Acute Glomerulonephritis_cs

Liceo de Cagayan University College of Nursing

Individual Care Study

Table of contents I.

Introduction a.Overview of the Case

b.Objective of the Study

c.Scope and Limitation of the Study II. Health History a. Profile of patient

b. Personal Health History

c. History of Present Illness d. Chief Complaint

III. Developmental Data IV. Medical Management a.Medical Orders and rationale b.Drug study V.

Pathophysiology with Anatomy and Physiology

VI. Nursing Assessment (System Review & Nursing Assessment II) VII. Nursing Management a.Ideal Nursing Management (NCP)

b.Actual Nursing Management (SOAPIE) VIII.Referrals & Follow-up

IX. Evaluation and Implications X.

Bibliography

I. INTRODUCTION A. Overview of the Case

AcuteGlomerulonephritis is the disease of the kidney in which there is an inflammation of the glomerular capillaries. In most cases, the stimulus of the reaction is group A streptococcal infection, which ordinarily precedes the onset of glomerulonephritis by 2 to 3 weeks.

B. Objective of the Study

The study generally aims to investigate the condition of an adult man and further understand the extent of the case.

Specifically, the health care provider sought to;

•

Perform Physical Assessment,

•

Data Base and History taking that solidifies the present diagnosis of the client.

•

Identify the development and changes encountered by the client.

•

Identify the nursing problems which will be the basis of the care plan.

•

Develop Plan of the Care and Implement nursing interventions relevant and suitable for the case.

As nursing students they will be able to improve their skills in accordance to patient’s needs and condition.

The purpose of the study is to gather significant data to broaden our knowledge with regards to the condition of the patient and to improve our abilities as future health care providers. Moreover, this case study will enable us to apply the acquired skills we obtained in the classroom set-up.

C. Scope and Limitation of the Study

The study focuses only on one of the many problems of the kidney, mainly the glomerulonephritis and its causes and effects on

patients that are being diagnosed to it. Also, the study tackles on how this problem is being acquired.

II. HEALTH HISTORY A. Client’s Profile Name : Wife : Address : Civil Status : Sex : Age : Religion : Educational Status Income Nationality : Date of Admission Time of Admission Informant : Height Weight

: : : : : :

Lisdan, Elpedio N. Lisdan, Jemma San Rafael, Talakag, Bukinon province Married Male 42 years old Roman Catholic Elementary level 2,000 php/month Filipino January 27, 2009 9:10 am Patient 158 centimetres 52 kg

Vital Signs during Assessment Temperature Pulse Rate : Respiratory rate : Blood Pressure :

:

Admitting Diagnosis : Attending Physician

36.7 °C 55 bpm 20 cpm 150/110 mmHg Acute Glomerulonephritis related to nephritic syndrome; hypertension

:

Dr. Joseph Borong

B. Family and Personal Health Patient’s History Allergies: - No known allergies on foods and drugs. Injuries/ Accident in the past:

- Patient had not experience injuries or accident in the past. Blood Transfusion: - Patient didn’t receive blood in the past. Family health history: - Experienced Hypertension and Kidney disorder (2006)

Social History Alcohol use: - Patient occasionally drinks alcoholic beverages, as seldom as once in 2 months. Tobacco use: - Patient often smokes. Home and Environment: - Resides at San Rafael, Talakag - Living status is just enough for their family needs

C. Chief Complaint and History of Present Illness Noted to have edema; condition noted for a week – prior to admission as onset of fever on and off associated with dysuria – tea colored urine.

III. DEVELOPMENTAL DATA • The Developmental Stages of Erik Erickson

Middle Adulthood: 35 to 65: Generativity vs. Self absorption or Stagnation Now work is most crucial. Erickson observed that middle-age is when we tend to be occupied with creative and meaningful work and with issues surrounding our family. Also, middle adulthood is when we can expect to "be in charge," the role we've longer envied. The significant task is to perpetuate culture and transmit values of the culture through the family (taming the kids) and working to establish a stable environment. Strength comes through care of others and production of something that contributes to the betterment of society, which Erikson calls generativity, so when we're in this stage we often fear inactivity and meaninglessness.

• Freud's Psychosexual Stages of Development The Genital Stage In the genital stage, as the child's energy once again focuses on his genitals, interest turns to heterosexual relationships. The less energy the child has left invested in unresolved psychosexual developments, the greater his capacity will be to develop normal relationships with the opposite sex. If, however, he remains fixated, particularly on the phallic stage, his development will be troubled as he struggles with further repression and defenses. •

Robert Havighurst Developmental Task Theory

Middle Adulthood (30-60 years) Achieving adult social and civic responsibility; Reaching and maintaining satisfactory performance in one’s occupational career; Developing adult leisure time activities; Relating oneself to one’s spouse as a person; To accept and adjust to the physiological changes of middle age; Adjusting to aging parents. Assisting teenage children to become responsible and happy adults; achieving adult social and civic responsibility.

• Piaget's Theory of Cognitive Development Formal operational stage (Adolescence and adulthood) In this stage, intelligence is demonstrated through the logical use of symbols related to abstract concepts. Early in the period there is a return to egocentric thought. Many people do not think formally during adulthood.

IV. MEDICAL MANAGEMENT A. Medical Orders and Rationale Doctor’s Order

Rationale

01/27/09 ➢ Please admit

•

To monitor patient’s medical

condition and proper management.

➢ TPR q 4h ➢ Full low salt, low fat diet

•

To monitor any abnormal changes in vital signs

•

For proper nourishment and for prevention of disease that may lead to severity of the condition

•

To promote good nutritional status

•

To monitor body fluids & prevent dehydration

•

For treatment of hypertension, edema associated with CHF, cirrhosis and renal disease

•

For treatment of lower respiratory infection, UTI & dermatologic infection

•

First line treatment for heartburn and short term treatment of active duodenal ulcer

•

Treatment for pulmonary tuberculosis that is not responsible to 1st line antituberculosis

•

For proper hydration of the patient and carefully monitor the fluid losses

•

To monitor body fluids & prevent dehydration

➢ Give 1 egg white a day ➢ 0.9 NaCl @ KVO rate ➢ Furosemide i amp q 12h x 3doses

➢ Cefuroxime 750 mg q 8h IVTT

➢ Omeprazole 20mg icap OD P.O. ➢ Captopril 25mg itab BID P.O.

➢ I & O q shift

01/28/09 ➢ IVF 0.9 NaCl @ KVO rate ➢ Spironolactone 50mg itab TID P.O. ➢ Continue meds.

B. Drug Study Generic Name of Ordered Drug

Date Ordere d

Classification

Dose/ Frequen cy/ Route

Cefuroxi me

01/27/0 9

Antibiotic (Cephalos porin – 2nd generatio n)

750 mg q 8h IVTT

Mechanis m of Action

Specific Indicati on

Contraindication

Inhibits For Contra synthesis of lower indicated bacterial respirato with allergy cell wall, ry to causing cell infection cephalospori death. , UTI & n or derma penicillins tologic infection

Side Effects/ Toxic Effects

Nursing Precauti on

Hyperse nsitivity, nephrot oxicity, pain at injection site

Assess for hepatic or renal impairme nt Assess for skin status Check for sensitivit y tests

Generic Name of Ordered Drug

Date Ordere d

Classificatio n

Dose/ Frequen cy/ Route

Mechanism of Action

Specific Indicati on

Contraindication

Side Nursing Effects/ Precauti Toxic on Effects

Furosemi de

01/27/0 9

Loop Diuretic

Amp of 12h x 3 doses

Inhibits reabsoption of Na and Cl from the proximal and distal tubules and ascending limb of the loop of Henle, leading to a Na-reach diuresis

Hyperte n-sion, Edema associat ed with CHF, cirrhosis and renal disease

Contraindic ates allergy to furosemide; anuria, hepatic coma

Polyuna, Nocturia , Rash, Anemia, Muscle spasms, Cardiac arrythmi as

Assess for allergy to furosemi de Assess for skin color, lesions and edema CBC, serium electrolyt es

Generic Name of Ordered Drug

Date Ordere d

Classificatio n

Dose/ Frequen cy/ Route

Mechanism of Action

Specific Indicati on

Contraindication

Side Nursing Effects/ Precauti Toxic on Effects

Omeprazo le

01/27/0 9

Antisec retory drug; Proton Pump Inhibito r

20mg icap OD P.O.

Gastric acid pump inhibitor: Supresses gastric acid secretion by specific inhibition of hydrogen- K ATPase enzymes system at secretory surface of the gastric parietal cells.

First line treatme nt for heartbur n and short term treatme nt of active duodena l ulcer

Contraindicated with hypersensitivity to omeprazole or its component. Use cautiously pregnancy lactation

Rash, Assess alopecia for , hypersen nausea, sitivity to vomiting omepraz Epistasis ole , fever Assess for skin lesions Assess for urinary output

Generic Name of Ordered Drug

Date Ordere d

Classificatio n

Dose/ Frequen cy/ Route

Mechanism of Action

Specific Indicati on

Contraindication

Side Nursing Effects/ Precauti Toxic on Effects

Captropil

01/27/0 9

ACE inhibito r

25mg itab BID P.O.

Polypeptide Antibactic; against Mycobacteriu m tuberculosis

Treatme nt hypertension

Contraindicated allergy to capreomyci n; preexisting auditory impairment

Polyuria, Assess Tachyfor cardia, allergy to proteinu captropil riacough dry Assess mouth for skin color and lesions For CBC and differenti al

Generic Name of Ordered Drug

Date Ordere d

Classificatio n

Dose/ Frequen cy/ Route

Mechanism of Action

Specific Indicati on

Contraindication

Side Nursing Effects/ Precauti Toxic on Effects

Spironolactone

01/28/0 9

Diuretic s

50mg itab TID P.O.

Cause loss of sodium bicarbonate and calcium while saving potassium and hydrogen ions

To counter act potassiu m loss caused by other diuretics

Hypersensitivity; Hyperkalem ia

Clumsy Headach e Dyscrasi as

Monitor intake & output Daily weight during therapy Monitor BP before administering

V. PATHOPHYSIOLOGY

VI. ASSESSMENT GASTRO INTESTINAL TRACT:

EENT: [ ] impaired vision

[ ] blind

[ ] pain [ ] reddened [ ] drainage [ ] gums [ ] hard of hearing

[ ] obese [ ] distension [ ] mass [ ] dysphagia [ ] rigidly [ ] pain [x] no problem

[ ] deaf [ ] burning [x] edema [ ] lesion [ ] teeth

[ ] no problem GENITO URINARY and GYNE:

RESPIRATORY: [ ] asymmetric [ ] tachypnea [ ] apnea

[ ] rales [x] cough

[ ] barrel chest [ ] bradypnea

[x] pain [x] urine color [ ] vaginal bleeding [ ] hermaturia [ ] discharge [ ] nocturia [ ] no problem

[ ] shallow [ ] rhonchi [x] sputum [ ] diminished [ ] dyspnea [ ] orthopnea [ ] labored [ ] wheezing [ ] pain problem

[ ] cyanotic [ ] no

CARDIO VASCULAR: [ ] arrhythmia [ ] tachycardia [ ] numbness [ ] diminished pulses [ ] edema [ ] fatigue [ ] irregular [ ] bradycardia [ ] murmur [ ] tingling [ ] absent pulses [x] pain [ ] no problem

NEUROLOGICAL: [ ] paralysis [ ] stuporous [ ] unsteady [ ] seizures comatose

[ ] lethargic

[ ]

[ ] vertigo confused

[ ] tremors

[ ]

[ ] vision problem

[ ] grip

[x] no

MUSCULOSKELETAL: [ ] appliance [ ] stiffness itching [ ] petechiae drainage

[ ] hot

[ ] [ ]

[ ] prosthesis [ ] swelling lesion

[ ]

[ ] poor turgor [ ] cool deformity

[ ]

[ ] wound color

[ ] rash

[ ] skin

[ ] flushed pain

[ ] atrophy

[x]

[ ] ecchymosis [ ] diaphoretic[ ] moist

[ ] no problem

NURSING ASSESSMENT II SUBJECTIVE COMMUNICATION: [ ] Hearing Loss “wala [ ] Visual Changes wala [x] Denied gihapon” verbalized by husband

OBJECTIVE Comments: man –

As

tiil” As lized by patient

Respiratory: [x] regular [ ] irregular Describe: regular breathing but associated with pain mana pd siya As

Right: Right lung is symmetrical to left lung. Left: Left lung is symmetrical to right lung.

the

bug-

man mga verba

Heart Rhythm [x]regular [ ] irregular Ankle Edema: present in lower extremities Pulse Carotid Radial DP Femoral Right: 62 65 60 not assessed Left: 62 65 60 not assessed Comments: Pulse sites are palpable and its rate are within normal range.

the

NUTRITION: Diet: DAT but decreased fluid intake [ ]N [ ]V Comments: “Wala Character man…perma[ ] recent charge nente nay gana” in weight, appetite verbalized [ ] swallowing the patient

[ ] Speech

the

CIRCULATION: [ ] chest pain Comments: “Sakit! [x]leg pain at… [x]numbness of extremities nanghubag na [ ] denied gni ako

[ ] Language [ ] Hearing

R L Pupil Size: 3-5 mm difficulties Reaction: PERRLA

OXYGENATION: [ ] dyspnea Comments: “Nah! [ ] smoking history gapanigarilyo Oftentimes siya -giubo [x] cough karon oh.’ [x] sputum verbalized by [ ] denied wife

[ ] Glasses [ ] Contact lens Aide

[ ] dentures Patient Upper Lower As

by

[x] none

Full

Partial

[√]

[ ]

[ ]

[ ]

[ ]

[√]

With

Difficulty [x] denied

ELIMINATION: Usual bowel pattern frequency Once a day daily [ ] constipation Remedy

[ ] urinary once [ ] urgency [x] dysuria [ ]

hematuria January 27, 2009 incontinence Date of last BM

[ ] [ ] polyuria

[ ] diarrhea character place

[ ] foly in [ ] denied

Comments: urinate once Sounds: daily due to pain sounds and excrete small Distention: amount. Yes [x] No (color,

Bowel Audible Abdominal Present [ ] Urine consistency

, odor)

tea color of

urine,

inconsistent

MANAGEMENT OF HEALTH & ILLNESS: [x] alcohol [ ] denied (amount, frequency) Occasionally – once in 2 months [ ] SBE Last Pap Smear: N/A LMP:

Briefly describe the patient’s ability to follow treatments (diet, meds, etc.) for chronic health problems (if present): The patient is properly following her medications

SUBJECTIVE SKIN INTEGRITY: [ ]dry wala man [ ] itching [x] other - edematous [ ] denied the

OBJECTIVE

Comments: “ - nanghupong lang ko” as verbalized by Patient.

[ [ [ [

] ] ] ]

dry pale flushed moist

[x] cold [] warm [ ] cyanotic

* rashes, ulcers, decubitus (describe size, location, drainage): No presence of any ulcers, decubitus or rashes.

ACTIVITY/SAFETY: [ ] convulsions dili man [ ] dizziness at lang [ ] limited motion of joints

Comments: “ hinuon, buggyud ako tiil Kay

nanghupong

Naman –

kaya Limitation in nako.” ability to by the [ ] ambulate [ ] bathe self [ ] other [x] denied

man hinuon as verbalized patient

COMFORT/SLEEP/AWAKE: [ ] pain Comments: “ok (location, raman hinuon” Frequency, As verbalized Remedies) by the patient. [ ] nocturia [ ] sleep difficulties [x] denied COPING: Occupation : Farmer Members of household: 6 Most supportive person: Wife

[ ] LOC and orientation: Oriented to time and space Gait: [ ] walker [ ] cane [ ] other [x] steady [ ] unsteady [ ] sensory and motor losses in face or extremities None [ ] ROM limitations: patient can performed range of motion

[ ] facial grimaces [ ] guarding [ ] other signs of pain Edema on both extremities [ ] siderail release form signed (60 + years) None

Observed non-verbal behavior None The person and his phone number that can be reached any time

SPECIAL PATIENT INFORMATION _______________ Daily weight _________________ _______________ BP q shift _______________ Neuro VS _______________ _______________ CVP/SG. Reading ________ collection

Date Ordered

Diagnostic/labor atory exams

01/27/09

CBC

01/27/09

Urinalysis

_______________ PT/OT _______________ Irradiation ______________ Urine test ______________ 24 hour urine

Date done

Date ordered

01/27/09

01/27/09

I.V. Fluids/Blo od 0.9 Nacl iL @ KVO rate

Date disc.

VII. NURSING MANAGEMENT A. Ideal Nursing Management Nursing Diagnosis: ➢ Excessive fluid volume related to glomerulonephritis INTERVENTIONS

RATIONA

•

Monitor intake and output

•

To check fluid balance an

•

Observe for fever

•

To check for infection sin greater risk

•

Elevate edematous extremities, change

•

position frequently

To reduce tissue pressure breakdown

•

After elevating, place in semi-fowlers position

•

To facilitate movement o improving respiratory eff

•

Provide quiet environment

•

To promote ventilation an stimuli

•

Administer furosemide I amp of 12h as

•

For the treatment for ede

prescribed by the physician

Nursing Diagnosis: ➢

Ineffective airway clearance related to productive cough INTERVENTIONS

•

Assess the airway patency

RATIONA •

To check the effectivity o for further management

•

Elevate the head part of the bed/change

•

To enhance drainage of/v

position q 2h •

Encourage deep-breathing and coughing

lung segments •

To mobilize secretions

exercise •

Monitored the fluid intake

•

To help liquefy secretions edema

•

Instruct to have proper clothing, not too tight

•

To provide warm body/en

and not too loose

Nursing Diagnosis: ➢

Acute pain related to edema INTERVENTIONS

RATIONA

•

Monitor vital signs

•

Because vital signs are a experienced

•

Acknowledge patient’s verbalization of pain & allow him to describe it

•

Pain is subjective experie no other one can felt abo

•

Perform pain assessment each time occurs

•

To rule out worsening of condition/developing com

•

Elevate edematous extremities, change position frequently

•

To reduce tissue pressure breakdown

•

Provide quiet environment

•

To promote ventilation an stimuli

•

Administer Spironolactone 50mg itab TID P.O. as prescribed by the physician

•

For the treatment for ede

B. Actual Nursing Management S

O

A

P

“Bug-at lang akong tiil kay nanghupong naman ko.” As verbalized by the patient • • •

Edema Oliguria Restlessness

Fluid volume excess related to Glomerulonephritis

Long term: At the end of 2 days, pt. will be able to lessen or diminished the symptoms of glomerulonephritis that produces excessive fluid. Short term: At the end of 8 hours, the pt. will be able to reduce the excessive fluid volume.

I

1) Monitor vital signs especially temperature ➢ To check & assess for infection since the pt. has a higher risk 2) Monitor intake & output ➢ To monitor & check fluid volume & prevent dehydration 3) Elevate the edematous extremities ➢ To reduce tissue pressure & risk in skin breakdown 4) Place in a semi-fowlers position, change position frequently ➢ To facilitate movement of diaphragm & improve respiratory effort 5) Administer furosemide 1 ampule every 12h as prescribed by the physician ➢ For the treatment of edema

At the end of 8 hrs, the pt reduces the excess fluid in his body thru excretion of stored fluids.

E

HEALTH TEACHINGS

Name of Patient: Gloria Yabo

MEDICATIONS

EXERCISE

TREATMENT

OUT-PATIENT (Check-up)

DIET

Encourage to follow the dosages and proper timing of his meds. Such as the Furosemide 1 ampule every 12hours x 3doses, Omeprazole 20mg 1capsule once a day, Captopril 25mg 1tablet twice a day, & Spironolactone 50mg 1 tablet thrice a day. As prescribed by his physician. Encourage bed rest and frequent changes of position, early ambulation, and deep breathing exercise. Encourage/instruct to keep the edematous extremities to elevate as often; limit of water intake; monitor intake and output; provide warm environment; provide egg white a day; weight the pt. daily, at the same time. Encourage pt. that when his discharged, he must have a regular check-up to his physician until it’s needed. To evaluate the progress of his condition. Instruct to limit intake of salty & fatty foodsand enrich/increase the intake of foods rich in potassium such as bananas…

VIII. REFERRALS AND FOLLOW-UP

Since the patient is suffering from Acute Glomerulonephritis, it is advised for him to stay in the hospital for a better and thorough management regarding on her condition. Acute Glomerulonephritis are very critical in a man’s condition that is why the patient needs an urgent hospital service for him to be monitored every now and then. If the doctor has already approved the release or discharge of the patient from the hospital, the patient is highly advised to have a regular check-up on her personal physician to take out the risk from the said ailment. If the patient will again suffer the Acute Glomerulonephritis, it is best for him to be admitted to a tertiary-leveled hospital for better monitoring of his critical condition, knowing that even a single mistake worsen his condition.

IX. EVALUATION AND IMPLICATIONS

After conducting this care study, I was able to appreciate more the essence of utilizing the nursing process in the care and management of my patient. It was indeed a tough job on conducting this study yet, it gave me a big impact regarding how useful it is in my chosen profession. Nursing really demands a tender loving care attitude. It demands patience and it is calling that cannot be merely taken for granted. Moreover, this care study taught us to stand on our own by not depending on others just to make this. This provides us, the students, a big learning regarding on how well we take care of or patients in the real clinical setting. Most of all, this study teaches the students to provide clients care more efficiently and competently to achieve an effective and quality nursing care.

X. BIBLIOGRAPHY









Doenges, Marilyn E. et.al Nurses Pocket Guide: Diagnoses, Interventions and Rationale. 9th edition pages 278-279, 472-477, 576-578 F. A Davis Company Philadelphia, 2004. Lippincott Williams & Wilkins, Manual of Nursing Practice, 8th edition, volume 1.

Deglin, et al. Davis’s Drug Guide for nurses, 9th edition. Smeltzer, Suzanne C. et al. Textbook of Medical-Surgical Nursing, 11th edition, volume 2.