INTRODUCTION

A. Background of the study

During our third day of hospital duty at Amang Rodriguez Medical
Center Pedia Ward, we encountered a patient with Acute Glomerulonephritis.
Mr. J VS, 4 years old, was admitted with the chief complaint of edema and
swelling of the testicles on February 20, 2010.

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. There are many diseases that cause an
active inflammation within the glomeruli. Some of these diseases are
systemic 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.

Most original research focuses on the post streptococcal patient. Acute

glomerulonephritis is defined as the sudden onset of hematuria, proteinuria,
and red blood cell casts. This clinical picture is often accompanied by
hypertension, edema, and impaired renal function.

Although this is primarily a disease of children, with ages 4-12 being at

high risk, it can occur at almost any age. Males are more susceptible than
females, with a ratio of 1.7-2:1. No specific race is considered at high risk of
acquiring this illness, though those in lower socioeconomic brackets are more
prone to this due to environmental and sanitary conditions.

B. Objectives of the Study

General
The general objective of this case presentation is to foster and
develop knowledge and skills in providing care and management for a
patient with acute glomerulonephritis.

Specific
KNOWLEDGE
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 • To discuss acute glomerulonephritis.

• To identify and enumerate the clinical manifestations, nursing

management and interventions for patients who have this disease.
• To know the different medications that need to be taken by the patient,
including its side effects which can be harmful to the patient.
SKILLS
• To be able to obtain, document, and present a comprehensive medical
history.
• To perform initial physical examination such as general assessment of the
patient’s appearance, position and degree of comfort.
• To perform the necessary skills in providing care for a client with acute
glomerulonephritis.
ATTITUDES
• To learn how to establish rapport with the client and significant others.

• To be able to recognize the importance of patient and familial preferences

when selecting among treatment options.

C. Scope and Limitation of the Study

The scope of the study encompasses the anatomy, physiology, and
pathophysiology of the disease acute glomerulonephritis. While dealing with
Mr. J VS’s case, we are subjected with the following limitations of our study:
• The group only had 2 days (Feb. 24-25, 2010) of actual interaction with the
patient at Amang Rodriguez Medical Memorial Center in Marikina City,
Metro Manila.
• The group credited the study on the references prior to books, researches in
the internet and data collected from the interview with the client/family
members, physical assessment and the patient’s chart.

D. Conceptual Framework
For this case, we used Elizabeth Ahmann’s Concept of Family-
Centered Care. This concept focuses on rendering care by involving the
client’s family in the various stages of the client’s care. This focuses on the
following key concepts:

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 • The family is the most constant thing in the child’s life

• Nursing strategies must encourage the family’s involvement

• Parent-professional collaboration or partnership

Since parental involvement and parent-professional collaboration is

vital in rendering care, it has to be achieved using the following strategies:

• Establish a caring environment

• Active listening; eliciting and focusing on parental goals and

aspirations

• Effective communication; ascertaining the parents’ perception of

the child’s condition

• Explaining and clarifying misconceptions

• Acknowledgement and acceptance of differences

• Recommending interventions; elicit parent’s suggestions on plan of

care

• Negotiating disagreements regarding the child’s plan of care

DIAGRAM

CA
RE
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CLINICAL SUMMARY
A. General Data
Name: JVS
Address: Batasan Hills, QC
Age: 4 y/o
Religion: Roman Catholic
Civil Status: Single
Nationality: Filipino
Date of Birth: March 15, 2006
Date of Admission: February 18, 2010
Ward and Room: Neuro Adolescence Pedia Ward
Admitting Diagnosis:
Attending Physician: Dr. Navarro
Sources of Information: Patient, Relatives and Related Medical Personnel
The Scale of Reliability: Primary & Secondary sources were used

B. Chief Complaint
Enlargement of the testicles

C. History of Present Illness

2 weeks PTA – Client had an episode of sore throat; no consult done; no meds
taken; only gargled with warm water and salt.
A few days PTA – Client’s mother noted tea-colored urine, along with diminished
urinary frequency. Edema noted around the eyes, ankles and testicles, with

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 testicular enlargement causing alarm for mother. Sought consult at private clinic
 referred to Amang ER  admitted to Pedia ward

D. Past Medical History

Fall from crib: 1 y/o
Measles: 2 y/o
2 weeks PTA: Sore throat (undiagnosed) – possible streptococcal infection
E. Family History
Asthma reported on father’s side
Hypertension reported on mother’s side
F. Immunization Record
Type Date Administered

BCG March 15, 2006 (at birth)

DPT 1 -

DPT2 -

DPT3 -

OPV1 -

OPV2 -

OPV3 -

G. Developmental milestones
Development Milestone Age

Smiled: 2months

Hold head up when prone: 4months

Turned self from supine to prone: 4months

1st tooth erupted: 6months

Sat with support 7months

Crawled: 7months

Walked alone: 11months

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 Said 1st word: 6months

Spoke sentences: 1y/o

Bowel and bladder control: 1y/o

H. Review of System- All Subjective Complaints

SYSTEM COMPLAINT
General Weakness, pallor
CNS None
CVS None
Respiratory Occasional episodes of DOB
GIT Constipation
GUT Oliguria, dysuria, hematuria
Extremities Grade 1 bipedal edema
Musculoskele
Body weakness
tal

I. Physical Assessment
A. General Appearance/ Survey:
The client is conscious, coherent, ambulatory but looks weak and pale.
B. Measurement

NORMAL ANALYSIS/
FINDINGS
VALUES INTERPRETATION

73rd percentile of
BMI= wt kg
BMI or within
Ht m²
Height 94cm normal range.
=14.5kg
Weight 14.5kg However height
(0.94m)²
and weight are
=16.4 kg/m²
within the 15th
percentile

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 BP: 80/50-
BP=110/80 Hypertensive
100/70
Temp=38.4 °C Febrile
T: 36.5 – 37.5
Vital Signs PR=112 bpm Normal
°C
RR=22 Normal
P: 75-120
cycles/min
R: 15-25

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 C. Head to Toe Assessment

ANALYSIS/
BODY PARTS NORMAL FINDINGS ACTUAL FINGDINGS INTERPRETATI
ON
A. HEAD
1. Skull • Rounded, (normocephalic and • Rounded, (normocephalic and
symmetrical, with frontal, parietal, symmetrical, with frontal, parietal,
and occipital prominence), smooth and occipital prominence), smooth
• Normal
skull contour skull contour
• Smooth, uniform consistency; absence • Smooth, uniform consistency;
of nodules or masses absence of nodules or masses
2. Hair • Evenly distributed hair • Evenly distributed hair

• thick hair • thick hair

• silky, resilient hair • dry • Normal

• no infection of infestation • no infection of infestation

• variable amount • variable amount

3. Face • Symmetric or slightly asymmetric
facial features; palpebral fissures
equal in size, symmetric nasolabial
folds
• Symmetric facial movements
• Eye/Vision
4.1 Eyeball • Movement symmetrical can move to
the 6 cardinal position of gaze
• Not protruding
• Slightly asymmetric facial features;
• Periorbital
Periorbital area slightly puffy but non-
edema, fluid
tender; symmetric nasolabial folds
volume
• Symmetric facial movements
excess
• Movement symmetrical can move to
the 6 cardinal position of gaze • Normal
• Not protruding

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4.2 Lid • Shiny, smooth and pink or red • Slightly pale • Indicates
margins anemia
4.3 • Pink • Pale • Indicates
Conjunctiva anemia
4.4 Sclera • White • White • Normal
4.5 Pupils • PERRLA • PERRLA • Normal
4.6 Eyebrow, • Hair evenly distributed; skin intact; • Hair evenly distributed; skin intact;
Lashes, Color, Eyebrows symmetrically aligned; Eyebrows symmetrically aligned;
Symmetry, equal movement equal movement • Normal
quality of hair, • Lashes equally distributed; curled • Lashes equally distributed; curled
placement slightly outward slightly outward
4.7 Eye • Both eyes coordinated, move in • Both eyes coordinated, move in
movement in unison, with parallel alignment unison, with parallel alignment • Normal
all direction
• VISION TESTING
1. Visual • When looking straight ahead, client • When looking straight ahead, client
• Normal
Field can see objects in periphery can see objects in periphery
2. Visual • Able to read newsprint • Able to read newsprint
acuity • Able to correctly identify distant • Able to correctly identify distant • Normal
letters letters
• EARS
1. Pinna • Color same as facial skin • Color same as facial skin • Normal

• Symmetrical • Symmetrical

• Auricle aligned with outer canthus of • Auricle aligned with outer canthus of
eye about 10˚ from vertical eye about 10˚ from vertical
• Mobile , firm and not tender • Mobile , firm and not tender

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 • Pinna recoils after it is folded. • Pinna recoils after it is folded.
2. External • Distal 3 contains hair follicles and
rd
• Distal 3rd contains hair follicles and
Canal glands glands • Normal
• No discharges • No discharges noted
3. Hearing • Assess for normal tones • Assess for normal tones
acuity • Normal voice tones audible • Normal voice tones audible
• Normal
• Watch Tick test • Watch Tick test

• Able to hear tickling in both ears • Able to hear tickling in both ears
B. NOSE • Symmetric and straight • Symmetric and straight

• No discharge or flaring • No discharge or flaring

• Uniform color • Uniform color

• Nontender; no lesions • Nontender; no lesions • Normal

• Air moves freely as the client breathes • Air moves freely as the client
through the nares breathes through the nares
• Mucosa pink • Mucosa pink
C. MOUTH/ • Lips and Buccal mucosa; uniform pink, • Lips and Buccal mucosa; pale and
LIPS soft, moist, smooth texture slightly dry • Indicates
• Symmetry of contour • Symmetry of contour anemia
• Ability to purse lips • Ability to purse lips
1. Gums • Pink gums; moist, firm texture to • Slightly pale; slightly dry, firm texture
gums to gums • Indicates
• No retraction of gums(pulling away • No retraction of gums(pulling away anemia
from the teeth) from the teeth)
2. Teeth • Smooth, white, shiny tooth enamel • Smooth, slightly yellowish, shiny • Normal

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 tooth enamel
3. Tongue • Tongue/floor of the mouth: • Tongue/floor of the mouth:

• Central position • Central position

• Pink color (some brown pigmentation • Pale; slightly dry; slightly rough; thin
on tongue borders in dark-skinned whitish coating
clients);moist; slightly rough; thin • Smooth, lateral margins; no lesions
whitish coating • Raised papillae (taste buds) • Indicates
• Smooth, lateral margins; no lesions anemia
• Tongue movement: moves freely; no
• Raised papillae (taste buds) tenderness
• Tongue movement: moves freely; no
tenderness
4. Palate- • Light pink, smooth, soft palate • Light pink, smooth, soft palate
hard /soft • Lighter pink hard palate, more • Lighter pink hard palate, more
• Normal
irregular texture irregular texture
• Positioned in midline soft palate • Positioned in midline soft palate
5. Orophar • Pink and smooth posterior wall • Pink and smooth posterior wall
• Normal
ynx /Tonsil • No discharge; Of normal size • No discharge; Of normal size
D. CHEEKS • Even color • Pale • Indicates
anemia
E. NECK • Head at midline • Head at midline • Enlargeme

• No neck vein engorgement/distension • No neck vein engorgement/distension nt of lymph

nodes due to
• Coordinated, smooth and movements • Coordinated, smooth and movements
active
with no discomfort with no discomfort
infectious
• Pulses equal in strength and rhythm • Pulses equal in strength and rhythm
process
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 • Lymph nodes not palpable
F. CHEST • Symmetrical chest expansion
• Absence of abnormal sounds like
wheezing and crackles
• Normal rate (15-25 cycles/min)
• No murmurs, gallops noted
G. HEART
• Normal rate and rhythm
H. BREAST • Rounded shape, slightly unequal in
size, generally symmetric.
• Skin uniform in color same
appearance as skin of abdomen or
back.
• Skin smooth and intact.
• Areola: round and oval and bilaterally
the same
• Color varies widely, from light pink to
the dark brown
• Irregular placement of sebaceous
glands on the surface of the areola
(Montogomery’s tubercles)
• Nipples: Round, everted and equal in
size; similar in color soft and smooth;
both nipples point in same direction
• Breast
• Palpable cervical lymphadenopathy
• Symmetrical chest expansion • May
• Slight bibasilar crackles noted upon indicate onset
auscultation of pulmonary
• RR=25 cycles/min edema
• No murmurs, gallops noted
• Normal
• Normal rate and rhythm
• Rounded shape, slightly unequal in
size, generally symmetric. • Normal
• Skin uniform in color same
appearance as skin of abdomen or
back.
• Skin smooth and intact.
• Areola: round and oval and bilaterally
the same
• Color varies widely, from light pink to
the dark brown
• Irregular placement of sebaceous
glands on the surface of the areola
(Montogomery’s tubercles)
• Nipples: Round, everted and equal in
size; similar in color soft and smooth;
both nipples point in same direction
• Breast
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 • No tenderness, masses, nodules or • No tenderness, masses, nodules or
nipple discharge nipple discharge
I. ABDOM • Unblemished skin • Unblemished skin
EN • Uniform color • Uniform color

• Flat, rounded or scaphoid • Flat

• Tendernes
• No evidence of enlargement of liver or • No evidence of enlargement of liver
s is due to
spleen. or spleen.
swelling or
• Symmetric contour • Symmetric contour
hyperplasia
• Symmetric movements caused by • Symmetric movements caused by of renal
respiration respiration parenchyma
• Audible bowel sounds; absence of • Normoactive bowel sounds; absence
arterial bruits of arterial bruits
• No tenderness over costovertebral • Tenderness noted over costovertebral
angle upon palpation/percussion angle, (+) lumbar punch
J. UPPER • Absence of edema • Absence of edema
EXTREMITIE • Even color and smooth texture • Even color and smooth texture
• Normal
S
• Unlimited movements such as • Unlimited movements such as
adduction, abduction etc. adduction, abduction etc.
K. LOWER • Absence of edema • Edema (Grade I) bipedal edema
EXTREMITIE • Even color and smooth texture • Slightly gray in color, smooth texture • Fluid
S volume
• Unlimited movements such as • Limited dorsiflexion, slight tenderness
adduction, abduction, etc. reported. excess

• Full and equal pulses • Full and equal pulses

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I. Activities of Daily Living

Before During Analysis/

Hospitalization Hospitalization Interpretation
Fluid restriction
and dietary
modification is
indicated to
Restricted fluid minimize fluid
At least 6 glasses,
and protein volume excess
1. Fluid and healthy appetite,
intake, slight and preserve
Nutrition dislikes some
decrease in kidney function.
veggies.
appetite Decrease in
appetite may be
due to lesser
palatability of
hospital food.
Formed stools, Incidence of Changes in
adequate urine constipation elimination
output, yellowish noted, decreased pattern due to
2. Elimination
urine – as urinary frequency disease process
verbalized by and output, tea and fluid
mother colored urine restriction.
Excessive
Energetic, movement speeds
3. Safety, Decreased energy,
“sobrang likot” as up protein
Activity and “minsan
verbalized by catabolism, and is
Exercise matamlay”
mother therefore not
advised.
Takes a bath
Occasional bath,
regularly, Alteration in
more of sponge
4. Hygiene somewhat hygienic practices
bathing. Oral care
and Comfort negligent about related to
done when
oral care and hospitalization
remembered.
handwashing
5. Rest and 6 hrs or more of Asleep most of the Conserving

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 energy; following
Sleep sleep time orders to minimize
activity
6. Substance The client is a
Not applicable Not applicable
Abuse child
7. Sexual The client is a
Not applicable Not applicable
Activity child

J. Laboratory/ Diagnostic Exams

a. Hematology Report

RESULT REFERENCE
TEST INTERPRETATION
2/19/10 2/21/10 VALUES
Possibly due to
RBC 3.62 4.28 4.6-6.2 x 106/uL
hematuria
Due to increased
Hgb 9.20 11.6 10.0-18.0g/dL
blood volume
Due to increased
Hct 26.7 32.8 40.0-54.0% blood volume but
decreased RBC
3
Platelet 313 385 150-450 x 10 /uL Normal
May indicate
WBC 10.8 6.9 5-10 x 103/uL
infection

b. Urinalysis

REFERENCE
TESTS RESULT INTERPRETATION
VALUES
Pale yellow, straw
Color Amber Normal
to amber
Clear to slightly
Transparency Turbid Increased sediments
hazy
Reaction Acidic Acidic Normal
Specific Gravity 1.020 1.016-1.022 Normal
+1 (-) Glycosuria and
Glucose
proteinuria due to
Protein +2 (-)
increased
glomerular

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 permeability
Pyuria, indicatory of
WBC >100/HPF
UTI
RBC + NTC Hematuria

c. Ultrasound
KUB (FEB 22,2009)
Result:
The right kidney measures 8.0 x 3.4 x 2.8cm and the left measures
7.2 x 2.7 x 3.9cm with cortical thickness of 10cm,both kidneys have increase
parenchymal etchonegenicity.There is poor corticomedullary delineation, no
evident mass, lithiasis and hydronephrosis.

The urinary bladder is distended without wall thickening or

intravesical echoes.

Interpretation: Bilateral Renal Parenchymal Disease.Unremarkable

Urinary Bladder.

K. Final Diagnosis
Acute Glomerulonephritis

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COURSE IN THE WARD

On February 18, 2010 at 9:10 am, the patient was brought to Pediatric ward
from ER via wheelchair and admitted to Neuro/Adolescent Room. The patient was
then placed on a low salt and low fat diet ordered by Dra. Navarro.

On February 24, 2010 at 4:10 pm, we received patient on bed, awake with IV
heplock at right metacarpal vein. The I & O and vital signs are monitored, RR=22,
PR=112, BP=110/80, Temp= 38.4°C, Weight = 14.5 kg. He was febrile and we
gave him a Tepid Sponge Bath (TSB) to lower his temperature. After 30minutes, his
temperature subsides at 37.9°C.

On February 25, 2010 at 3:50 pm, the patient was still on bed, with IV
heplock, awake and not cooperative. I & O was taken and recorded. The vital signs
were also monitored, RR=24, PR=122, BP=100/60, Temp=37.7°C, Weight = 14.4
kg. After all intervention was done, health teaching regarding on proper personal
hygiene practices, to weigh daily, reporting signs of protein deficiency, increased
ICP, or DOB was told to the patient and to guardian.

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ANATOMY

The Kidneys
The kidneys are two, bean-shaped
organs that are located in the back
part of the abdomen, on either side of
the spine and approximately between
the twelfth thoracic and third lumbar
vertebrae. Often, the left kidney is
positioned up to an inch higher than
the right kidney. Each kidney is about
4-5 inches long and about two inches
thick, weighing 4-6 ounces in the
average adult. Because of the
presence of many blood vessels, the
kidneys are colored a dark reddish-
brown.

Each kidney features a concave lateral

side, where an opening, called
the hilus, admits the renal artery, the
renal vein, nerves, and the ureter.
Within the kidney is the renal sinus,
or cavity. Within the renal sinus are
the functional group of the filtration
called the nephrons, of which there
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 are more than a million within each
kidney. At the top of each kidney is an
adrenal (also called suprarenal) gland.

The Nephron

The nephron is the functional unit of the

kidney, responsible for the actual
purification and filtration of the blood.
About one million nephrons are in
thecortex of each kidney, and each one
consists of a renal corpuscle and a renal
tubule which carry out the functions of
the nephron. The renal tubule consists of
the convoluted tubule and the loop of
Henle.

The nephron is part of the homeostatic

mechanism of the body. This system
helps regulate the amount of water, salts, glucose, urea and other minerals in the
body. The nephron is a filtration system located in the kidney that is responsible for
the reabsorption of water, salts. This is where glucose eventually is absorbed in the
body.

The Loop of Henle is the part of the nephron that contains the basic pathway for
liquid. The liquid begins at the Bowman's capsule (upper left) and then flows
through the proximal convoluted tubule. It is here that Sodium, water, amino acids,
and glucose get reabsorbed. The filtrate then flows down the descending limb and
then back up. On the way it passes a major bend called the Loop Of Henle. This is
located in the medulla of the kidney. As it approaches the top again, hydrogen ions
(waste) flow into the tube and down the collecting duct.

So, essentially, nutrients flow in through the left and exit through the right. Along
the way, salts, carbohydrates, and water pass through and are reabsorbed.

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 The Glomerulus

The glomerulus is the main filter of the nephron and is located within the
Bowman's capsule. The glomerulus resembles a twisted mass of tiny tubes through
which the blood passes. The glomerulus is semipermeable, allowing water and
soluble wastes to pass through and be excreted out of the Bowman's capsule as
urine. The filtered blood passes out of the glomerulus into the efferent arteriole to
be returned through the medullary plexus to the intralobular vein.

Bowman's Capsule
The Bowman's capsule contains the primary filtering device of the nephron, the
glomerulus. Blood is transported into the Bowman's capsule from the afferent
arteriole (branching off of the interlobular artery). Within the capsule, the blood is
filtered through the glomerulus and then passes out via the efferent arteriole.
Meanwhile, the filtered water and aqueous wastes are passed out of the Bowman's
capsule into the proximal convoluted tubule.

PATHOPHYSIOLOGY
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 Most forms of acute poststreptococcal glomerulonephritis are mediated by an
immunologic process. Both cellular and humoral immunity is important in the
pathogenesis of acute poststreptococcal glomerulonephritis. Humoral immunity in
acute poststreptococcal glomerulonephritis is presumed to be mediated by the in
situ formation of nephritogenic streptococcal antigen-antibody complexes and
circulating immune complexes. The most widely proposed mechanism for the
development of acute poststreptococcal glomerulonephritis is that nephritogenic
streptococci produce proteins with unique antigenic determinants. These antigenic
determinants have a particular affinity for sites within the normal glomerulus.

Following release into the circulation, these antigens bind to these sites
within the glomerulus. Once bound to the glomerulus, they activate complement
directly by interaction with properdin. Glomerular-bound streptococcal antibodies
also serve as fixed antigens and bind to circulating antistreptococcal antibodies
forming immune complexes. Complement fixation via the classical pathway leads to
generation of additional inflammatory mediators and recruitment of inflammatory
cells.

Polymorphonuclear leukocytes are also often observed as part of the

inflammatory process. In persons with the most severe disease, the glomeruli
appear bloodless because of the associated edema of the capillary walls, which
impedes glomerular perfusion. A direct correlation exists between the severity of
the histologic process and the clinical manifestations of the disease during the
acute phase and possibly the prognosis.

In most patients with moderate-to-severe AGN, a measurable reduction in

volume of glomerular filtrate (GF) is present, and the capacity to excrete salt and
water is usually diminished, leading to expansion of the extracellular fluid (ECF)
volume. The expanded ECF volume is responsible for edema and, in part, for
hypertension, anemia, circulatory congestion, and encephalopathy.

CLINICAL MANIFESTATIONS

• Oliguria/anuria, due to decreased glomerular filtration rate (GFR)

• Elevated BUN and serum creatinine, due to decreased urine output

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 • Hematuria (microscopic or gross), occurs in approximately 30% of
cases; urine may appear dark, cola-colored or tea-like

• Proteinuria, primarily albumin, due to increased permeability of

glomerular membrane

• Edema (facial, periorbital and/or pedal), hypertension, anemia,

increased ICP, pulmonary edema, all related to increased circulating
blood volume/excess extra-cellular fluid (ECF)

• Tenderness over the costo-vertebral angle ( + kidney punch), due to

swelling of kidneys

ASSESSMENT AND DIAGNOSTICS

• History taking; 1-3 weeks post-streptococcal infection (1-2 weeks post-

pharyngitis)

• Urinalysis; dark urine, (+) RBC, albumin, casts; specific gravity > 1.020

• CBC; decreased Hgb, Hct

• Blood chemistry; elevated BUN and serum creatinine

• Kidney biopsy, electron microscopy and immunofluorescent analysis

• Antistreptolysin O; increased in 60-80% of patients

• KUB; enlarged kidneys

COMPLICATIONS

• Hypertensive encephalopathy

• Heart failure

• Pulmonary edema

• Rapidly progressive glomerulonephritis  end-stage renal disease

(ESRD)

MEDICAL MANAGEMENT
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 Acute glomerulonephritis is usually self-limiting, so management is aimed at
treating symptoms, preserving kidney function and treating complications promptly.
Pharmacologic treatment depends on a case-to-case basis. If there is residual
streptococcal infection, then penicillin is the drug of choice; however, other
antibiotics can also be given. Loop diuretics and antihypertensives are used to
control hypertension. Sodium is restricted, as is fluid intake because of fluid volume
excess. Carbohydrates are given liberally to provide energy and to reduce
catabolism of proteins. As for proteins, there are two schools of thought: dietary
restriction or increased intake. Dietary restriction is merited only when there is
nitrogen retention (elevated BUN) and/or renal insufficiency. However, due to
albuminuria, the client loses more proteins than can be replaced. Hence, most diets
would include foods high in albumin and other complete proteins, such as egg
whites and dairy products.

NURSING MANAGEMENT

• Intake and output are measured carefully and recorded.

• Patient’s daily weight is also recorded using the same scale at the
same time of the day as previous weighing sessions.

• Assess also for signs of increased ICP, such as headaches or blurring

of vision.

• Client is also advised to report immediately should any sign or

symptom of renal failure occur (fatigue, nauseas, vomiting, diminishing
urine output).

• Maintain dietary and fluid restrictions to avoid worsening edema and

hypertension.

• Stress the importance of follow-up check-ups to monitor BP, urinalysis,

blood chemistry and CBC, to determine whether there is progress in
the management of the disease.

• Educate client and significant others on proper administration of

medications, especially those taken orally; include adverse effects,

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 dosage, time, frequency, and the desired actions of the medications
taken and the precautions to be followed.

'

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25 | P a g e
PROBLEM LIST

• Fluid volume excess related to decreased glomerular filtration rate as

evidenced by decreased urine output, edema and hypertension

• Hyperthermia related to ongoing infectious process as evidenced by

Temp=38.4 °C

• Imbalanced nutrition: less than body requirements related to increased

glomerular permeability and protein catabolism as evidenced by proteinuria

• Knowledge deficit related to medical management of the disease as

evidenced by questioning attitude by the mother

• Anxiety related to outcome of treatment

• Impaired parent-child interaction related to irritability of child

• Risk for impaired skin integrity related to edema/altered skin turgor

Note: Underlined diagnoses are considered priority problems which the group will
address, and upon which we will formulate plans of care.

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FLUID VOLUME EXCESS

ASSESSMEN DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

T
Subjective: Fluid volume Short Term: Independent After
excess related After 2 days 1. Evaluated extent of fluid • Obtain baseline performing
Objective: to decreased of excess: for comparison. interventions

• No urine glomerular intervention, • Assessed vital signs: BP, Objective and for 2 days, the

output for filtration rate the client PR, RR, quality of pulse, subjective data client:

the day as evidenced will: respiratory effort, and help identify • Had vitals
by decreased weight. underlying cause near normal
• Periorbital
urine output, •Maintain and monitor levels, no
and bipedal • Noted complaints
decreased fluid progress. longer
edema associated with fluid
Hgb & Hct volume at a complains of
noted excess: edema, poor skin
and functional headaches,
• Irritable turgor, distention of neck
hypertension level as and has
when awake veins, sudden increase in
evidenced weight visibly
• LOC:
by stable reduced
lethargic • Obtained and compared
vital signs, periorbital
lab results (Hct, Hgb, • High Fowler’s
• UA: SG=
ideal body edema.
Serum electrolytes, helps facilitate
1.020
weight, and BUN/Creatinine, total • Complied and
breathing,
• CBC:
reduction protein/albumin) actively
elevation of legs
Hct =26.7%
of edema. 2. Positioned client: high participated
promote venous
Hgb = 9.2 in the
Fowler’s with legs elevated return
• VS: BP = Long Term: interventions
• Fluid restriction

27 | P a g e
 110/80 • The client is based on urine presented
• Wt = 14.5 will have output, weight • Verbalized
kg normal 3. Limited sodium and fluid and response to that was
fluid intake to prescribed value: therapy. willing to
volume. •Advised family members • To monitor other comply with
to remove water, food or sources of excess health
drinks from bedside. fluid teachings

•Identified potential provided as to

sources of fluid (IV and fluid and

oral meds, food, etc), and dietary

factor them in when restrictions.

•Understanding and
determining fluid intake. comfort promotes
4. Assisted client and compliance.
family to cope with the
discomfort caused by fluid
restrictions:
• Explained the rationale
behind fluid restriction.
• Encouraged the family to
provide a supportive and • Prevent fluid
caring atmosphere overload and
Dependent address
•Administered IV fluids and causative factors.
meds as prescribed.

28 | P a g e
HYPERTHERMIA

ASSESSMEN DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

T
Subjective: Hyperthermia Short Term: Independent After
• “Kanina pa related to After 2 hours 1. Assessed and evaluate performing
sya mainit” ongoing of client’s current status: • Obtain baseline interventions
– as infectious intervention, • Assessed vital signs: for comparison. for 2 hours, the
verbalized process as the client Temperature. Objective and client:
by the evidenced by will: subjective data •Temp = 37.9
• Noted environmental
mother Temp=38.4 °C •Maintain help identify °C. Although
factors that may
body contribute to increased underlying cause target body
Objective: temperatur body temperature (tight and monitor temperature

• Warm, moist e at a clothing, poor ventilation, progress. was not

skin functional hot and humid achieved, the

level as environment) • These reduction is
• VS:
evidenced 2. Performed measures to procedures significant
Temp=38.4
by Temp reduce body temperature: promote heat enough.
°C
<37.8 °C. loss via various Further
• Rendered continuous TSB
mechanisms. management
for 15-30 minutes,
Long Term: may be
repeated as needed.
indicated if
• The client
29 | P a g e
will have no • Loosened clothing. temperature
fever and • Promoted adequate is not
maintain ventilation. • Understanding maintained at
normal and comfort current level
• Turned air conditioner on,
body promotes or increases
if applicable.
temperatur compliance. in the future.
3. Assisted client and
e • Complied and
family in planning and • Enhanced
performing future self-care knowledge can actively

needs: lead to better participated in

health practices. the

• Demonstrated proper
interventions
procedure for TSB.
presented
• Explained the rationale
behind intervention done
• Encouraged the family to
provide a supportive and • To address
caring atmosphere underlying

Dependent factors.

•Administered IV fluids and

meds as prescribed.

30 | P a g e
IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS

ASSESSMEN DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

T
Subjective: Imbalanced Short Term: Independent After
• “Ayoko nutrition: less After 8 hours 1. Assessed nutritional status: performing
nyan” than body of • Assessed body weight, lab • Obtain baseline interventions
(pointing to requirements intervention, values (serum creatinine, for comparison. for 8 hours, the
meal tray) related to the client BUN, UA protein). Objective and client:
increased will: subjective data • Consumed
• Determined cliet’s dietary
Objective: glomerular •Comply help identify high-calorie
patterns and preferences
permeability with dietary underlying food within
• BMI = 16.4 • Assessed for other factors
and protein restrictions cause, aid in restrictions.
• UA: that influence nutritional
catabolism as planning of care • Had no signs
•Prevent status (current diet not to
Protein = +2
evidenced by and monitor of progression
symptoms client’s liking, lack of
Glucose =
proteinuria progress. of edema.
associated resources, lack of
+1

31 | P a g e
 with protein understanding about diet)
deficiency 2. Promoted a diet based on
current nutritional status: • Reduces the
Long Term: •Promoted a low-sodium, sources of
• The client low-potassium, high- restricted foods,
will have calorie, protein- restricted at the same
balanced but albumin-rich diet time provides
nutritional (graham crackers, low-salt the caloric and
status even crackers, egg whites, dairy nutritional needs
with dietary products) of the client and
restrictions. •Identified food within the spares protein.
client’s preferences but • Preferences are
complies with dietary considered to
restrictions. Provided a promote
list. compliance.
•Advised family members • Prevents
to remove water, food or deviations from
drinks from bedside. prescribed diet.
3. Assisted client and
family to cope with the • Understanding
discomfort caused by and comfort
restrictions in the diet: promotes
• Explained the rationale compliance and
behind dietary restriction. also increases
• Encouraged the family to appetite.
32 | P a g e
 provide a supportive and
caring atmosphere
• Provided alternatives for
improving diet without
deviating from the • Makes diet more
prescribed one. palatable to the
4. Monitored and client.
recorded client’s progress: • To evaluate
• Weighed patient daily progress and to
• Assessed for signs of detect
inadequate protein intake complications
(edema, delayed healing, early
decreased serum albumin
levels)
Collaborative
•Coordinated with other
health care personnel • Ensures
(physician, nutritionist). continuity of
care as to diet
and
management of
disease.

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34 | P a g e
DISCHARGE PLAN

MEDICATION

- Nifedipine 10 mg TID

- Discuss the importance of medication compliance to the client and

significant others with regards the time of intake , dosage and route.

- Advise client to report immediately any signs of adverse effects or unusual

reactions to drug prescribed.

- Encourage client to report progress with regards to medications prescribed.

- Provide health teaching o self administration of take home meds. such as

route , time, frequency and dosage.

EXERCISE/ENVIRONMENT

- Advice client and his family to try to have or maintain safe , clean, comfortable
and calm environment .

- Advise significant others to be supportive.

TREATMENT

- Ensure follow up and self care.

- Advice client or significant others to take in time prescribed medicines

specially high blodd pressures

- Ensures dietary restrictions on salt, fluids protein ad other substances may be

recommended

- Tell significant others to closely watch and monitor for signs of developing
kidney failure.

HEALTH TEACHING/ HYGIENE

35 | P a g e
 - Describe to the client the signs and symptoms to be reported immediately
(Blood in the urine , foamy urine, swelling on he face , legs and abdomen).

- Clearly and specifically explain the nature of the disease, its coarse and
eventual prognosis of the condition to the child ( if old enough to understand )
and parents or caregivers. They need to understand that while complete
resolution is expected, a small possibility exists for persistent disease and
that an even smaller possibility exists for progression . This info is necessary
for some patients to ensure that compliance with the follow up program
occurs.

- Clearly outline a follow-up plan and discuss the plan with the family . BP
measurements and urine examinations for proteins and blood constitutes the
basis of follow up plan. Perform examination at 4-week or 6-week intervals
for the first 6 months and at 3 to 6 month intervals thereafter, until both
hematuria and proteinuria have been absent and BP has been normal for 1yr.
Documenting that low C3 Has returned to normal after 8-10 weeks may be
useful.

OPD

- Advise significant others to immediately consult his physician if signs and

symptoms of the diseases occurs or persist.

- Remind client of his check-up schedules and appointments . tell him to attend
them as diligently as he can . this is to rule out the recurrence or progression
of the problem.

DIET

- Promote a low sodium, low protein diet.

- Emphasize limitation of fluid and salt intake at home to minimize vascular

overload and hypertension.

SPIRITUAL

36 | P a g e
- Counseling: Tell the client that neither he nor GOD is to blame for his
condition , everything happens for a reason , GOD will not give you a problem
you cant handle.

- Advise relatives or significant others to provide moral support and widen their
understanding. Also tell them to pray for the client to help with the recovery

37 | P a g e
DRUG STUDY
Contraindica Nursing
Drug Classification Actions Indication Side Effects
tions Considerations
Generic Therapeutic – Inhibits the Edema due Hypersensitivit CNS - Instruct to take
Name: diuretics reabsorption to CHF; y, cross Dizziness, furosemide as
Furosemid Pharmacology- of sodium and hepatic or sensitivity with Encephalopathy, directed
e Loop diuretics chloride from renal disease thiazides and headache, insomnia, - Caution to change
Pregnancy the loop of hypertension sulphonamides EENT positions slowly to
Brand Category C Henie and unlabelled may occur; hearing loss, tinnitus minimize orthostatic
Name: distal renal uses- pre-existing GI hypotension
Lasix tubule; hypercalcemi electrolyte constipation, - Instruct to consult
increases a of imbalance, diarrhea, dry mouth, health care
renal malignancy hepatic coma dyspepsia, nausea, professional regarding
excretion of or anuria; vomiting a diet high in
water, some liquid GU potassium
sodium, products may excessive urination - Advise to contact
chloride, contain DERM health care
magnesium, alcohol, avoid photosensitivity, professional
hydrogen and in patients rashes immediately if muscle
calcium; may with alcohol ENDO weakness, cramps,
have renal intolerance. hyperglycemia nausea, dizziness,
and F AND E numbness or tingling
peripheral hypochloremia, of extremities occurs
vasodilatory hypokalemia,
effects; hypomagnesemia,

38 | P a g e
 effectiveness hyponatremia,
persists in hypovolemia,
impaired metabolic alkalosis
renal function HEMAT
blood dyscrasias
THERAPEUTI
METAB
C EFFECTS-
hyperglycemia,
diuresis and
hyperuricemia
subsequent
MS
mobilization
Arthralagia ,muscle
of excess fluid
cramps, myalgia
(edema,
MISC
pleural
increased BUN
effusions);
decreased
blood
pressure
Generic Therapeutic- Inhibits Management Hypersensitivit CNS -Gen. Info: advise to
Name: anti anginals, calcium of y; sick sinus Headache, abnormal take medicine
nd
Nifedipine anti- transport into hypertension syndrome 2 dreams, anxiety, exactly as directed,
hypertensive myocardial (extended or 3rd degree confusion, dizziness, even if feeling well
Brand Pharmacolog and vascular released AV block drowsiness, -Caution to change
Name: ic-calcium smooth only)angina (unless an jitteriness, position slowly to
Adalat, channel muscle cells, pectoris artificial nervousness, minimize orthostatic
Nefedical blockers resulting in vasospastic pacemaker is psychiatric hypotension
xl, Pregnancy inhibition of (Prinzmetal’s in place)blood disturbances, -Instruct the patient to
39 | P a g e
Procardia, category c excitation- ) angina pressure, weakness avoid concurrent use
Procardia contraction Unlabelled <90mmhg; co- EENT of OTC medications
xl coupling and uses: administration Blurred vision, and natural/ herbal
subsequent prevention of with grapefruit disturbed products, especially
contraction. migraine juice equilibrium, cold preparations
THERAPEUTI headache; epistaxis, tinnitus without consulting
C EFFECTS- management Respiratory health care
systemic of CHF or Cough, dyspnea, professional
vasodilation, cardiomyo- shortness of breath -Advise the patient to
resulting in pathy CV notify health care
increased Arrhythmias, CHF, professional if
blood peripheral edema, irregular heartbeat,
pressure; bradycardia, chest dyspnea, swelling of
coronary pain, hypotension, hands or feet,
vasodilation, palpitations, pronounced
resulting in syncope, tachycardia dizziness, nausea,
decreased GI constipation or
frequency Abnormal liver hypotension occurs
and severity function studies, or if headache is
of attacks of anorexia, severe
angina. constipation, -Inform that angina
diarrhea, dry mouth, attacks may occur
dysgeusia, 30mins after
dyspepsia, nausea, administration
vomiting because of reflex

40 | P a g e
GU tachycardia
Dysuria, nocturia, -Advise to contact
polyuria, sexual health care
dysfunction, urinary professional if chest
frequency pain does not
DERM improve, worsens
Dermatitis, after therapy or
erythemia, occur with
multiforme, diaphoresis; if
increased sweating, shortness of breath
pruritus/ urticarial, occurs; or if
rash persistent headache
MS occurs
Joint stiffness, -Caution to discuss
muscles cramps exercise restrictions
Neuro with health care
Paraesthesia, tremor professional before
exertion
-Instruct in proper
technique for
monitoring blood
pressure

41 | P a g e
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REFERENCES

Books:

Smeltzer, Barbara & Bare, Brenda (2008). Brunner & Suddarth’s Textbook of
Medical-Surgical Nursing (11th ed.). Philadelphia: Lippincott Williams & Wilkins.

Doenges, Marilynn E.; Moorhouse, Mary Frances; Murr, Alice C. (2008). Nurses
pocket guide: Diagnosis, Prioritized Interventions, and Rationales (11th ed.).
Philadelphia: F.A. Davis Company

Gordon, Marjory (2007). Manual of Nursing Diagnosis (11th ed.). Massachusetts:

Jones & Bartlett Publishers, Inc.

Berman, Audrey; snyder, Shirlee; Kozier, Barbaba; Erb, Glenora (2008). Kozier &
Erb’s Fundamentals of Nursing (8th ed). Singapore: Pearson Education South Asia
Pte. Ltd

____. (2008). PPD’s drug guide. (2nded.)Philippines: Medicom Pacific Inc.

Web sites:

http://emedicine.medscape.com/article/980685

http://intro.docere.co.uk/pdfs/paeds/Models.pdf

http://emedicine.medscape.com/article/239278

http://emedicine.medscape.com/article/777272

http://coe.fgcu.edu/faculty/greenep/kidney/index.html

http://kidshealth.org/parent/nutrition_fit/nutrition/bmi_charts.html

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