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CHAPTER I
INTRODUCTION
Bright initially described acute glomerulonephritis in 1927.Acute nephritic
syndrome is the most serious and potentially devastating form of the various renal
syndromes.

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Acute glomerulonephritis also known as poststreptococcal glomerulonephritis
comprises 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. Hippocrates originally
described the manifestation of back pain and hematuria, which lead to oliguria or anuria.
With the development of the microscope, Langhans was later able to describe these
pathophysiologic glomerular changes. Acute glomerulonephritis inflammation of the
blood vessels in the kidney, which causes the kidneys to malfunction. The most common
cause of acute glomerulonephritis is a throat infection with the bacteria, Streptococcus
and can be due to a primary renal disease or to a systemic disease. Acute GN is defined
as the sudden onset of hematuria, proteinuria, and red blood cell (RBC) casts. Common
symptoms of this disease include blood in the urine, fever, nausea, rash, leg swelling and
high blood pressure.
Treatment of AGN is mainly supportive, because there is no specific therapy for
renal disease. When acute GN is associated with chronic infections, the underlying
infections must be treated and is usually treated with medications and a kidney diet and
kidney dialysis may be necessary in some patients.
There has been a significant decline in the incidence of acute glomerulonephritis
in developed countries such as the US, and cases are reported only sporadically. The
declining incidence rates are probably related to improved nutritional status in these
countries and more liberal use of antibiotics. Developing countries, such as those in
Africa and the Caribbean, appear to have a higher potential for development of

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streptococcal infections, and the incidence of acute glomerulonephritis is proportionally
higher in these areas.
Males are twice as likely to have the condition as females, and although
glomerulonephritis can appear at any age, 90% of cases occur in those under 40 years.
The disease most often develops in boys between 2 and 14 years (Kazzi, 2009).
This case study focuses on how an individual could acquire acute
glomerulonephritis; what are the causes, its signs and symptoms, its development and its
treatment. The discussion are mainly centered to the certain patient we had at CRMC. All
data used in this research came from the course of stay in the hospital. Moreover, with
this study we also aimed to be able to gain wholistic growth and have knowledge and
skills enhancement as future members of the health team.
In our 3 days stay in the said hospital, we had handled various cases of patient.
Among those, our selected patient’s condition captured our attention and we became
interested with our patient’s diagnosis.
As health advocates, we should be aware and informed about the condition, how
it happened, its complications and the appropriate nursing plans to be implemented in
order to meet the needs of the patient. This case study provides sufficient information
about a disease of the kidney’s called, acute glomerulonephritis.

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CHAPTER II
OBJECTIVES
General Objectives
This case study aims to conduct an extensive and comprehensive research about
Acute glomerulonephritis through conducting effective gathering methods and using

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appropriate communication skills in conversing to our exposure in the Pedia Ward of
Cotabato Regional and Medical Center.
Specific Objectives
In order to serve as our guide in finishing this mini case study, we have
formulated the following goals:
 Establish a trusting relationship with our client and his family in order to gain
cooperation and gather information needed for this mini case study.
 Assess our patient thoroughly and holistically to come up with an accurate
physical assessment.
 Determine client’s personal background as well as history and present conditions.
 To define Acute Glomerulonephritis.
 To know the clinical manifestation, nursing management and interventions for patients who
have this disease.
 Trace the pathophysiology of the client’s condition.
 To know the different medication for patients with AGN and know their side effects which
can be harmful.
 To know how AGN is diagnosed and the important laboratory examinations that will
confirm AGN
 Discuss the nursing interventions and the medical surgical management for the
client.
 To know the nursing priorities to consider when dealing with patients of AGN
 Formulate effective nursing care plans based on identified nursing problems.

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 Provide information for the client’s parents to broaden their knowledge, ideas and
level of awareness regarding her condition.
 To be able to recognize the importance of patient and familial preferences when
selecting among treatment options.
CHAPTER III
PATIENT’S HISTORY
Baseline Information
A. Personal Data
NAME: Baby AGN
AGE: 12y.o

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SEX: Male
STATUS: Child
NATIONALITY: Filipino
DATE OF BIRTH: August 20, 2000
RELIGION: Islam
B. Clinical Data
ROOM: PEDIA WARD ROOM C
DATE OF ADMISSION: January 19, 2013
ATTENDING PHYSICIAN: Myla Faye R. Villamor, MD
DIAGNOSIS: To consider Acute Glomerulonephritis, Severe Acute
Malnutrition
INITIAL VS: Temperature: 36.9
Heart rate: 104bpm
Respiratory rate: 36 bpm
Blood pressure: 90/60mmHg
HEALTH HISTORY
Family health history
According to the mother of the client, they don’t have any history similar to the
case of their son. The mother has a family history of hypertension and asthma. On the
other hand, the father has a family history of arthritis and anemia. The mother was older
than her husband. She also stated that she gave birth to the client at the age of 32 years
and was delivered at home at exactly 7 months and 3 weeks. The client is the youngest
among her 5 children. During pregnancy, the mother had complete pre-natal check-up
and completely immunized with Tetanus Toxoid vaccine. Also, the mother stated that

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she don’t usually eat salty foods but loves to drink native coffee even during pregnancy.
Moreover, her children were all bottle fed. Regarding the diet of the client, he loves to
eat salty foods like junk foods and carbonated drinks such as coke.
Past health history
According to the mother, the child has complete immunization. During childhood,
the child had common colds associated with cough, sore throat and fever. Every time the
child gets sick, they’re going to the nearest health center to seek for consultation and
were usually given with paracetamol for fever. The child had never been admitted and it
was his first hospitalization when he was diagnosed with Acute Glomerulonephritis.
Present Health History
A month prior to admission, the client had on and off fever with facial edema,
noticed to have gradual onset of pallor and no consultation done and also no mediation
given. Three days prior to admission, the client had complaints of on and off abdominal
pain associated with tea-colored urine. The signs and symptoms become persistent and
so, they prompted consultation to outpatient department of CRMC. Chest X-ray,
ultrasound and urinalysis was performed. The mother stated that the doctor suspected the
child to have urinary tract infection and they were advised to admit the patient but they
refused.
On the day of admission, the client reported that the signs and symptoms such as
abdominal pain is no longer tolerable and still with blood in the urine. The parents then
decided to admit their child.

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CHAPTER IV
PHYSICAL ASSESSMENT
A. GENERAL PHYSICAL SURVEY
Appearance and behaviour:
1. Age, sex & race: Female, Filipino-Asian
2. Body built: Ectomorphic

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3. Posture & gait: Good posture with normal and balanced gait
4. Hygiene and grooming: poor hygienic status, untrimmed nails
5. Dress : dressed appropriately, shorts is worn for 2 days (wears loose t-shirt
and shorts)
6. Odor of body and breath: no body odor, breath odor is mildly foul
7. Signs of distress: no signs of distress
8. Apparent state of health: appeared unhealthy, the child is so thin
9. Attitude: cooperative, answers questions directly
10. Affect & mood: verbal cues are congruent with the nonverbal cues
11. Speech: clear and understandable, speaks in moderate pace.
12. Thought process: logical, answers question appropriately
Measurements:
Height: 116 centimeters
Weight:19 kilograms
Neurologic:
State of consciousness: Alert
Orientation: oriented
Emotional state: relaxed and calm
Vital signs:
Temperature: 36.9 0C
Cardiac rate: 104 bpm, regular
Pulse rate: 100 bpm, regular
Respiratory rate: 36bpm

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B. CEPHALOCAUDAL ASSESSMENT
a. HEAD: normocephalic
b. FACIAL MOVEMENT: symmetrical
c. FONTANELS: closed
d. HAIR:
Color: black
Amount and distribution: well-distributed hair
Texture: Soft
Presence of parasites: none
e. SCALP:
Symmetry: symmetrical
Texture: smooth
Lesions: none
f. SKULL: Rounded skull
g. FACE: dark brown complexion
h. FOREHEAD: Smooth and firm
i. EYES:
Eyebrows: symmetrical in shape
Position and appearance: lashes are short and evenly distributed, and
curled outward; upper margins of lid cover
approximately 2 mm of the iris
Blinking: 13blinks per minute on both eyes
Conjunctiva: Pale palpebral conjunctiva and without discharges

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Bulbar conjunctiva is clear with visible tiny vessels
Cornea: transparent, smooth and moist cornea noted
Sclera: anicteric sclera
Iris and pupil: round shape, equal and with uniform color of iris
Pupils reaction to light: Brisk
a. EARS:
Symmetry: Symmetrical ears
External canal: no discharges
External pinnae: normoset
Hearing: normal
j. NOSE:
Patency: both patent
Sinuses: no tenderness
Smell: normal in both nose
k. MOUTH:
Lips: symmetrical lip, without lesions
Color of the lips: upper lip is dark reddish brown, lower lip is pale
Gums: pale in color and dry
Tongue: Furred tongue and with some lesions noted on the taste buds
Pharynx: midline uvula, not inflamed, pinkish
l. NECK: supple neck
m. SKIN: rough and dry, warm to touch, dark brown in color
n. NAIL:

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Color: pale nail beds
Texture: nail round and soft
Condition of nail bed: smooth nails
Capillary refill: 2 seconds
o. CHEST/LUNGS: Chest and lung expansion symmetry are equal, intercostals
spaces are equal; respiratory rhythm and depth are even, friction rub upon
auscultation
p. ABDOMEN: Abdominal distention noted
q. GENITO-URINARY: With minimal urine output, tea – colored urine
r. UPPER EXTREMITIES: Patient’s upper limbs, shoulders and arms were
symmetrical. No deformities and swelling noted. No tenderness on the bones
of the wrists and fingers and no structural deviations.
s. LOWER EXTREMITIES: Lower limbs were symmetrical. Presence of edema
+ 1on right lower leg.
C. Focused Assessment
Abdominal Assessment
A.) Inspection
Skin: color of the abdomen is lighter than the exposed parts of the body.
Umbilicus: flat, centrally located at the midline and pale in color.
Contour: distended and round in contour.
Symmetry: abdomen is symmetrical upon inspection.
Enlarged organs: no enlarged organs based on diagnostic tests

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B.) Auscultation
Bowel sounds: Hypoactive bowel sounds heard in all four quadrants
upon auscultation.
C.) Percussion
Entire Abdomen: no presence of solid masses and dullness heard upon
percussion
D.) Palpation: no presence of tenderness, no masses and enlarged organs
CHAPTER V
ANATOMY AND PHYSIOLOGY

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The Urinary System
The Urinary System is a system of organs that produces and excretes urine from
the body. Urine is a transparent yellow fluid containing unwanted wastes, mostly excess
water, salts, and nitrogen compounds. The major organs of the urinary system are the
kidneys, a pair of bean-shaped organs that continuously filter substances from the blood
and produce urine. Urine flows from the kidneys through two long, thin tubes called
ureters. With the aid of gravity and wavelike contractions, the ureters transport the urine
to the bladder, a muscular vessel. The normal adult bladder can store up to about 0.5 liter
(1 pt) of urine, which it excretes through the tube like urethra.

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An average adult produces about 1.5 liters (3 pt) of urine each day, and the body
needs, at a minimum, to excrete about 0.5 liter (1 pint) of urine daily to get rid of its
waste products. Excessive or inadequate production of urine may indicate illness and
doctors often use urinalysis (examination of a patient’s urine) as part of diagnosing
disease. For instance, the presence of glucose, or blood sugar, in the urine is a sign of
diabetes mellitus; bacteria in the urine signal an infection of the urinary system; and red
blood cells in the urine may indicate cancer of the urinary tract.
Functions of the urinary system
Excretion. The kidneys are the major excretory organs of the body. They remove waste
products, many of which are toxic, from the blood. Most waste products are metabolic by
products of cells and substances absorbed from the intestine. The skin, liver, lungs, and
intestines eliminate some of these waste products, but they cannot compensate if the
kidneys fail to function.
Blood volume control. The kidneys play an essential role in controlling blood volume by
regulating the volume of water removed from the blood to produce urine.
Ion concentration regulation. The kidneys help regulate the concentrate of the major
ion in the body fluids.
pH regulation. The kidneys help regulate the pH of the body fluids. Buffers in the blood
and the respiratory system also play important roles in the regulation of pH.
Red blood cell concentration. The kidneys participate in the regulation of red blood cell
production and, therefore, in controlling the concentration of red blood cells in the blood.
Vitamin D synthesis. The kidneys, along with the skin and the liver, participate in the
synthesis of vitamin D.

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Kidneys
The kidneys are bean-shaped organs, each about the size of a tightly clenched fist.
They lie on the posterior abdominal wall, behind the peritoneum, with one kidney on
either side of the vertebral column. Structures that are behind the peritoneum are said to
be retroperitoneal. The kidneys are abundantly supplied with blood vessels- they process
blood the kidneys receive 20 – 25% of the resting cardiac output via the right and left
renal arteries. In adults, blood flow through both kidneys (renal blood flow) is about 1200
ml per minute.
Function of the kidneys
The functions of the kidney are regulation of blood ionic composition, regulation
of blood pH , regulation of blood volume, regulation of blood pressure, maintenance of
blood osmolarity , production of hormones, regulation of blood glucose level , and
excretion of wastes and foreign substances.
Three layers of tissue surround each kidney
The renal capsule. The deep layer, smooth, transparent sheet of dense irregular
connective tissue. Serves as a barrier against trauma and helps maintain the shape of the
kidneys. Continuous with the outer coat of the ureter.
The adipose capsule. Middle layer, a mass of fatty tissue surrounding the renal capsule.
Protects kidney from trauma and holds it firmly in place in the abdominal cavity.
The renal fascia. The superficial layer, thin layer of dense irregular connective tissue.
anchors the kidney to surrounding structures and to the abdominal wall.
Glomerulus

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In the kidney, a tubular structure called the nephron filters blood to form urine. At
the beginning of the nephron, the glomerulus is a network (tuft) of capillaries that
performs the first step of filtering blood. The glomerulus is surrounded by Bowman's
capsule. The blood is filtered through the capillaries of the glomerulus into the Bowman's
capsule. The Bowman's capsule empties the filtrate into a tubule that is also part of the
nephron.
A glomerulus receives its blood supply from an afferent arteriole of the renal
circulation. Unlike most other capillary beds, the glomerulus drains into an efferent
arteriole rather than a venule. The resistance of these arterioles results in high pressure
within the glomerulus, aiding the process ofultrafiltration, where fluids and soluble
materials in the blood are forced out of the capillaries and into Bowman's capsule.
A glomerulus and its surrounding Bowman's capsule constitute a renal corpuscle,
the basic filtration unit of the kidney. The rate at which blood is filtered through all of the
glomeruli, and thus the measure of the overall renal function, is the glomerular filtration
rate (GFR).
Afferent circulation
The afferent arteriole that supplies the capillaries of a glomerulus branches off of
an interlobular artery in the renal cortex. Glomerular capillary pressure, and thus
glomerular filtration rate, can be influenced by constriction or relaxation of the afferent
arteriole, resulting in decreases or increases in pressure. As an example, one study
involving rats found that having narrowed afferent arterioles contributed to the
development of increased blood pressure. Sympathetic nervous system action as well as

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hormones can also impact glomerular filtration rate by modulating afferent arteriole
diameter.
Layers
If a substance has passed through the glomerular capillary endothelial cells,
glomerular basement membrane, and podocytes, then it enters the lumen of the tubule
and is known as glomerular filtrate. Otherwise, it exits the glomerulus through the
efferent arteriole and continues circulation as discussed below and as shown on the
picture.
Endothelial cells
The endothelial cells of the glomerulus contain numerous pores (fenestrae) that,
unlike those of other fenestrated capillaries, are not spanned by diaphragms. The cells
have fenestrations that are 70 to 100 nm in diameter. Since these pores are relatively
large, they allow for the free filtration of fluid, plasma solutes and protein. However they
are not large enough that red blood cells can be filtered.
Glomerular basement membrane
The glomerular endothelium sits on a very thick (250–350 nm) glomerular
basement membrane. The glomerular basement membrane (GBM) of the kidney is the
basal lamina layer of the glomerulus. The glomerular capillary endothelial cells, the
GBM and the filtration slits between the podocytes perform the filtration function of the
glomerulus, separating the blood in the capillaries from the filtrate that forms in
Bowman's capsule. The GBM is a fusion of the endothelial cell and podocyte basal
laminas.

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Podocytes
Podocytes line the other side of the glomerular basement membrane and form part
of the lining of Bowman's space. Podocytes form a tight interdigitating network of foot
processes (pedicels) that control the filtration of proteins from the capillary lumen into
Bowman's space.
The space between adjacent podocyte foot processes is spanned by a slit
diaphragm formed by several proteins including podocin and nephrin. In addition, foot
processes have a negatively charged coat (glycocalyx) that limits the filtration of
negatively charged molecules, such as serum albumin. The podocytes are sometimes
considered the "visceral layer of Bowman's capsule", rather than part of the glomerulus.
Ureters
The ureters are two slender tubes that run from the sides of the kidneys to the
bladder. Their function is to transport urine from the kidneys to the bladder.
Bladder
The bladder is a muscular organ and serves as a reservoir for urine. Located just
behind the pubic bone, it can extend well up into the abdominal cavity when full. Near
the outlet of the bladder is a small muscle called the internal sphincter, which contract
involuntarily to prevent the emptying of the bladder.
Urethra
The urethra is a tube that extends from the bladder to the outside world. It is
through this tube that urine is eliminated from the body.

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CHAPTER VI
PATHOPHYSIOLOGY
Schematic Diagram
Predisposing Factors:
>Child (12 y.o)
>Gender (Male)
Precipitating Factor:
>Post-streptococcal
infection (sore throat)
Release of antigen by the
group a beta-hemolytic
streptococci into the
circulation

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Swelling of capillary
membrane and infiltration
with leukocytes
Scarring and loss of glomerular
filtration membrane
Thickening of the glomerular
filtration membrane
Decrease ability to form
filtrate from glomeruli
plasma flow
Decrease glomerular
filtration rate
Dark or tea
colored urine
Hematuria

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Narrative
Glomerulonephritis also known as glomerular nephritis (GN) or glomerular
disease is a disease of the kidney, characterized by inflammation of the glomeruli.
Glomeruli are very small blood vessels in the kidneys that act as tiny little filters - there
are about one million glomeruli in each kidney. The disease damages the kidneys' ability
to remove waste and excess fluids from the body. GN can be acute, meaning there is a
sudden attack of inflammation, or chronic (long-term and coming on gradually). People
can develop glomerulonephritis on its own, in which case it is called primary
glomerulonephritis. If it is caused by another disease, such as diabetes or lupus, infection,
or drugs it is called secondary glomerulonephritis (Nordqvist, 2009).
Glomerulonephritis (GN) is a disease condition where immunologic mechanisms
trigger inflammation of the glomerulus as well as the proliferation of glomerular tissue
resulting into basement membrane, mesangium, and capillary endothelium damage
(Papanagnou, 2008).
Etiologies may vary, however, majority of the cases are idiopathic while one of
the known causes of GN include infection such as that of streptococcal infection (Pais,
Decrease urinary output
Retention of water and
sodium Increase blood volume
Hypertension
Fluid Shifting
Facial & lower
extremities edema

A Case Study 24
Kump, & Greenbaum, 2008). Because of this, clinical manifestations of patients with GN
include hematuria, proteinuria and RBC casts which may be accompanied by azotemia,
oliguria, and decreased GFR (glomerular filtration rate).
According to Mayo Clinic, a variety of conditions can cause glomerulonephritis,
ranging from infections that affect the kidneys to diseases that affect the whole body,
including the kidneys. Sometimes the cause is unknown. Here are some examples of
conditions that can lead to inflammation of the kidneys' glomeruli:
Infections
 Post-streptococcal glomerulonephritis. Glomerulonephritis may develop a week
or two after recovery from a strep throat infection or, rarely, a skin infection
(impetigo). An overproduction of antibodies stimulated by the infection may
eventually settle in the glomeruli, causing inflammation. Symptoms usually
include swelling, reduced urine output and blood in the urine. Children are more
likely to develop post-streptococcal glomerulonephritis than are adults, and
they're also more likely to recover quickly.
 Bacterial endocarditis. Bacteria can occasionally spread through your
bloodstream and lodge in your heart, causing an infection of one or more of your
heart valves. Those at greatest risk are people with a heart defect, such as a
damaged or artificial heart valve. Bacterial endocarditis is associated with
glomerular disease, but the exact connection between the two is unclear.
 Viral infections. Among the viral infections that may trigger glomerulonephritis
are the human immunodeficiency virus (HIV), which causes AIDS, and the
hepatitis B and hepatitis C viruses.

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Immune diseases
 Lupus. A chronic inflammatory disease, lupus can affect many parts of your
body, including your skin, joints, kidneys, blood cells, heart and lungs.
 Goodpasture's syndrome. A rare immunological lung disorder that may mimic
pneumonia, Goodpasture's syndrome causes bleeding (hemorrhage) into your
lungs as well as glomerulonephritis.
 IgA nephropathy. Characterized by recurrent episodes of blood in the urine, this
primary glomerular disease results from deposits of immunoglobulin A (IgA) in
the glomeruli. IgA nephropathy can progress for years with no noticeable
symptoms. The disorder seems to be more common in men than in women.
Vasculitis
 Polyarteritis. This form of vasculitis affects small and medium blood vessels in
many parts of your body, such as your heart, kidneys and intestines.
 Wegener's granulomatosis. This form of vasculitis affects small and medium
blood vessels in your lungs, upper airways and kidneys.
Conditions that are likely to cause scarring of the glomeruli:
 High blood pressure. Damage to your kidneys and their ability to perform their
normal functions can occur as a result of high blood pressure. Glomerulonephritis
can also cause high blood pressure because it reduces kidney function.
 Diabetic kidney disease. Diabetic kidney disease (diabetic nephropathy) can
affect anyone with diabetes. Diabetic nephropathy usually takes years to develop.
Good control of blood sugar levels and blood pressure may prevent or slow
kidney damage.

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 Focal segmental glomerulosclerosis. Characterized by scattered scarring of
some of the glomeruli, this condition may result from another disease or occur for
no known reason.
Chronic glomerulonephritis sometimes develops after a bout of acute
glomerulonephritis. In some people there's no history of kidney disease, so the first
indication of chronic glomerulonephritis is chronic kidney failure. Infrequently, chronic
glomerulonephritis runs in families. One inherited form, Alport syndrome, may also
involve hearing or vision impairment.
Glomerular lesions in acute GN are the result of glomerular deposition or in situ
formation of immune complexes. On gross appearance, the kidneys may be enlarged up
to 50%. Histopathologic changes include swelling of the glomerular tufts and infiltration
with polymorphonucleocytes. Immunofluorescence reveals deposition of
immunoglobulins and complement. Acute GN involves both structural changes and
functional changes. Structurally, cellular proliferation leads to an increase in the number
of cells in the glomerular tuft because of the proliferation of endothelial, mesangial, and
epithelial cells. The proliferation may be endocapillary (ie, within the confines of the
glomerular capillary tufts) or extracapillary (ie, in the Bowman space involving the
epithelial cells). In extracapillary proliferation, proliferation of parietal epithelial cells
leads to the formation of crescents, a feature characteristic of certain forms of rapidly
progressive GN. Leukocyte proliferation is indicated by the presence of neutrophils and
monocytes within the glomerular capillary lumen and often accompanies cellular
proliferation. Glomerular basement membrane thickening appears as thickening of
capillary walls on light microscopy. On electron microscopy, this may appear as the

A Case Study 27
result of thickening of basement membrane proper (eg, diabetes) or deposition of
electron-dense material, either on the endothelial or epithelial side of the basement
membrane. Electron-dense deposits can be subendothelial, subepithelial,
intramembranous, or mesangial, and they correspond to an area of immune complex
deposition. These structural changes can be focal, diffuse or segmental, or global.
Functional changes include proteinuria, hematuria, reduction in GFR (ie, oligoanuria),
and active urine sediment with RBCs and RBC casts. The decreased GFR and avid distal
nephron salt and water retention result in expansion of intravascular volume, edema, and,
frequently, systemic hypertension (Parmar, 2012).
Acute poststreptococcal glomerulonephritis (APSGN) results from an antecedent
infection of the skin or throat caused by nephritogenic strains of group A beta-hemolytic
streptococci. The concept of nephritogenic streptococci was initially advanced by Seegal
and Earl in 1941, who noted that rheumatic fever and acute poststreptococcal
glomerulonephritis (both nonsuppurative complications of streptococcal infections) did
not simultaneously occur in the same patient and differ in geographic location. Acute
poststreptococcal glomerulonephritis occurs predominantly in males and often
completely heals, whereas patients with rheumatic fever often experience relapsing
attacks. Most forms of acute poststreptococcal glomerulonephritis (APSGN) are mediated
by an immunologic process. Cellular and humoral immunity is important in the
pathogenesis of this disease, and humoral immunity in APSGN. Nonetheless, the exact
mechanism by which APSGN occur remains to be determined. The 2 most widely
proposed theories include (1) glomerular trapping of circulating immune complexes and
(2) in situ immune antigen-antibody complex formation resulting from antibodies

A Case Study 28
reacting with either streptococcal components deposited in the glomerulus or with
components of the glomerulus itself, which has been termed “molecular mimicry”
(Bhimma, 2012).
In most cases of acute glomerulonephritis, a group A betahemolytic streptococcal
infection of the throat precedes the onset of glomerulonephritis by 2 to 3 weeks (Fig. 45-
3). It may also follow impetigo (infection of the skin) and acute viral infections (upper
respiratory tract infections, mumps, varicella zoster virus, Epstein-Barr virus, hepatitis B,
and human immunodeficiency virus infection). In some patients, antigens outside the
body (eg, medications, foreign serum) initiate the process, resulting in antigen-antibody
complexes being deposited in the glomeruli. In other patients, the kidney tissue itself
serves as the inciting antigen (Brunner & Suddarth, 2009).
CHAPTER VII
COURSE IN THE HOSPITAL

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DATE/TIME ORDER RATIONALE
1/19/13
3pm
Wt. 21kg
Bp: 110/70
-Admit to miscellaneous ward
-secure consent to care
-VS q4 hr
-Low salt diet
-LABS:
1. CBC, BT STAT
2. U/A
3. Serum creatinine, BUN
4. ESR
5. UTZ of KUB
-start venoclysis: D5.3 NaCl 500cc @
60cc/hr
-Meds:
1.Pen G 525,000 "u" IVTT q6hr ANST
2. Ranitidine 21mg IVTT q8hr
-For legal purposes;
protection between the
patient,health providers
and the institution
- Serve’s as baseline
information for any
changes in the health status
of the pt.
-Because sodium attracts
water causing water
retention
-to determine abnormal
values in the blood
components which can
help diagnose the condition
of the client and to know
the blood type in case
blood transfusion is needed
- check kidney function &
help diagnose other dse.,
determines whether
bacteria are present in the
urine, strains &
concentration
- to assess residual renal
function & the need for
dialysis or transplantation
-to detect presence of
infection
- to delineate the size,
shape and position of the
kidneys and to reveal
urinary system
abnormalities
- to tx electrolytes and
water imbalances
-to treat infections
- healing and/or prevention
of ulcers; decreased
secretion of gastric acid

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3. Furosemide 20mg IVTT q12hr
-MIO q shift & record without fail
-Monitor BP q4hr & record
-weigh pt. daily
- Management of renal dse.
; diuresis and subsequent
mobilization of excess
fluid
- to determine the balance
in the intake & output of
the pt in terms of fluids as
well as to check for
adequate circulation &
functioning of the kidneys
-Because patient may
exhibit high BP due to
current condition
-to check if there is
retention of fluids (a
kilogram increase in wt is
equal to a litre of fluid
retention)
1/20/13
6:30
-Increase Pen G to 1m unit q6hr
-For urine cs
-ff-up UTZ of tom AM
-cont. IVF @SR
-D/c Furosemide
-change IVF to D5W 1l @150cc x8hr
-med revising IVF(D5.3% NaCl x 150cc)
then terminate once consumed
-Metoclopramide 3mg IVTT now
-continue meds:
1. Pen G
2. Ranitidine
-follow-up UTZ result
-ff. CXR result
-ff CBC result
-the previous dose is not
enough to treat the
infection
-determines whether
urine, as well as the strains
and concentration . Also
identify the antimicrobial
therapy that is best suited
for the particular strains
identified
-therapeutic effect has been
already met
-can cause fluid overload
-to treat electrolytes and
fluid imbalances
-decrease or prevention of
nausea and vomiting

A Case Study 31
-for urine CS -determines whether
urine, as well as the strains
and concentration. Also
identify the antimicrobial
therapy that is best suited
for the particular strains
identified
1/22/13
10am
-cont. meds
-still for re-UA & urine c/s- provide request
-ff-up CXR result
-IVF TF: D5.3 NaCl 500cc@60cc/hr
-continue monitoring -to prevent complication,
aids in treating pt.
1/23/13 8am
-ReCBC today
-cont. meds
- ff-up ESR, ASO titer
-ff-up CXR result
-IVF tf with D5 IMB 500cc @SR
to determine if pt is
progressing or improving
with his condition
1/24/13 -to receive 1"u" of PRBC of pt's blood type
B
-Transfuse 280cc in 4hr after proper
screening and crossmatching
- Furosemide 10mg IVTT TID & post BT
-Oxacillin 525mh IVTT q6 ANST
-for serum electrolytes
-limit oral fluid intake
-IVF Tf: D5.3 NaCl 500cc @SR
-cont. monitoring
-because pt's rbc decreased
As well as the haemoglobin
-to prevent cardiac
overload post BT
-to treat infections
-to check electrolytes status
of the patient
-to prevent fluid overload
-to treat electrolytes and
fluid imbalances
1/26/13 -cont. meds Pen G
-still for BT follow-up of blood please
-cont. IVF @SE
-cont. monitoring
-weigh pr. Daily before breakfast
1/27/13
6am ongoing
-cont. meds
-reCBC 6hr post BT

A Case Study 32
BT
(+) vomiting
1x yesterday
-IVF tf with D5IMB 500cc @SR
1/28/13
11am
Pen G
Oxacillin
-reinserted IVF
-cont. meds
-cont. monitoring
1/29/13
8:15am
D4 Oxacillin
D8 Pen G
(-) edema
UO- 0.8cc/hr
-cont. meds- Oxacillin and Pen G
-resume Furosemide 20mg IVTT q12hr
-IVF tf: D5 IMB 800cc @SR
1/30/13
5:30am
Hgt: 141
Weak pulses
7am
-IV push 210cc of PNSS now
-hold Furosemide temporarily
-repeat serum electrolytes STAT
-repeat BP after IV push
-run another 210cc of PNSS now
-start Dopamine 7.8 cc/hr via perfusor
pump
-close watch
-to prevent fluid deficit
-to check electrolytes status
of the patient
-to check effectiveness of
the therapy
--adjunct to standard
measures to improve blood
pressure, cardiac output
and improve renal blood
flow
8:30am
NO MIO
No conscious
ambulation
370
Wt 19
3pm
-pls. Wt pt now and record
-continue MIO q shift and record without
fail.
-repeat CXR APL today without fail
-cont. meds: Pen G D8-D9 Oxacillin D5-
D6
-IVF to KVO
-limit OFI to 220cc
-pls. Incorporate 10meqs KCl to present
IVF regulate @SR
-treatment or prevention of
K depletion
1/31/13 -still for x-ray APL now(rpt) today without
fail pls.
-cont. meds
-cont. IVF @SR
-cont. monitoring I&O q shift; daily wt.
-refer accordingly.
2/1/13 -shift Pen G to Ceftriaxone 2.9 mg IVYT
OD, +20cc D5W as side drip via soluset

A Case Study 33
-D/C Pen G once @ Ceftriaxone
-IVF TF: D5LR 1L @KVO
-ff-up repeat CXR

A Case Study 34
CHAPTER VIII
HRP NSG. DX AMB PATHOPHYSIOLOGY
CLIENT
OUTCOME
INTERVENTION RATIONALE EVALUATION
E
X
C
H
A
N
G
I
N
G
Imbalance
nutrition:
Less than
body
requiremen
ts related to
increased
metabolic
needs
SUBJECTIVE
“Medyo
gumaan siya.
Hind na kasi
siya
kumakain” as
verbalized by
the mother.
OBJECTIVE
-Weight loss
without
adequate
calorie
intake.
-slightly
pallor
Intestinal fluid output
overwhelms the
absorptive capacity of
the GI tract
Damage the villous
brush border of the
intestine
malabsorption of
intestinal contents
Leading to an osmotic
diarrhea
Release of toxins that
binds to a specific
enterocyte receptors
Release of chloride
ions into the intestinal
Within 4 days
of duty, the
significant
others will
verbalizes and
demonstrates
selection of
food/meals
that will
achieve a
cessation of
weight loss.
INDEPENDENT
-Obtain vital signs
frequently.
-Monitor Intake and
out put
-Discourage to give
beverages that are
caffeinated and
carbonated
beverages.
-Instruct adequate
hydration treatment.
-To monitor some
complication that
present in the
disease process and
will have baseline
comparisons.
-To monitor
nutrional intake of
the patient and
body functions.
-Caffeinated
beverages may
decrease appetite
and carbonated
beverages may lead
to satiety.
-To prevent
dehydration
GOAL MET.
Patient
verbalize
“Medyo
kumakain na
siya ng mabuti
hidi tulad dati.
Medyo
bumabalik na
din yung
katawan niya”;
normal sin
color; afebrile;
capillary refill
of less than 2
seconds.
NURSING CARE PLAN # 1

A Case Study 35
lumen, leading to
secretory diarrhea
-Monitor
Intravenous fluid
therapy.
COLLABORATIVE
-Administer
medications as
prescribed.
-To ensure proper
hydration.
-To treat underlying
illnesss.

A Case Study 36
CLIENT
OUTCOME
E
X
C
H
A
N
G
I
N
G
Loose bowel
movement
related to
Diarrhea
secondary to
disease
process
SUBJECTIVE
“6 na beses
siyang
dumumi sa
ngayon tapos
matubig, sa
ihi naman
kakaunti lang
2-3x” as
verbalized by
the mother.
OBJECTIVE
-Increase
bowel sounds
noted
-Frequent and
often severe,
mushy stools
-decreased skin
turgor
-capillary refill
more than 2
seconds.
overwhelms the
the GI tract
Damage the villous
brush border of the
intestine
malabsorption of
intestinal contents
diarrhea
binds to a specific
Release of chloride
lumen, leading to
secretory diarrhea
Within 4 days
of duty,
mother of
patient will
report reduction
in frequency
of stools and
return to more
normal stool
consistency.
INDEPENDENT:
- Observe and record
stool frequency,
characteristics,
amount, and
precipitating factors.
-Identify foods and
fluids that precipitate
diarrhea.
-Monitor Intake and
Output.
-Observe
for excessively dry
skin and mucous
membranes, decreased
skin turgor, slowed
capillary refill
COLLABORATIVE
Administer parenteral
-Helps differentiate
individual disease
and assess severity
of episode.
-Avoiding intestinal
irritants promotes
intestinal rest.
-Provides information
about aver all fluid
balance, renal function,
and bowel disease
control, aswell as
guidelines or fluid
replacement.
-Indicates excessive
fluid loss/resultant
dehydration.
-Maintenance
GOAL MET.
Mother
verbalized “4
na beses lang
siya
nakabawas
ngayong araw.
Mejo matubig
pa din pero
hindi na gaya
ng dati”;
capillary refill
less than 2
seconds; good
skin turgor.

A Case Study 37
fluids, blood
transfusions as
indicated
-Administer anti-
diarrheal
medications as
prescribed.
of bowel rest requires
alternative fluid
replacement to
correct losses/anemia.
Note: fluids
containing sodium
may be restricted in
presence of regional
enteritis.
-Reduces fluid losses
from intestines.

A Case Study 38
CLIENT
OUTCOME
E
X
C
H
A
N
G
I
N
G
Deficient
fluid
volume
related to
frequent
passage of
loose
watery
stools
secondary
to diarrhea
SUBJECTIVE
“6 na beses
siyang
dumumi sa
ngayon tapos
matubig, sa ihi
naman
kakaunti lang
2-3x” as
verbalized by
the mother.
OBJECTIVE
-Weight loss
noted
-drymucous
membranes
-weakness noted
-loose watery
stools noted
overwhelms the
the GI tract
Damage the villous
brush border of the
intestine
malabsorption of
intestinal contents
diarrhea
binds to a specific
Release of chloride ions
into the intestinal lumen,
leading to secretory
diarrhea
Within 4 days
of duty, the
patient will
maintain fluid
volume as
evidence by
hydration
status, intake is
equal as output
and good skin
turgor.
INDEPENDENT:
-Establish rapport.
-Monitor I & O
-Increase and
maintain fluid
intake.
-Instruct mother to
provide frequent
oral care.
COLLABORATIVE:
-Administer
intravenous fluid as
prescribed.
-Administer
prescribed
medications
-To gain parents trust
-To ensure accurate
picture of fluid status
-To prevent dehydration
and maintain hydration
status
-To prevent oral mucous
membrane from dryness
-To deliver fluids
accurately and at desired
type and rate.
-To treat underlying
cause
GOAL MET.
Patient has
normal urine
output; good
skin turgor and
good hydration
status; afebrile;
responsive

A Case Study 39
CLIENT
OUTCOME
K
N
O
W
I
N
G
Risk for
Impaired
Skin
integrity
related to
altered
fluid status
SUBJECTIVE
“6 na beses
siyang
dumumi sa
ngayon tapos
matubig, sa
ihi naman
kakaunti lang
2-3x” as
verbalized by
the mother.
OBJECTIVE
-slightly dry
skin
-decreased skin
turgor
-slightly pallor
-slightly dry
lips
overwhelms the
the GI tract
Damage the villous
brush border of the
intestine
malabsorption of
intestinal contents
diarrhea
binds to a specific
Release of chloride
lumen, leading to
secretory diarrhea
Within 4 days
of duty, the
mother of the
patient will
verbalize that
the child’s
perinea and
rectal
tissue remains
pink and
intact.
INDEPENDENT:
-Assess skin of
perineum and
rectum for signs of
skin
Breakdown or
irritation.
-Instruct mother to
change diapers every
2 hours as needed.
-Instruct mother to
wash diaper area after
each soiling.
COLLABORATIVE:
-Notify the physician
if the skin
is severely broken or
peeling or
if a rash is present.
-Early assessment
and
intervention can
prevent
worsening of the
condition
-Minimizes skin
contact with
chemical irritants
from stool
and urine
-Removes traces of
stool if
Present
-For early
detection and
treatment.
GOAL MET.
“Wala man
gapula-pula
mga singit nya.
Gina hugasan
ko ko yan para
hindi ma
irritate” as
verbalized by
the mother;
perinea and
rectal tissue
remains pink
and intact;
afebrile; moist
skin; good skin
color and skin
turgor.

A Case Study 40
CLIENT
OUTCOME
F
E
E
L
I
N
G
Fear
related to
perceived
threat or
danger
secondary
to the
presence
of the
health
care
provider.
SUBJECTIVE
“Takot potalga
yan siya sa naka
puti” as
verbalized by the
mother
OBJECTIVE
-sweating
-crying in the
presence ofthe
health care
provider
-dryoral mucous
membranes
overwhelms the
the GI tract
Damage the villous
brush border of the
intestine
malabsorption of
intestinal contents
diarrhea
binds to a specific
Release of chloride ions
into the intestinal lumen,
leading to secretory
diarrhea
Within 4 days
of duty, patient
will show
decrease or
absence of fear
manifested by
decrease
crying and
smiling.
INDEPENDENT:
-Establish rapport.
-Let the patient play
with your
instruments e.g
stethoscope,
thermometer etc.
-Maintain calm and
tolerant manner
while interacting
with the patient.
-Instruct the mother
to stay beside the
child when in the
presence of the
health care
provider.
-Encourage rest
periods.
-To gain trust of the
child and parents
-The child’s fear will
decrease if the child
will know that these
instruments are not
harmful
-Patient’s feeling of
stability increases in
a calm and
nonthreatening
atmosphere.
-To let the patient
feel secure when
interacting with the
health care provider.
-To improve the
child’s ability to cope
GOAL
PARTIALLY
MET.
Patient is still
crying in the
presence of
health care
provider but can
be stopped if
the health care
provider let the
child play while
interacting.

A Case Study 41
GENERIC
NAME
BRAND
NAME
CLASSIFICATION
MODE OF
ACTION
INDICATION CONTRAINDICATION
ACTUAL
DOSE
USUAL
DOSE
S/E
NSG.
INTERVENTIONS
F
U
R
O
S
E
M
I
D
E
L
A
S
I
X
L
O
O
P
D
I
U
R
E
T
I
C
S
 Rapid-
acting
potent
sulfonami
de “loop”
diuretic
and
antihyper
tensive
with
pharmaco
logic
effects
and uses
almost
identical
to those
of
ethacryni
c acid.
Exact
mode of
action not
clearly
defined;
decreases
renal
vascular
Treatment
of edema
associated
with CHF,
cirrhosis of
liver, and
kidney
disease,
including
nephrotic
syndrome.
May be
used for
manageme
nt of
hypertensio
n, alone or
in
combinatio
n with
other
antihyperte
nsive
agents, and
for
treatment
of
hypercalce
History of
hypersensitivity to
furosemide or
sulfonamides;
increasing oliguria,
anuria, fluid and
electrolyte
depletion states;
hepatic coma;
pregnancy
(category C),
lactation.
Furose
mide
20mg
IVTT
q12°
IV/IM
20–40
mg in 1
or more
divided
doses up
to 600
mg/dse
CV:Postural
hypotension,
dizziness with
excessive
diuresis, acute
hypotensive
episodes,
circulatory
collapse.
Metabolic:Hy
povolemia,
dehydration,
hyponatremia,
hypokalemia,
hypochloremi
a metabolic
alkalosis,
hypomagnese
mia,
hypocalcemia
(tetany),
hyperglycemia
, glycosuria,
elevated BUN,
hyperuricemia
;.
GI:Nausea,
vomiting, oral
and gastric
burning,
anorexia,
diarrhea,
 Observe 10Rs
accurately.
 Monitor BP
during periods of
dieresis.
 Report adverse
reaction/symptoms
to physician.
 Monitor for S&S
of hypokalemia
such as muscle
weakness,
diminished knee
reflexe, biceps,
etc.
 Monitor I&O ratio
and pattern. Report
decrease or
unusual increase in
output. Excessive
diuresis can result
in dehydration and
hypovolemia,
circulatory
collapse, and
DRUG STUDY # 1

A Case Study 42
resistance
and may
increase
renal
blood
flow.
Therapeutic
effects :
Inhibits
reabsorption
of sodium
and chloride
primarily in
loop of
Henle and
also in
proximal and
distal renal
tubules; an
antihypertens
ive that
decreases
edema and
intravascular
volume.
Reportedly
less ototoxic
than
ethacrynic
acid.
mia. Has
been used
concomitan
tly with
mannitol
for
treatment
of severe
cerebral
edema,
particularly
in
meningitis.
constipation,
abdominal
cramping,
acute
pancreatitis,
jaundice.
Urogenital:Al
lergic
interstitial
nephritis,
irreversible
renal failure,
urinary
frequency.
Hematologic:
Anemia,
leukopenia,
thrombocytop
enic purpura;
aplastic
anemia,
agranulocytosi
s (rare).
SpecSenses:T
innitus,
vertigo,
feeling of
fullness in
ears,hearing
loss (rarely
permanent),
blurred vision.
Skin:Pruritus,
urticaria
hypotension

A Case Study 43
GENERIC
NAME
BRAND
NAME
CLASSIFICATION
MODE OF
ACTION
ACTUAL
DOSE
USUAL
DOSE
S/E
NSG.
INTERVENTIONS
B
E
N
Z
Y
L
P
E
N
I
C
I
L
L
I
N
N
A
C
R
Y
S
T
A
P
E
N
T
A
N
T
I
-
I
N
F
E
C
T
I
V
E
S
MOA:
 A natural
penicillin
that
inhibits
cell wall
synthesis
during
active
multiplicat
ion.
Bacteria
resists
penicillin
by
producing
penicillina
ses-
enzymes
that
convert
penicillins
to inactive
penicillic
acid.
Moderate
to severe
systemic
infections,
neurosyphil
is
Hypersensitivity
Sodium restricted
patients
525,00
0 “u”
IVTT
q6°
(ANST
)
Children
younger
than
12yrs is
25,000
to
400,000
units/kg
daily IM
or IV q4
to 6hrs
CNS:
neuropathy,s
eizure,
Lethargy,con
fusion
Hallucination
CV:heart
failure
Thrombophle
bitis
GI:
Nausea&vo
miting,
Enterocolitis
Pseudo-
colitis
GU:Interstiti
al colitis,
neuropathy
Hematologic:
anemia
leucopenia
 Observe 10Rs
accurately.
 Assess patient for
allergic reaction.
 Do not give PEN
G with other anti-
biotic at the same
time.
 Administer the
drug aseptically.
 Administer the
drug slowly.
 Emphasized the
drug’s side affect
to patient.
 Instruct patient to
report occurrence
of adverse effects
promptly.
DRUG STUDY # 2

A Case Study 44
GENERIC
NAME
BRAND
NAME
CLASSIFICATION
MODE OF
ACTION
ACTUAL
DOSE
USUAL
DOSE
S/E
NSG.
INTERVENTIONS
R
A
N
I
T
I
D
I
N
E
H
C
L
Z
A
N
T
A
C
ANTI-ULCER  Competiti
vely
inhibits the
action of
the h2
receptors
of the
parietal
cells of the
stomach,
inhibiting
basal
gastric
acid
secretion
that
stimulates
by
food,insuli
n,histamin
e,
cholinergi
cagonist
and
gastrin.
Maintenanc
e therapy
for
duodenal
or gastric
ulcer,
gastroesp[h
ageal
reflux,
erosive
esophagitis
Contraindicatedwit
h sinus
hypersensitivity
Lactation
Acute porpuria
Use cautiously in
patients with
impaired renal or
hepatic faiure.
21mg
one
IVTT
q8°
1-
10mg/kg
daily
given as
2
divided
doses
CNS:
Vertigo,
malaise,
headache
EENT:
Blurred
vision
Hepatic:
Jaundice
 Observe 10Rs
accurately.
 .Assess patient for
abdominal
pain,rate, presence
of blood in emesis,
stool.
report abdominal
pain
 Provide concurrent
antacid therapy.
 Emphasized the
side effects to
patient.
DRUG STUDY # 3

A Case Study 45
GENERIC
NAME
BRAND
NAME
CLASSIFICATION
MODE OF
ACTION
ACTUAL
DOSE
USUAL
DOSE
S/E
NSG.
INTERVENTIONS
C
E
F
T
R
I
A
X
O
N
E
R
O
C
E
P
H
I
N
ANTI-
MICROBIAL
ANTI-
PARASITIC
 Inhibits
bacterialce
ll wall
synthesis,r
endering
cell
wallosmoti
cally
unstable,le
ad-ing to
cell death.
 Treatm
ent of
LRIT
(e.g.
bronchitis,
pneumonia,
bronchopn
eumonia,
emphysem
a,
lungabsces
s),
skin
andsoft
tissue
infections.
Pre-
operative p
rophylaxis
toreduce c
hance
of post-
operativesu
rgical
infections
 Hypersensitivity
tocephalosporins
and penicillins,
lidocaineor any
other
localanaesthetic
productof the
amide type.
2.9mg
IVTT +
20cc
Distille
d water
1gram
BID
Phlebitis
Rash
Diarrhea
Vomiting
 Observe 10Rs
accurately.
 Assess for
allergies.
 Teach patient to
report sore
throat, bruising,
bleeding and joint
pain
 Advise patient
towatch out
for perineal
itching,fever,
malaise,redness,
pain,swelling,
rashdiarrhea
 Administer the
drug slowly.
DRUG STUDY # 4

A Case Study 46
GENERIC
NAME
BRAND
NAME
CLASSIFICATION
MODE OF
ACTION
ACTUAL
DOSE
USUAL
DOSE
S/E
NSG.
INTERVENTIONS
M
E
T
O
C
L
O
P
R
O
M
I
D
E
P
L
A
S
I
L
ANTIEMETIC
S
 Stimulat
es
motility
of upper
GI tract,
increases
lower
esophag
eal
sphincter
tone, and
blocks
dopamin
e
receptors
at the
chemore
ceptor
trigger
zone.
Prevention
of
chemothera
py-induced
emesis. Tre
atment of
postsurgica
l
and diabeti
c gastric
stasis.
Facilitation
of small
bowel
intubation
in radiogra
phic
procedures.
Manageme
nt
of esophag
eal reflux.
Treatment
and
prevention
of postoper
ative
nausea and
. Contraindicated
in: Hypersensitivit
y; Possible GI
obstruction or
hemorrhage;
History
of seizure disorder
s;
Pheochromocytom
a;
Parkinson’s diseas
e. Use Cautiously
in: History of
depression;
Diabetes (may
alter response to
insulin); Renal
impairment
(reduce dose in
CCr <50
ml/min); OB,
Lactation: Safety
not established;
Pedi: some syrup
products contain
benzoate, a
metabolite of
benzyl alcohol
3mg
IVTT
q6
1–
2mg/kg
q4-6hrs
CNS:
drowsiness,
extrapyramid
al
reactions, res
tlessness,
NEUROLEP
TIC
MALIGNAN
T
SYNDROM
E, anxiety,
depression,
irritability,
tardive
dyskinesia. C
V:
arrhythmias
(supraventric
ular
tachycardia,
bradycardia),
hypertension,
hypotension.
GI: constipati
on, diarrhea,
dry mouth,
nausea. Endo
 Observe 10Rs
accurately
take metoclopramid
e as directed. Take
missed doses as
soon as
remembered if not
almost time for next
dose.
 Pedi: Unintentional
overdose has been
reported in infants
and children with
the use
of metoclopramide
oral solution. Teach
parents how to
accurately read
labels and
administer medicati
on.
 May cause
drowsiness.
Caution patient
to avoid other
activities
requiring alertness
DRUG STUDY # 5

A Case Study 47
vomiting
when
nasogastric
suctioning
is
undesirable
.
Unlabeled
uses:
Treatment
of hiccups.
Adjunct
manageme
nt of
migraine
headaches.
which can cause
potentially fatal
gasping syndrome
in neonates.
Prolonged clearanc
e in neonates can
result in high
serum concentratio
ns and increase the
risk for
methemoglobinem
ia. Side effects are
more common in
children especially
extrapyramidal
reactions; Geri:
More susceptible
to
oversedation and
extrapyramidal
reactions
:
gynecomasti
a. Hemat:
methemoglo
binemia,
neutropenia,
leukopenia,
agranulocyto
sis.
until response to
medication
is known.
 Advise patient to
notify health care
professional
immediately if
involuntary
movement of eyes,
face, or limbs
occurs.

A Case Study 48
GENERIC
NAME
BRAND
NAME
CLASSIFICATION
MODE OF
ACTION
ACTUAL
DOSE
USUAL
DOSE
S/E
NSG.
INTERVENTIONS
O
X
A
C
I
L
L
I
N
B
A
C
T
O
C
I
L
ANTI-
INFECTIVES
(PENICILLINS
)
A
penicillinase
– resistant
penicillin
that inhibits
cell-wall
synthesis
during
microorganis
m
multiplicatio
n; bacteria
resists
penicillins by
producing
penicilllinase
– enzymes
that convert
penicillins to
inactivate
penecillic
acids.
Oxacillin
resists these
enzymes.
Systemic
infections
caused by
penicillinas
e-
producing
staphyloco
cci
Contraindicatedwit
h allergies
topenicillins,cepha
losporins, or other
allergens.
Use cautiously
withrenal
disorders,pregnanc
y,lactation
.
525mg
IVTT
q6IVT
T
250-
500mg
q4
CNS:
Lethargy,hall
ucinations, se
izures
GI:
Glossitis,
stomatitis,gas
tritis, sore
mouth,
furryor black
hairytongue,
nausea,vomit
ing,
diarrhea,abdo
minal pain,
diarrhea,
enterocolitis,
pseudomemb
ranouscolitis,
nonspecifich
epatitis
GU:nephritis
-
oliguria,prote
inuria,
hematuria,ca
sts, azotemia,
pyuria
 Observe 10Rs
accurately
 Side effects may
beexperienced,
suchas: upset
stomach,nausea,
diarrhea(small
frequentmeals),
mouthsores
(performfrequent
mouthcare) and
pain atinjection site.
 Report difficulty
of breathing,
rashes,severe
diarrhea,severe pain
atinjection
site,mouth sores.
 Finish entire
courseof therapy
asprescribed
 Give drug slowly.
DRUG STUDY # 6

A Case Study 49
Hematologic:
anemia,thro
mbocytopeni
a,leukopenia,
neutropenia,p
rolonged
bleeding
time(more
common
thanwith
other
penicillinase-
resistant
penicillins)

A Case Study 50
CHAPTER X
Determination Actual Value Normal Value Interpretation Nursing Intervention
Urinalysis
Color
Albumin
Sugar
Transparency
pH
Dark Yellow
4+
Negative
Cloudy
Acidic
Straw-yellow color
Negative
Negative
Clear to slightly hazy
4.6 – 8.0
 Deviations from normal
color can be caused by
certain drugs and various
vegetables such as
carrots, beets, and
rhubarb.
 possibly the patient has
glomerular damage
 Within normal value
 Cloudy urine may be
evidence of phosphates,
urates, mucus, bacteria,
epithelial cells, or
leukocytes.
 High protein diets
increase acidity.
 Instruct the patient to void
directly into a clean, dry
container. Sterile,
disposable containers are
recommended. Women
should always have a
clean-catch specimen if a
microscopic examination
is ordered. Feces,
discharges, vaginal
secretions and menstrual
blood will contaminate the
urine specimen.
 Cover all specimens
tightly, label properly and
send immediately to the
laboratory.
 Observe standard
LABORATORY STUDY #1

A Case Study 51
specific gravity
RBC
1.015
Abundant
1.053 – 1.030
Negative
 Low specific gravity
reflects diluted urine,
Overhydration, early
renal disease, and
inadequate ADH
secretion reduce specific
gravity.
 Damage to glomeruli or
tubules allows RBCs to
enter the urine. Trauma,
disease, or surgery of the
lower urinary tract also
causes blood to be
present
precautions when handling
urine specimens

A Case Study 52
Hematology
WBC
RBC
HGB
HCT
PLT
MCV
MCH
13.6
4.15
80
0.28
926
67
19.3
4.0-10.0x10^g/l
4.70-6.10x10^12/L
130-170g/L
0.42-0.50
100-300x10^g/L
86-100fL
 It is possible indicated as
bacterial infections.
 It is possible indicated
anemia due to decrease
RBC production
 Possible as anemeia due
to decreased RBC
production
 Possible as anemia due to
decreased RBC
production
 Possible indicated as
cachexia
 Possibly indicates as a
iron deficiency anemia
 Explain the procedure to
the mother
 Explain the importance of
the procedure and why it id
necessary
 Instruct the mother to have
the proper hygiene
 Assist in the procedure
 Instruct the mother to
report any signs of
infection like fever
 Regulate IV as ordered to
provide adequate hydration
LABORATORY STUDY #2

A Case Study 53
MCHC
RDW
Differe
ntial Count
Neutrophil
Lymphocyte
Monocyte
Eosinophils
Basophils
288
12.1
46.7
17.4
24.4
11.0
0.5
26-31pg
310-370g/l
11.6-13.7%
40-70
19-48
3 -9
1-4%
0.5-1%
 Possibly indicated as a
microcytic anemia
microcytic anemia
 Within normal range
 Possibly indicated as
acute viral infections.
 Increased possible
indicated as a chronic
infections.
 Increased due to parasitic
and allergic reactions.
 Possibly problem like
blood dyscrasia

A Case Study 54
BUN
Creatinine
1.8lmm0l/L
60.1mm0l/L
2.1-7.1
53-97
low protein diet or
malnutrition
 Instructed the mother to
increased protein in the diet
 Clean the venipuncture site
first with an alcohol swab
and then with a providone-
iodine swab, starting at the
site and working outward
in a circular motion.
 Monitor the venipuncture
site for bleeding and signs
of infection.
 Document the tentative
diagnosis and current or
recent antimicrobial
therapy on the laboratory
request.
LABORATORY STUDY #3

A Case Study 55
Urinalysis
Color
Albumin
Bilirubin
Transparency
pH
Specific gravity
RBC
Yellow
Negative
Negative
Clear
Acidic
1.005
Abundant
Straw-yellow color
Negative
Negative
Clear
4.6 – 8.0
1.015-1.025
Negative
 High protein diets
increase acidity
 Low specific gravity
reflects diluted urine,
Overhydration, early renal
disease, and inadequate
ADH secretion reduce
specific gravity.
 Damage to glomeruli or
tubules allows RBCs to
enter the urine. Trauma,
disease, or surgery of the
lower urinary tract also
causes blood to be present
 Instruct the patient to void
directly into a clean, dry
container. Sterile,
disposable containers are
recommended. Women
should always have a
clean-catch specimen if a
microscopic examination
is ordered. Feces,
discharges, vaginal
secretions and menstrual
blood will contaminate the
urine specimen.
 Cover all specimens
tightly, label properly and
send immediately to the
laboratory.

Observe standard
precautions when handling
urine specimens
LABORATORY STUDY #4

A Case Study 56
Hematology
WBC
RBC
HGB
HCT
PLT
MCV
MCH
MCHC
13.0
3.75
74
0.25
777
67
20
294
4.0-10.0x10^g/l
4.70-6.10x10^12/L
130-170g/L
0.42-0.50
100-300x10^g/L
86-100fL
26-31pg
310-370g/l
RBC production
 Possible as anemeia due
to decreased RBC
production
decreased RBC
production
cachexia
microcytic anemia
microcytic anemia
the mother
the procedure and why it
id necessary
the proper hygiene
report any signs of
provide adequate
hydration
LABORATORY STUDY #5

A Case Study 57
Diff count
Neutrophil
Lymphocyte
Monocyte
Eosinophils
Basophils
48
17
9
25
1
40-70
19-48
3 -9
1-4%
0.5-1%
 Possibly indicated as
acute viral infections
 Increased due to parasitic
and allergic reactions.

A Case Study 58
Hematology
WBC
RBC
HGB
HCT
PLT
MCV
MCH
MCHC
17.2
4.35L
101L
0.31
680
72
23.1
323
4.0-10.0x10^g/l
4.70-6.10x10^12/L
130-170g/L
0.42-0.50
100-300x10^g/L
86-100fL
26-31pg
RBC production
 Possible as anemeia due to
decreased RBC
production
decreased RBC
production
cachexia
microcytic anemia
the mother
the procedure and why it
id necessary
the proper hygiene
report any signs of
provide adequate
hydration
LABORATORY STUDY #6

A Case Study 59
Diff count
Neutrophil
Lymphocyte
Monocyte
69.9
23.0
7.1
310-370g/l
40-70
19-48

A Case Study 60
Electrolytes
Na
K
Ca
137.7
3.39
1.26
135-148mm0l/L
3.35-5.3mm0l/L
1.13-1.32mm0l/L
 The pt. Experiences
abdominal and muscle
cramps tingling of finger
around mouth .Indicated
as a
hyperyhroidism,diarrhea,
vit d deficiency.
 Assess specific client risk,
noting chronic disease
processes that may lead to
electrolyte imbalances,
including kidney disease,
metabolic or endocrine
disorders, chronic
alcoholism, cancer or
cancer treatments,
conditions causing
hemolysis such as massive
trauma, multiple blood
transfusions; sickle cell
disease.
1. Note client’s age and
developmental level,
which may increase
risk for electrolyte
imbalance
2. Monitor heart rate and
rhythm by palapation
and asculatation.
3. Ascultate breath
sounds, assess rate and
depth of respirations
and ease of respiratory
effort, observe color of
LABORATORY STUDY #7

A Case Study 61
nailbeds and mucous
membranes, and note
pulse oximetry or
blood gas
measurement, as
indicated.

A Case Study 62
X-RAY RESULT
January 23,2013
CHEST PA
There is a confluence of opacity in left upper lung field. Heart is not enlarged.
Diaphragm and catosphrenic sinuses are intact. The bony thorax is unremarkable.
Impression:
IMPRESSION: Pneumonic consolidation
January 27,2013
KUB UTZ
The right kidney measures 8.8x4.0cms while left measures 9.1x4.6cms. the cortical
echoes are echogenic than normal and show distinct cortico medullary junctions. The
pelvo calyceal systems are intact. No ectasia nor lithiasis seen. These are no focal renal
mass lesions detected. The ureters are not dilated. The urinary bladder is distended show
in a irregular mucosal wall. There are no intravertical lithiasis seen
Negative for ascites.
IMPRESSION:
Normal sized kidneys with diffuse parenchymal disease,cystitis

A Case Study 63
CHAPTER XI
DISCHARGE PLANNING
A. MEDICATIONS
 Instruct the client as well as the parents to report for any signs of allergic
reactions.
 Inform and instruct the parents about the purpose, route, frequency and
dose of administration of the drugs being prescribed to be taken at home.
 Notify the parents of the side effects and adverse effects of the drugs that
are possible to occur while giving the medications.
 Educate the parents that medicines are prescribed to promote the recovery
and healing of the patient, thus maintenance and implementation must be
observed.
 Instruct the mother not to take unprescribed drugs by his physician to
avoid ineffectiveness of the drug.
® Medications are being given in order to facilitate recovery and healing of the
present altered condition of the patient, as well as to prevent further
complications that can cause other problems. Thus, it is important to educate
the patient for his to be able to know how to manage, handle and maintain
compliance to medical orders.
B. EXERCISE

A Case Study 64
 Explain importance of exercise in maintaining physical health.
 Explain to the client to avoid strenuous activities, since this can aggravate
proteinuria, hematuria and urine cast.
 Instruct patient that he can resume activities but may need close
monitoring and for further follow up with his care provider for continue
evaluation.
® Exercising is advised because it is believed that it can improve physical and
psychological well-being.
C. TREATMENT
 Encourage parents to comply with treatment regimen for their son.
 Explain to parents the importance of treatment regimen to be done at
home.
® Treatment regimen will help the patient to recover within a period of time to
develop physical well-being.
D. HYGIENE
 Educate client with the importance of proper hygiene in maintaining
physical well-being.
 Instruct client to bathe daily.
 Instruct the client to wash genitalia regularly specially after urinating and
bowel.
® Observing proper hygiene can help prevent further complications to
condition of the patient.

A Case Study 65
E. OUT-PATIENT DEPARTMENT FOLLOW UP
 Instruct parents to refer to his physician whenever symptoms of
complication and/or infection on their son occur and refer to his physician
for immediate management of their son’s condition.
 Instruct parents to have their son follow-up check up with his physician in
the exact day at the exact time of schedule, even if he doesn’t feel better,
after being discharged from the hospital.
 Instruct mother to seek immediate medical consultation for their son when
adverse effects or the undesirable effects to drugs occurs.
® Following up check-ups is important in order to assess the patient's
recovery status as well as to prevent any further problems.
F. DIET
 Educate parents and the client on the importance of well-balanced diet.
 Instruct parents to limit the fluid intake of their son depending on the
prescribed amount of fluid.
 Instruct the patient to avoid eating junk foods and other foods high in
sodium and potassium.
 Instruct the parents to serve foods high in calorie. Also foods which
contain complete or high quality protein which is used most efficiently by
the body such as egg, meat and some dairy products.
® Following diet prevents alteration in nutrition and helps in healing
process.

A Case Study 66
CHAPTER XII
RECOMMENDATION
To the Patient and Family
Since the client has prognosis, we recommend that the client should
continuously comply with the treatment .We recommend to the family that they
should follow health teachings taught by the health care providers such as proper
stoma care, proper hygiene before and after contact with the stoma and diet
appropriate with child’s condition and age.
To the Notre Dame University-College of Health and Sciences
Our group is proud to belong to such a peace loving school. We
recommend that the Notre Dame University’s College of Health and Sciences will
continue to maintain or improve their high quality of teaching not only on nursing
profession but also on developing the moral aspects of the student nurses through
inculcating moral values and giving high emphasis on the FIRES. Help us realize
our mistakes and face our difficulties, in that way we can maximize our learning.
To the Student Nurses
We have also evaluated ourselves upon doing this case and we have
decided to follow the recommendation of our clinical instructor. To provide
tender loving care to the patient is our main goal and continuous monitoring and
application of nursing interventions is compulsory for patient’s recovery. Careful
collection of data should be observed to obtain more accurate information.
To the Readers
The group recommends that the readers must also visit other sources of
information and not solely base everything on this case presentation alone. Use a
variety of sources makes a more complete understanding of the subject matter.
Everyone should consider being healthy as a priority and not a choice in
life. You can prevent diseases and have a healthy lifestyle by avoiding a sedentary
lifestyle and by visiting a physician 1 or 2 times a year.

A Case Study 67
REFERENCES
Bautista, J. (2008). Theoretical foundation of nursing (1st ed). The Philippine perspective.
Brunner and Suddarth (2009). Textbook of Med-Surg Nursing 12th Edition.
Halcomb, K.A (2010). Health promotion and health Education: nursing student’s
Perspectives. Retrieved August 21, 2012 from www.aacn.nche.edu/educa
tion.../baccessentials
John (2010). Home remedy for kidney problems. Retrieved September 14, 2012 from
http://www.drmitaljohn/best-way-home-remedy-for-gastro-problems
Kozier, B. et al. (2004). Fundamentals of Nursing (7th edition). California: Addison
Wesley
Osney Mead (1994). Blackwell’s Dictionary of Nursing Ltd. 2002
Scanlon, Valerie C. Essentials of Anatomy and Physiology (5th Edition).
Philadelphia; F.A Davis Company.
Pelaez, M.L. & Tamse, E. (2004). Manual of basic nursing procedures (3rd ed). Cotabato
City: Notre Dame University College of Health Sciences Printing Press.
Potter, P. & Perry, A.G. (2007). Basic nursing: essentials for practice (6th ed). Canada:
Mosby Inc., Elsivier Inc.
Schueler, S. et, al. (2013) Acute Glomerulonephritis. Retrieved February 5, 2013 from
http://www.freemd.com/acute-glomerulonephritis/home-care-kidney-diet.htm

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