and consultations to medical record were done. 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. PATIENTS PROFILE A. Biographical data NAME: AGE: GENDER: ADDRESS: BIRTHDAY: PLACE OF BIRTH: OCCUPATION: NATIONALITY: CIVIL STATUS: RELIGION: CHIEF COMPLAINT: DATE ADMITTED: TIME ADMITTED: FINAL DIAGNOSIS: Nephritis Patient Y 8 years old Male Bauko, Benguet March 29, 2003 Bauko, Benguet Student Filipino Single Roman Catholic Fever, painful swallowing October 04, 2011 10:45 am Acute Tonsillitis, Acute Glomeruluss

B. Past history of Illness Known case of having recurrent tonsillitis. The client had high fever and facial edema for about 3 days significant others reported that paracetamol and antibiotics was given. C. Present history of illness Upon assessment prior to admission, the patient experienced high fever, difficulty in swallowing, occurrence of

evident facial edema and cola-colored urine following his tonsillitis. Laboratory test are conducted and was admitted.

III. Cephalocaudal Assessment Physical examination follows a methodical head to toe format in the Cephalocaudal assessment. This is done systematically using the techniques of inspection, palpation, percussion and auscultation with the use of materials and investments such as the penlight, thermometer, Sphygmomanometer, tape measure and stethoscope and also the senses. During the procedure, We made every effort to recognize and respect the patients feelings as well as to provide comfort measures and follow appropriate safety precautions.

A. General Physical Assessment Patient is an 8 year old male, stands 42, with pulse rate of 92 beats per minute, respiratory rate of 33 breath per minute and a temperature of 37.8 C. He is conscious and coherent upon interaction but answers only the questions he is comfortable with. Most of the time, he is pacing inside the ward and appears withdrawn.

B. Assessment of the Head He has a round skull, no contusions, no bruises noted nodules and masses, and no tenderness palpated. He has a facial edema 1+ slight pitting/2 mm, disappears rapidly, noted upon inspection.

C. Assessment of the Eyes His eyes are symmetrical, black in color, almond shape. Pupils constricts when diverted to light and dilates when he gazes afar, conjunctivas are pink. Eyelashes are equally distributed and skin around the eyes is intact. The eyes involuntarily blink. Holding the penlight in the periphery, the client was able to spot the moving object. For visual acuity, he can read
8

writings on the chart. There is presence of periorbital edema on the face of the client.

D. Assessment of the Ears Ears are clean, no ear wax was noted and approximately of the same size and shape. Patient can hear normally spoken words.

E. Assessment of the Nose With narrow nose bridge, there were discharges noted upon inspection. No swelling of the mucous membrane and presence of nasal hairs.

F. Assessment of the Mouth He has a complete set of teeth with minimal dental caries noted. Oral mucosa and gingival are pink in color, moist and there were no lesions nor inflammation noted. Tongue is pinkish and is free of swelling and lesions. Lips are symmetrical, appears pale without bits noted upon observation. Gag reflex is present by using a tongue depressor and pressed in the posterior tongue. With painful swallowing noted.

J. Assessment of the Neck Enlarged Lymph nodes noted. Neck has strength that allows movement back and forth, left and right. Patient is able to freely move her neck.

H. Assessment of the Lungs and Thoracic Region No reports of pain during the inhalation and exhalation. Presence of rales sounds upon auscultation. No tenderness and masses, full and symmetric lung expansion, resonant sound upon percussion. Spinal cord is vertically aligned and has good
9

posture, with symmetric right and left shoulders.

J. Assessment of the Heart Patient has an audible heart sound. PMI is heard between 4th 5thintercostals space. Heart is pumping well with a pulse rate of 92 beats per minute and respiratory rate of 33 breathe per minute.

J. Assessment of the Abdomen Uniform in color, not distended, rounded symmetric contour and movements upon by respiration and with audible bowel sounds every 5 to 20 seconds, No lesions noted, relaxed abdomen with smooth and consistent tension.

MOTOR FUNCTION

K. Assessment of the Upper Extremities His bones and joints have no deformities & tenderness noted. He can sense touch, pain and temperature. He has decrease motor activity as verbalized by his mother classified as Level 1 activity intolerance. The client can walk in regular pace, on level indefinitely; one flight or more but more short of breath than normally.

Skin :slightly pallor; Skin is smooth, moist and soft to touch. Hands: Medium in size with 5 fingernails in each side. Nails are short, small dusty particles are present. Arms: Able to move through active ROM. Able to extend arms in front or push them out to the side.

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L. Assessment to the Lower Extremities The muscles in the lower extremities are symmetrical and well toned. The bones and joints in the lower extremities have no deformities and pain, temperature and touch is felt.

Neurological Assessment Behavior Patient is silent but is conscious and coherent upon interaction. He sits and walks if he wants to.

Motor Functioning -Able to move extremities through active ROM. Able to extend arms front but shows lack of interest in activity.

Reflexes -reflexes were present such as the blinking reflex and deep tendon reflex.

Sensory Functioning Patients sensory system is intact, he was able to distinguish touch, pain, hot and cold.

IV. LABORATORY RESULTS Hematologic and Blood Chemistry Date: October 4, 2011 Components Result Normal rates Male: 140-180 Female: 120-160 Leukocyte differential count Segmenters Leukocyte 12.70x10g/l 5.10x10g/l Increased 0.81 0.50-0.70 Increased Indication Normal

Hemoglobin mass 143g/dl

11

Lymphocyte Basophils Erythrocyte volume

0.24 0.01 0.42

0.20-0.90 0-2

Normal Normal

Male: 0.40-0.54 Normal Female: 0.370.47

IMPLICATION: The elevation of the number of leukocyte segmenters indicates the presence of an infection. Leukocytes are responsible for fighting foreign microorganisms that enters the body.

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URINALYSIS Physical Exam Components Color: Results Cola-colored Date: October 4, 2011 Normal findings Straw/amber Indication Hematuria

Transparency: slightly turbid Ph: Specific gravity: 4 1.031 4.6-7.0 1.0101.025 (gcm3) Increased Increased

Chemical exam Sugar: Protein: WBC/HPF: RBC/HPF: Amorphous urates: negative positive 2-5 13-6 Few

Date: October 4, 2011 Negative Negative 1-6/hpf 0-2 Normal Abnormal Normal

IMPLICATION: Urine output is most often reduced in acute glomerulonephritis, and the urine is concentrated and acidic. Thus, concentrated urine results to the increased urine specific gravity as shown in the above results. Glucose is not present while proteinuria resulted to positive. The presence of protein indicates a damage in the glomerular membrane most often caused by the presence of inflammation such as glomerulonephritis.

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V. ANATOMY AND PHYSIOLOGY Urinary System The body takes nutrients from food and uses them to maintain all bodily functions including energy and self-repair. When the body has taken what it needs from food, waste products are left behind in the blood and in the bowel. The urinary system, in working with the lungs, skin, and intestines to keep the chemicals and water in balance, removes a type of waste called urea from the blood. Urea is produced when foods containing protein, such as meat, are broken down in the body. Adults eliminate about a quart and a half of urine each day, depending on factors such as the amount of foods and fluid consumed, and how much fluid is lost through sweating and breathing.

KIDNEY ANATOMY

The kidneys are dark-red, bean-shaped organs. One side of the kidney bulges outward (convex) and the other side is indented (concave). There is a cavity attached to the indented side of the kidney, called the Renal Pelvis which extends into the ureter.

Each Kidney is enclosed in a transparent membrane called the renal capsule which helps to protect them against infections and trauma. The kidney is divided into two main areas a light

outer area called the renal cortex, and a darker inner area called the renal medulla. Within the medulla there are 8 or more cone-shaped sections known as renal pyramids. The areas between the pyramids are called renal columns.

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Kidney Anatomy and Excretion

The most basic structures of the kidneys are nephrons. Inside each kidney there are about one million of these microscopic structures. They are responsible for filtering the blood

removing waste products.

The renal artery delivers blood to the kidneys each day. Over 180 liters (50 gallons) of blood pass through the kidneys every day. When this blood enters the kidneys it is filtered and returned to the heart via the renal vein.

The process of separating wastes from the body's fluids and eliminating them is known as excretion. The body has four organ The urinary

systems that are responsible for excretion.

system is one of the main organ systems responsible for excretion. It excretes a broad variety of metabolic wastes, The

toxins, drugs, hormones, salts, hydrogen irons and water. kidneys are the main organs of the urinary system.

Kidney Anatomy and Blood Vessels The kidneys are full of blood vessels. integral to efficient kidney function. Blood vessels are Every function of the

kidney involves blood; therefore, it requires a lot of blood vessels to facilitate these functions. Together, the two kidneys contain about 160 km of blood vessels.

KIDNEY LOCATION

The normal kidney location is towards the back of the abdominal cavity, just above the waist. If you put your hands on your hips, your kidneys are located just about where your thumbs are. One kidney is normally located just below the liver, on the

15

right side of the abdomen and the other is just below the spleen on the left side.

In rare cases, however, one or both kidneys may be located much lower in the abdomen. This is not necessarily a problem except probably in the case of pregnancy. As the fetus begins to develop in the womb this could sometimes place pressure on the kidney which is located in the lower abdomen.

NORMAL KIDNEY SIZE The normal kidney size of an adult human is about 10 to 13 cm (4 to 5 inches) long and about 5 to 7.5 cm (2 to 3 inches) wide. It is approximately the size of a conventional computer mouse.

A kidney weighs approximately 150 grams. Kidneys weigh about 0.5 percent of total body weight.

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VI. PATHOPHYSIOLOGY SCHEMATIC: Pathophysiology of Tonsillitis Resulting To Acute Glomerulonephritis

Predisposing factors: Intake of foods like chocolates, soda & junk foods with poor oral hygiene. Invasion of streptococcus in the throat Streptococcal infection travels through circulation affecting the kidneys

Inflammation of the tonsils (a compensatory mechanism)

Recurrent and untreated tonsillitis Formation of antibody (as a compensatory mechanism) Proliferation of epithelial cells lining glomerulos and cells between endothelium and epithelium of capillary membrane Occlusion of the capillaries of the gromeluri vasospasm of afferent ventrioles

Signs & symptoms: Fever, Sore throat, Difficulty in swallowing Immune complex reaction in the glomerular

Streptococci produce proteins with unique antigenic determinants following release in circulation

Swelling of the capillary membrane & infiltration with leukocytes

Decrease Glomerular filtration rate

Increase permeability of base membrane

Decrease ability to form filtrate from glomeruli plasma flow

Periorbital edema, decrease urine output, cola colored urine output,proteinuri a and fluid retention

Retention of water and sodium; hypervolemia; circulatory congestion

Acute Glomerulonephritis
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NARRATIVE: Glomerulonephritis is a common disease to children. Children love to eat sweets like chocolates and/or salty foods like junk foods or chips. They are more susceptible in getting acute

glomerulonephritis compared to adult clients because the kidneys at young age are less efficient in regulating electrolyte and acid base balance and eliminating some toxins in the body. Just like the case of Patient Y, he is more vulnerable in acquiring acute glomerulonephritis because he loves eating chocolates and junk foods accompanied by poor oral hygiene which is the most common predisposing factor. He is unable to perform a good oral hygiene resulting then to the agent that eventually affects invasion of the streptococcus the tonsils and get inflamed

(Tonsillitis). The tonsils are lymph nodes in the back of the mouth and top of the throat. They normally help to filter out bacteria and other germs to prevent infection in the body. If tonsillitis is untreated, the streptococcus will now then travel to the circulation produce affecting proteins the kidneys. Nephritogenic antigenic

streptococci

with

unique

determinants. Following release to circulation, antigens bind to the sites within the glomerulus. Once bound to the glomerulus, they activate directly by interaction. The signs and symptoms of tonsillitis experienced by the client are: Fever, Sore throat and Difficulty in swallowing. During the process the of inflammation, there is a release into of the

material

from

organism

(streptococcus

agent)

circulation (antigen). There will be a formation of antibody as a compensatory mechanism to fight against the said antigen and the immune complex reaction will then happen in the glomerular capillary, which is the one responsible in filtering blood. Since infection is now present, there will be proliferation of

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the

epithelial

lining

of

the

glomeruli

and

cells

between

epithelium and endothelium of capillary membrane. Because of the said proliferation, swelling and damage of the capillary

membrane is expected and infiltration with leukocytes is then present resulting to presence of protein (proteinuria) and blood in the urine (hematuria). is a Due to swelling of of the the capillary in

membrane,

there

decrease

function

glumeruli

filtering the toxins and excess water in the body that should be excreted through urination. One of the electrolytes that are not excreted through urination is sodium resulting to fluid

retention and hypervolemia. If excess fluid is present the body of a child, the early sign is periorbital edema which was

experienced by the client. The signs and symptoms experienced by the client like

periorbital edema, decrease urine output, cola colored urine and fluid retention are the indicative signs and symptoms of acute glomerulonephritis.

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PRIORITIZATION OF NURSING PROBLEM

Actual 1. Excess fluid volume related to inability of the kidneys to maintain internal hoeostasis as evidenced y presence of edema 2. Activity intolerance related to electrolyte imbalance and fluid retention.

Potential 1. Risk for ineffective therapeutic regimen management related to lack of information about glomerulonephritis and treatment.

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VIII. SUMMARY OF FINDINGS Patient X 8 y/o, male. Patient lives with his family in Bauko, Benguet was and is being supported at the by his parents. room. Upon Upon

admission,

accommodated

Emergency

assessment the patient has fever with facial edema +1.

IX. CONCLUSION Acute children glomerulonephritis it is one of (AGN) the is a common that disease in

and

diseases

are

presented

commonly with hematuria which means red urine (blood in urine). AGN is active inflammation in the glomeruli. Each kidney is composed known as of about 1 million that microscopic filtering "screens" waste an

glomeruli

selectively process

remove

uremic

products. The

inflammatory

usually

begins

with

infection or injury (e.g., burn, trauma), then the protective immune system fights off the infection, scar tissue forms, and the process is complete. There are many diseases that cause an active inflammation within the glomeruli. Some of these diseases are systemic (i.e., other parts of the body are involved at the same time) 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. The severity and extent of glomerular damagefocal

(confined) or diffuse (widespread)determines how the disease is manifested. Glomerular damage can appear as subacute renal

failure, progressive chronic renal failure (CRF); or simply a urinary abnormality. The client in this case had an experience of streptococcal infection of the by 2 throat to 3 preceding weeks. He was the onset of

glomerulonephritis

treated

through

antibiotic agents and sodium restriction on his diet.

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X. RECOMMENDATION FOR THE PATIENT The recommendations formed were follows: Religiously follow the doctors order of total bed rest in the hospital and if she will be sent home. Have a follow up check-up regarding her condition and to prevent recurrence of complications. Willingness to cooperate with the health care provider so that there will be an effective therapeutic management.

FOR THE INSTITUTION They should maintain the strict and honest monitoring of the patients status as well as the accurate and on-time administration of medications. They should practice proper aseptic technique in any nursing procedures in the institution. Spend time and through assessment of the patient. Make an effort to explain and to orient the patient regarding the hospital protocols, environment and every procedure that will be done to her. The patient has the right to know every detail of every procedure or routine that will be done to her.

FOR THE STUDENTS The student nurses hold an important role in caring for their patients. Students first and foremost should know their patients well. Detailed and truthful assessment should be learned and enhanced so that every problem of the patients is known and attended. Interview is very important. Have the effort to study the patients case as well as the drugs. Learn to read and understand the chart, doctors orders and the special considerations given to the patient. Have special studies, extra researches so that you will not
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only learn but you can as well share that information with your patient. Be updated. Its nice when you got new learning something fresh to share.

FOR THE SCHOOL The school must develop special programs that will enhance the knowledge and skills of their students. The school should maintain a high standard of education. The school should have a lying-in clinic as a training ground so that in actual situation they can function well. Clinical instructors must be well versed and updated with the latest medical trend concerning Acute Glomerulonephritis so as to impart better knowledge to nursing students.

XI. APPENDICES

KIDNEY DIAGRAM

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