AGN REVIEWER Demographic Data The patients name is NJLM.

A five year old girl, and a grade 1 elementary pupil. The patient is a follower of a Roman Catholic religious group, currently living in 345 P. Quieta St., Bagong Silang, Mandaluyong City with both of the parents and two older siblings. The date of birth was on June 10, 2006 and is a Filipino. The patient was brought at Mandaluyong City Medical Center with chief complaints of Facial Swelling and Dizziness and was diagnosed with Hypertension to be considered Acute Glomerulonephritis (AGN). Medical Diagnosis and Chief Complaint The patient was admitted in Mandaluyong City Medical Center on December 8, 2011 with the admitting diagnosis of Essential Hypertension t/c Acute Glomerulonephritis (AGN) having chief complaints of facial swelling and dizziness. After five days prior to admission she manifested facial swelling, two days of vomiting, no loose bowel movement and no signs of fever. DISEASE ENTITY Statistical Report Since 1991, kidney disease has consistently ranked among the top ten causes of mortality in the governments registry of diseases. For every 100,000 population in 1998, nephritis and nephrotic syndrome accounted for 10.2 cases or 2.1% of total deaths (43). In a 6-year review, the PNSP reported a total of 5861 admissions in four accredited tertiary medical centers with fellowship programs in pediatric nephrology; of these admissions, 1533 patients (26%) had postinfectious acute glomerulonephritis, 1302 (22%) had idiopathic nephrotic syndrome, 812 (14%) were in renal failure for various causes, 335 (6%) had secondary chronic glomerulonephritis (Avner, Harmon, & Niaudet 2004). The Philippines has one of the highest numbers of kidney transplantations in Asia. From 1983 to 2000, 1829 transplantations were performed at the National Kidney and Transplant Institute, 69 of which were in pediatric patients aged 5 to 18 years of age (3.78%) (Avner, Harmon, & Niaudet 2004). According to Carapetis et al., using 11 population studies reporting the incidence of acute PSGN, evaluated the global burden of PSGN. In children from less developed countries and minority populations, they found that the median incidence of disease was 24.3 cases per 100,000 person-years. In people older than 15 yr in these same countries, they estimated the incidence to be two cases per 100,000 person-years, basing their calculations on data from Kuwait. In more developed countries, the incidence was estimated at 0.3 cases per 100,000 person-years on the basis of the Italian Biopsy Registry. The global incidence of acute PSGN was estimated at 472,000 cases per year, 456,000 of which occurred in less developed countries. The Morbidity rate of noninstitutionalized adults with diagnosed kidney disease is 3.9 million and the percent of noninstitutionalized adults with diagnosed kidney disease is 1.7%.

Risk/Aggrevating Factors Glomerulonephritis may be caused by specific problems with the body's immune system. Often, the precise cause of glomerulonephritis is unknown. Damage to the glomeruli causes blood and protein to be lost in the urine. The condition may develop quickly, with loss of kidney function occurring over weeks and months (called rapidly progressive glomerulonephritis). In about a quarter of people with chronic glomerulonephritis there is no history of kidney disease and the disorder first appears as chronic-renal failure. The following increase your risk of developing this condition: History of cancer, blood or lymphatic system disorders, exposure to hydrocarbon solvents, infections such as strep infections, viruses, heart infections,or abscesses and diabetes. Many conditions are known to cause or increase the risk for glomerulonephritis, including: Focal segmental glomerulosclerosis, goodpasture syndrome, Membranoproliferative GN, IgA nephropathy, Lupus nephritis or Henoch-Schonlein purpura, Anti-glomerular basement membrane antibody disease, Blood vessel diseases such as vasculitis or polyarteritis, and Amyloidosis. Pathophysiology Narrative In acute glomerrulonephritis, the exact incidence of AGN is not reported. It peaks at seven years of age, and occurs more often in males with a ration of 2:1. The etiology is usually an infectious agent that has been present in the body for at least 2 to 3 weeks prior to the clinical renal manifestations. The agents usually involved are bacterial or viral. The most common organism is streptococcus (group A beta). The primary site of infection is typically the throat or the skin (Potts & Mandleco, 2002). Two kinds of factors that cause the disorder are considered: a.) Predisposing factors such as gender and age; and the b.) Precipitating factors such as B-hemolytic Streptococcal, post infection, and poor intake of vitamin rich food. Any factors that enter the body causes reaction from the body as defense mechanism would initiate the formation of antigenantibody complexes. The antigen-antibody immune complexes will then be circulating in the blood stream that causes to have the possibility of trapping itself in the glomerular membrane. These cause an inflammatory response activating the complement system and releasing vasoactive substances and inflammatory mediators (Hogan, 2008). According to Mary Ann Hogan, the acute inflammatory response would cause the increased permeability of the glomerular capillaries allowing plasma proteins and blood cells to escape into urine causing to have positive hematuria and/or proteinuria. The other effect would be the thickening and scarring of the glomerular filtration membrane which causes to decrease the glomerular filtration rate (GFR). Diseases of the glomeruli disrupt glomerular filtration and alter the capillary membrane so that it becomes permeable to plasma proteins and blood cells. Increased glomerular capillary permeability leads to proteinuria, hemaaturia, pyuria, oliguria, edema, hypertension, and azotemia (Porth, 2009). Proteinuria, predominantly albuminuria, provides the most important evidence of glomerular injury. With progression from mild to sever glomerular injury, progressively increased amounts of larger plasma proteins, such as gamma globulins, are found in the
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urine. Hematuria can result from bleeding anywhere in the urinary tract. With glomerular disease, hematuria develops because of active inflammatory disease and damage of the capillary membrane. The red blood cells are either entrapped in casts or else degraded by tubular enzymes so that the urine is smoke- or cola-colored (Porth, 2009). According to Carol Porth, the hypoalbuminemia of glomerular disease has two causes: loss of albumin in the urine and dilution die to retention of sodium and water. The effect is to lower plasma colloidal osmotic pressure, causing edema. The hypertension is due to the increase in vascular volume caused by sodium and water retention and possible to increased synthesis of vasoconstrictor compounds by the kidney. Azotemia, a higher than normal blood level of urea or other nitrogen containing compounds in the blood, results from both a reduction in the filtration of urea and other nitrogenous wastes in the glomeruli and an increase in tubular reabsorption of these substances due to renal hypoperfusion (Porth 2009). Renin is an enzyme released by the juxtaglomerular cells of the afferent and efferent arteriole. Renin is thought to be released in response to a decrease in renal blood flow, a change in composition of the distal tubular fluid, or as the result of symphathetic nervous system stimulation. It combines with angiotensinogen, a plasma protein that circulates in the blood, to form angiotensin I. In the lungs, the angiotensin-converting anzyme changes angiotensin I to angiotensin II. Angtiotensin II is a potent vasoconstrictor and simulator of aldosterone release. It is also thought that angiotensin II contributes to the regulation of blood flow within the kidney. The rennin-angiotensin-aldosterone mechanism plays an important part in both short-term and long-term regulation of blood pressure (Porth, 2009). Symptoms usually subside in 10 to 14 days and 60% completely recover. The remaining 40% may have persistent impaired renal function, continued proteinuria and/or hematuria leading to chronic glomerulonephritis then renal failure. In rapidly progressive glomerulonephritis, glomerular cells proliferate along with macrophages forming crescentshaped lesions that obstruct the Bowmans space. This causes to have the manifestations of body weakness, nausea and vomiting, flu-like symptoms, oliguria, and abdominal or flank pain. Chronic glomerulonephritis involves a slow, progressive destruction of glomeruli with impaired renal function such as decreased size of the kidneys and it become granular or roughened. Eventually, all nephrons are destroyed (Hogan, 2008). Prognosis of Disease Prognosis is excellent; more than 95% of children recover completely (Davis & Avner, 2007). In some children and adults who do not recover completely from acute glomerulonephritis, other types of kidney disorders develop, such as asymptomatic proteinuria and hematuria syndrome or 3nephritic syndrome. Other people with acute glomerulonephritis, especially older adults, often develop chronic glomerulonephritis. The patient tends to become very curious and ask many questions whenever she cant understand something (http://www.merckmanuals.com).

ASSESSMENT Head-to-toe Assessment 1. Skin, Hair and Nails: Mild edema on hands and feet (extremities) (Dec. 8,2011) 2. HEENT: puffiness of periorbital area (Dec. 8, 2011) 3. Thorax & Lungs: accessory muscles are slightly used upon breathing due to productive cough, crackles heard upon asucultation (Dec. 8,2011). Presence of adventitious breath sounds upon auscultation (Dec. 8, 2011). Respirations are effort gained of a regular rhythm and mild deep depth (27 breaths per minute last Dec 8, 2011) 4. Cardiovascular: heart rate of 97 beats per minute (Dec. 8, 2011), blood pressure of 110/80 mm Hg (Dec. 8, 2011), Mild edema present in the feet 5. Abdomen: Pain perception on the right side of the abdomen was manifested (Dec. 8, 2011) 6. Genitourinary and Reproductive: tea-colored opaque urine (Dec. 8,2011) 7. Musculoskeletal: Full range of motion but with presence of mild edema on extremities (Dec. 8, 2011), Body weakness (Dec. 8, 2011) 8. Neurological: Can write and draw objects (Dec. 8, 2011), -Sensitive to touch and discrimination. The thresholds of touch, pain, and temperature is present (Dec. 8, 2011) Book Picture vs. Patients Manifestations SYSTEM Genitourinary NORMAL FINDINGS No blood urine PATIENTS MANIFESTATIONS in Cloudy, smoky Cloudy, smoky, brown urine brown urine (Dec. 9, 2011) Proteinuria (++) Proeinuria (Dec. 9, Hematuria 2011) Albuminuria Urine specific gravity: 1.015 Elevated urine (Dec. 9, 2011) specific gravity Mild hypertension Increase heart rate Increase blood pressure Increased blood pressure from 100/60 mm Hg (Dec. 8, 2011) to 110/80 mm Hg (Dec. 9, 2011) Heart rate of 102 bpm (Dec. 8, 2011), 97 bpm (Dec. 9, 2011) BOOK PICTURE

Cardiovasular

Heart Rate: Awake: 80-110 bpm Asleep: 60-90 bpm Blood pressure: 95-105/53-66 mm Hg

Neurologic Gastrointestinal

Lethargy Irritability Headache Nausea Vomiting Abdominal pain Anorexia Diarrhea

Headache (Dec. 6, 2011) Lethargic (Dec. 8-9, 2011) Nausea (Dec. 6, 2011) Vomiting (Dec. 6, 2011) Mild abdominal pain (Dec. 9, 2011)
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Head and Neck (EENT: Eyes, Ears, Neck, Throat0 Hematologic

Moderate periorbital Mild periorbital edema (Dec. 6-8, 2011)

edema

Hemoglobin: Transient anemia 120-150 gm/L Hematocrit: 0.38-0.48 gm/L Erythrocyte: 46x10 12/L Leukocyte: 510x10 9/L Thrombocyte: 150-350x10 9/L Warm to touch Pallor No edema Generalized edema Intact smooth and even. No lesions Back pain Weakness Fatigue 18-30 bpm Tachypnea Dyspnea

Hemoglobin: 106 gm/L Hematocrit: 0.32 gm/L Erythrocyte: 3.75x10 12/L Leukocyte: 12.0x10 9/L Thrombocyte: 576x10 9/L (Dec. 9, 2011)

Integumentary

Pallor (Dec. 8,2011) Mild edema on extremities (Dec. 8, 2011) Body weakness (Dec. 2011) Fatigue (Dec. 8, 2011) 8,

Musculoskeletal

Respiratory

27 breaths per minute (Dec. 8, 2011) 28 bpm (Dec. 9, 2011) Presence of crepitus breath sounds upon auscultation (Dec. 8, 2011)

THE MANAGEMENT Diagnostic Test Result and Significance Name of Test Complete Blood Count Normal Values RBC: 4-6 x 10/L Hct: 0.37-0.47 Hgb: 110-160 gm/L WBC: 5-10 x 10/L Lymphocytes: 0.25-0.35 x 10/L Monocytes 0.04-0.08 x 10/L Eosinophil: 0.02-0.04 Segments: 0.50-0.65 MCV: 82-98 MCH: 27-33 MCHC: 32-36 Color: Yellow Transparency: Hazy Specific gravity: 1.010 pH: 4.5-8.0 Glucose: (-) Ketone: (-) Blood: (-) Protein: (+) Nitrate: (+) Results N Hct: 0.32 N Hgb:106 H WBC: 8-10 L Lymphocyte s :0.35 H Segments: 0.62 Significance Increase segments (mature Neutrophils) reflect a bacterial infection since this are the bodys first line of defence against acute bacterial invasion.

Urinalysis

N Color: Yellow Transparenc y: Slightly Turbid H Specific gravity: 1.015 N pH: 5.0 N RBC:70100/upt A WBC:8-10 A Glucose: () A Protein: (++)

Orange-colored urine indicates concentrated urine caused by fever and sweating reduced fluid intake. Diabetes increases the amount of sugar in the urine thus it increases the specific gravity of it. Protein and Glucose is also present with DM.Positive result in nitrate and the presence of WBC may indicate the presence of bacteria.

Throat or Finding organisms that skin cultures grow in healthy throat tissues (normal flora). These organisms include non-hemolytic and alphahemolytic streptococci, some Neisseria species, staphylococci, diphtheria and hemophilus organisms, pneumococci, yeasts, and Gram-negative rods.

An abnormal result means bacteria or other organism is present. This is usually a sign of infection.

Blood Urea 2.5-6.4 mmol/L Nitrogen (BUN)

Antistreptoly adult: 160 Todd units/ml sin titer child: six months to two (ASO) years: 50 Todd units/ml; two to four years: 160 Todd units/ml; five to 12 years: 170-330 Todd units/ml newborn: similar to the mother's value

A BUN: 7.60 The patients result for BUN mmol/L is within normal range. Increase level of BUN can be caused by excessive protein intake , kidney damage, certain drugs, low fluid intake, intestinal bleeding Increased levels are seen after the second week of an untreated infection in acute streptococcal infection, and are also increased with acute rheumatic fever, acute glomerulonephritis (66% of patients will not have high ASO titers), and scarlet fever. A greater than normal value can indicate inflammation due to infection, autoimmune disease, or certain types of cancer. A lower than normal value can indicate diseases such as congestive heart failure, sickle cell anemia, and polycythemia (Not provided) The patients result for creatinine is in normal range which means there is no glomerulonephritis, pyelonephritis, acute tubular necrosis, urinary tract obstruction, reduced renal blood flow, diabetic nephropathy, nephritis and gigantism. The creatinine clearance test is used to estimate the glomerular filtration rate (GFR). It compares the level of creatinine in urine with the creatinine level in the blood.(Dugdale, 2009). The test is to detect kidney
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Sedimentatio n rate

Males under 50: 015 mm/hr. Males 50 and older: 020 mm/hr. Females under 50: 020 mm/hr. Females 50 and older: 030 mm/hr. Children: 313 mm/hr. Newborns: 02 mm/hr. 62-106 umol/L

Creatinine

24-hour 14 to 26 mg per kg of body urine for mass per day for men creatinine 11 to 20 mg per kg of body clearance mass per day for women

Abdominal X- The pictures made by the X-

ray

Chest X-Ray

rays show that the stomach, small and large bowel, liver, spleen, kidneys, and bladder are normal in size, shape, and location. No growths, abnormal amounts of fluid (ascites), or foreign objects are seen. Normal amounts of air and fluid are seen in the intestines. Normal amounts of stool are seen in the large intestine. Normal chest X-ray shows normal size and shape of the chest wall and the main structures of the chest. Abnormalities that can be detected by chest x-ray are excessive fluid, fluid around the lungs, enlarged heart, or abnormal structure of the heart.

stones, an obstruction (blockage), a perforation (hole) in the intestines, or an abdominal mass such as a tumor.

A chest x-ray is picture of the chest that shows your heart, lungs, airway, blood vessels, and lymph nodes. It help find some problems with the organs and structures inside the chest.

Therapeutic/Medical Intervention The treatment for acute glomerulonephritis depends on the underlying cause, as well as how poorly the kidneys are functioning. Mild cases of acute glomerulonephritis may resolve without treatment. Treatment is directed at the underlying cause, but also includes medications to control high blood pressure and a kidney diet to reduce the stress on the kidneys. Short-term kidney dialysis may be necessary for severe cases of glomerulonephritis that result in sudden kidney failure (Shueler, 2011). Surgeries/Treatment TREATMENT Dietary restrictions PROCEDURE Provide a low calorie diet, low protein, low sodium diet, low potassium diet, low phosphorus diet, low phosphorus diet, more on calcium supplements, and Vitabmin B supplements (Schueler, 2011) Limiting the amount of SIGNIFICANCE For most children a regular diet is allowed, but it should contain no added salt. Meal preparation and service require special attention, since the child is indifferent to meals during the acute phase (Hockenberry, 2005).

Fluid restriction

To maintain fluid balance.

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fluid in the diet (Schueler, 2011). Regular monitor of Vital Signs are carefully vital signs, body measured, and any weight, and intake and deviations are reported output. and recorded. The volume and character of urine are noted, and the child is weighed daily (Hockenberry, 2005). Peritoneal dialysis Fluid is placed inside the abdominal cavity Waste products seep into the fluid through the tissue in the abdomen Fluid is removed from the abdomen (Schueler, 2011); Hemodialysis Blood flows through a machine that filters waste from the bloodstram (Schueler, 2005). Antihypertensive Captopril medications Nidefipine Oral corticosteroid Prednisone- may worsen medications certain types of flomerulonephritis, such as poststreptococcal (Hogan, 2008). Diuretic medication Furosemide (Lasix) Antibiotic therapy Penicillin Immunosuppressive therapy

Vital signs provide clues to the severity of the disease and early signs of complications (Hockenberry, 2005). A record of daily weight is the most useful means for assessing fluid balance (Hockenberry, 2005) To provide timely and effective catheter insertion without unduly long waiting times or delay, during which potential candidates for peritoneal dialysis may lose interest in this dialysis modality (Chow,2009)

It timely alleviate the serious complications which are caused by Renal Failure Used to control hypertensive To enhance remission of nephritic syndrome (Hogan, 2008).

Used to control hypertensive. To kill or slow down the growth of bacteria Cyclophosphamide To decrease risk of end-stage renal (Cyoxan, Nerosar, disease (Hogan, 2008). Procytox) Azathioprine (Imuran) Chlorambucil (Leukeran)

Nursing Care Plan Problem #1: Mild Facial Swelling and Increased Blood Pressure (December 8, 2012) Assessment Objective Data: Mild Facial Swelling (started last Dec. 6, 2011) 1 + Edema on hands and feet (Dec. 8, 2011) Dry lips and mouth (Dec. 6, 2011) BP of 110/80 mmHg (last Dec.8, 2011) Normal Value: 95-105/53-66 mm Hg Weight of 16 kg. (Dec. 8, 2011) Normal Value: 16 kg Urine Specific Gravity: 1.015 (Dec. 9, 2011) Normal Value: 1.003-1.030

Nursing Diagnosis: Excess fluid volume related to decreased glomerular filtration and increased sodium and water retention secondary to increased oncotic pressure. The decreased filtration of plasma results in an excessive accumulation of water and retention of sodium. Edema typically results from salt and water retention (Hockenberry, 2007). Expected Outcomes: NOC: Fluid Balance Nursing Intervention: NIC: Fluid Management Independent: Assessed for edema (periorbital or dependent areas). Sodium and water retention leads to edema (Sparks, 2005). Assessed skin turgor, mucous membrane every shift. Fluid loss first occurs in extracellular spaces, resulting in poor skin turgor, dry mucous membrane. Calculated fluid intake and plan amounts to offer throughout the day. An intake/output ratio of 1:1 reflects normal hydration and kidney function. Limited foods with moderate to high sodium content. Further reduction in sodium intake will help balance fluid and sodium retention. Documented intake and output to prevent excessive fluid intake. Performed daily weight measurement on the same scale at the same time of day. Weight gain is an early sign of fluid retention. Weight loss indicates improvement in condition. Monitored I.V. fluid infusion every hour. Because fluid balance is less stable in children, infusing too rapidly or too slowly can lead to fluid imbalance more quickly than in adults. Secured the IV site by wrapping it in a soft bandage to protect the site and allow the child to move his hand or arm freely.

Dependent: Administered Furosemide 16 mg TIV. Diuretics cause excretion of excess fluid by preventing reabsorption of water and sodium. Administered Captopril 25 mg tab b.i.d. Inhibits ACE, preventing conversion of angiotensin I to angiotensin II, a potent vasoconstrictor. Less angiotensin II decreases
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peripheral arterial resistance, decreasing aldosterone secretion, which reduces sodium and water retention and lowers blood pressure (McCain, 2008). Administer Diazepam 0.6 ml TIV for active seizure. A benzodiazepine that probably potentiates the effects of GABA, depresses the CNS, and suppresses the spread of seizure activity (McCain, 2008).

Collaborative: Recorded intake and output every shift. Include urine, stools, vomitus, nasogastric or chest tube drainage, and any other output to obtain fluid status. Increased output and decreased intake result in fluid deficit. Checked urine specific gravity every voiding. Increased specific gravity indicates lack of fluids to dilute urine.

Problem # 2: Cold, clammy, and pale skin (Dec. 8, 2011) Assessment Objective Data: Mild Facial Swelling (since last Dec. 6, 2011) Mild edema on hands and feet (Dec. 8, 2011) Pale, cold, and clammy skin (Dec. 8, 2011) BP: 110/80 mm Hg (Dec. 8, 2011) Normal Value: 95-105/53-66 mm Hg HR: 96 bpm Normal Value: 70-115 bpm Slow capillary refill within two seconds

Nursing Diagnosis: Decreased Cardiac Output related to increased peripheral resistance secondary to sodium and water retention. The GFR declines because of the decrease in filtration pressure. Poor perfusion can result from renal vasoconstriction, hypotension, hypovolemia, hemorrhage, or inadequate cardiac output (Porth, 2009). Expected Outcomes: NOC: Circulation Status Nursing Intervention: NIC: Cardiac Precautions Independent: Monitored vital signs with frequent monitoring of BP. Hypertension is experienced by the majority of patients with renal failure (Gulanick, 2007) Assessed skin warm and peripheral pulses. Peripheral vasoconstriction causes cool, pale diaphoretic skin (Myers, 2007) Assessed level of consciousness. Early signs of cerebral hypoxia are restlessness and anxiety, leading to agitation and confusion (Gulanick, 2007). Monitored prodysrhythmias and irregular heart beat. Cardiac dysrhythmias may result from the low perfusion state, acidosis, hypoxia, hyperkalemia, or hypocalcemia (Gulanick, 2007). Observed for signs of decreased cardiac output. This increase myocardial contractivity (Myers, 2007).
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Dependent: Administered oral and IV fluids as prescribed. Use fluid restrictions as appropriate. Optimal fluid balance improves cardiac output (Gulanick, 2007). Administered oxygen as needed. Oxygen improves arterial saturation (Gulanick, 2007). Administered Nifedipine 5 mg 1 tab SL as prescribed. These temporarily equilibrate electrolyte disturbances and reduce the risk for dysrhythmias (Myers, 2007).

Collaborative Monitored laboratory study findings for serum potassium, blood urea nitrogen and creatinine. This test provide data on electrolyte imbalances and accumulated toxins. The BUN may also be increased from nonrenal causes such as dehydration; however, in those situations, the creatinine will not be elevated. Hyperkalemia can cause the most serious life threatening dyrhythmias (Myers, 2007).

Problem #3: Altered Physical Activity (December 8, 2011) Assessment Objective Data: Body weakness Fatigue Inability to walk independently Productive cough PR: 96 bpm Normal Value: 70-115 bpm RR: 28 bpm Normal Value: 20-25 BPM BP: 110/80 mm Hg Normal Value: 95-105/53-66 mm Hg

Nursing Diagnosis: Activity Intolerance related to fatigue secondary to infectious process. During the acute phase children are generally quite content to lie in bed. As they begin to feel better and their symptoms subside, they will want to be up and about. Activities should be planned to allow for frequent rest periods and avoidance of fatigue (Hockenberry, 2005). Expected Outcomes: NOC: Energy Conservation Nursing Intervention: NIC: Energy Management Independent: Provided and maintain bedrest during acute stage. Rest decreases the production of waste materials, which place increased stress on the kidneys. Discussed with patient the need for activity, which will improve physical and psyhosocial well-being. Identified activities patient considers desirable and meaningful such as drawing and coloring images to enhance their positive impact. Instructed and help patient to alternate periods of rest and activity to reduce the bodys oxygen demand and prevent fatigue.
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Identified and minimize factors that decrease patients exercise tolerance to help increase activity level. Monitored physiologic responses to increased activity (including respirations, heart rate and rhythm, and blood pressure) to ensure return to normal a few minutes after exercising. Taught patient exercises for increasing strength and endurance, which will prove breathing and gradually increase activity level. Encouraged gradual activity increase as the condition improves to maintain muscle strength and motor movement. Supported and encourage activity to patients level of tolerance. This helps develop the patients independence.

Problem # 4: Difficulty of compliance in fluid restriction (Dec. 8, 2011) Assessment Objective Data: Stored water in water container on bed side Mild facial swelling of the patient. Nissin wafers often eaten by the patient

Nursing Diagnosis: Noncompliance related to poor in understanding of the purpose of fluid restriction as manifested by providing water and food intake against prescription. Foods high in sodium and salted treats are eliminated, and parents and friends are advised not to bring snacks as potato chips or pretzels. Fluid restriction, is more difficult, and the amount permitted should be evenly divided throughout the waking hours. Meal preparation and service require special attention, since the child is indifferent to meals during the acute phase. Again, collaboration with parents and the dietitian and special consideration for food preferences facilitate meal planning (Hockenberry, 2005). Expected Outcomes: NOC: Compliance Behavior Nursing Intervention: NIC: Self-Responsibility Facilitation Independent: Listened to patients reasons for noncompliance. Active listening may reveal concerns not clearly stated in words and helps individualize the reach the teaching process. Approached mother and patient in nonjudgemental manner. This demonstrates unconditional positive regard for patient and significant others. Identifed specific areas of patients noncompliant behaviour to help develop appropriate interventions. Attempted to identify influencing factors associated with noncompliant behaviours, such as lack of understanding, unrealistic expectations, and cultural differences. Reasons for noncompliance may range widely and include lack of knowledge, forgetting, feeling beter or worse, and getting contradictory advice from family, friends, and health care providers.
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Emphasized positive aspects of compliance. Understanding that compliance can reduce risk factors, prevent complications, and help manage certain chronic diseases may encourage patient to comply. Helped patient clarify his values to allow him to explore the intellectual and emotional components of the values which form the basis for his behaviour. Contract with patient to practice only nonthreatening behaviours. This involves both patient and caregiver in a formal commitment and gives patient a sense of personal control. Used support systems to enforce or inforce negotiated behaviours. Support from patients family helps foster compliance. Given positive reinforcement for compliant behaviour to encourage patient to continue such behaviour. Determined whether patients perceived noncompliance actually stems from a lack of financial resources. Contact appropriate agencies to help patient meet the costs of medical treatment and supplies and other financial needs. Helping patient meet the financial requirements of treatment improves compliance. Established an environment of mutual trust and respect to enhance learning. Regularly discussed progress toward goal achievement with the child and family members. Evaluation helps to reinforce effective learning techniques and identify ineffective techniques. Taught the parents the signs and symptoms of upper respiratory infection leading to a streptococcal infection, including elevated temperature, sore throat, and cough. Knowing the signs and symptoms of recurring infection should prompt parents to seek medical advice and treatment, when necessary. Advised the parents the importance of keeping all follow-up appointments. Follow-up visits are essential to determine resolution of disease and any further complications.

Dependent: Explained to the parents the need to maintain the child on a sodium-restricted diet as prescribed until his edema subsides and the kidneys resume normal functioning. This type of diet is necessary because excessive sodium intake limits water excretion.

Problem #5: Lost of appetite (December 8, 2012) Assessment: Objective Data: Skin and bones except on areas of edema (Dec. 8, 2011) Body malaise (Dec. 8, 2011) Eating less than amount of the food served (Dec. 8, 2011) Imbalanced diet mostly eating wafer and sky flakes (Dec. 8, 2011) Weight of 16 kg (Dec. 8, 2011) Normal Value: 16 kg

Nursing Diagnosis: Risk for Imbalanced Nutrition: Less than body requirements related to poor food intake decreased appetite secondary to inflammatory process. Fat metabolism decreases during the acute-phase response and amino acids are also used for glucose production and energy. A common manifestation of infection and inflammation is a decrease in food appetite that
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occurs at a time during which metabolism and the need for energy substrates are often markedly increased. The acute-phase anorexia can be a major factor in the negative nitrogen balance and body weight loss that occurs with injury and infection (Porth, et. al, 2009). Expected Outcome: NOC: Nutritional Status: Food and Fluid Intake Nursing Intervention: NIC: Nutrition Management Independent: Educated the parent to offer small, frequent meals. Small frequent meals are more easily tolerated by sick children. Serving smaller quantities of food at one meal seems less overwhelming to a child and enables him to eat more at each sitting. Restricted sodium and protein meals. The protein and sodium restriction is necessary for children with renal problems. Sodium caused fluid retention. Protein restrictions may be necessary in severe cases because of the kidneys inability to metabolize protein. Given the child some choices as to foods he likes. Giving the child some choices increases the chance he will eat. Obtain and record childs weight each morning before the first feeding to accurately monitor the response to therapy.

Dependent: Provided parenteral fluids as ordered to ensure adequate fluid electrolyte levels.

Collaborative: Recorded and describe food intake. Refer family members to a dietitian or nutritional support teal for dietary management. A dietitian or nutritional support team can individualize the childs diet within prescribed restrictions. Monitored electrolyte values and report abnormalities. Poor nutritional status may cause electrolyte imbalances.

Discharge plan Nursing Goals Medication compliance Patient will comply with the medication regimen ordered by the doctor. Orders Rationale Cefuroxime (Heroginox) 500mg Compliance to medications TID x 7 days will provide fast recovery Captopril 25 mg tab b.i.d from illness. Nifedipine 5 mg tab SL Furosemid 16 g TIV Patient can usually return to normal activities in 2-3 weeks after laparoscopic surgery. Within 12 hrs of surgery patient may get up and move around to enhance blood circulation and for fast
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Exercise Instruct the patient that: Patient will be able to Within 12 hrs of surgery patient verbalize importance of may get up and move around. exercise Patient can usually return to normal activities in 2-3 weeks after laparoscopic surgery.

recovery after surgery. Treatment Teach the patient the To prevent further Patient will be able to importance of complying with complication of the disease. comply with the the ordered medications. treatment plan on the medication ordered. Hygiene The patient appropriate hygiene. will do Instruct how to perform proper To prevent self-care wound dressing changes and bacteria. irrigations as prescribe. To monitor condition. invasion of

Out-patient To come back one week after Advised patient to go to discharge for removal of the OPD for the follow Stitches. up check-up. Watch for surgical complications such as continuing pain or fever, Diet Liquid or soft diet until the Patient will verbalized infection subsides the need of high energy giving foods Spirituality Encourage patient and his The patient will verbalize family to: the feelings of being Have trust and faith in God Gods hand. always. Have time in spiritual activities like praying for faster recovery.

patients

Continued pain and fever may indicate an abscess or wound dehiscence.

Soft diet is low in fiber and easily breaks down in the gastrointestinal tract God is the great healer.

General Evaluation of the Study Summary In most children, acute glomerulonephritis run a limited benign course. After most symptoms fade, proteinuria and impaired clearance of urea and creatinine may remain for as long as 2 months. However, to be cautious is very significant in which possible severe conditions may occur where children appear to suffer destruction from the initial inflammation that results in chronic renal insufficiency. The focus of the nursing care is to alleviate symptoms and to provide support such as educating client and family regarding disease process. This study also conducted/performed health teachings regarding on activity level and dietary restrictions. One of the researchers greatest achievements was to alleviate the patients fear and anxiety.
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In conclusion, having the role as a student nurse or future registered nurses is to have the desire in becoming the source of relief and knowledge for our patients. Thus, in order to become an effective health care provider, building rapport is necessary for the patients to trust their health care providers. Rapport is very important of which it helps in dealing patients as a partner with nurses upon conducting effective nursing care because of the patients cooperation and compliance.

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