Liceo de Cagayan University College of Nursing

Individual Care Study

Table of contents

I. Introductiona. Overview of the Caseb. Objective of the Studyc. Scope and Limitation of the Study

II. Health Historya. Profile of patientb. Personal Health Historyc. History of Present Illnessd. Chief Complaint

III. Developmental Data

IV. Medical Managementa. Medical Orders and rationaleb. Drug study

V. Pathophysiology with Anatomy and Physiology

VI. Nursing Assessment (System Review & Nursing Assessment II)

VII. Nursing Managementa. Ideal Nursing Management (NCP)b. Actual Nursing Management (SOAPIE)

VIII. Referrals & Follow-up

IX. Evaluation and Implications

X. Bibliography

I. INTRODUCTION

A. Overview of the Case

Acute Glomerulonephritis is the disease of the kidney in which there is an

inflammation of the glomerular capillaries. In most cases, the stimulus of the reaction is

group A streptococcal infection, which ordinarily precedes the onset of

glomerulonephritis by 2 to 3 weeks.

B. Objective of the Study

The study generally aims to investigate the condition of an adult man and further

understand the extent of the case.

Specifically, the health care provider sought to;

Perform Physical Assessment,

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

Identify the development and changes encountered by the client.

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

Develop Plan of the Care and Implement nursing interventions relevant and

suitable for the case.

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

needs and condition.

The purpose of the study is to gather significant data to broaden our knowledge with

regards to the condition of the patient and to improve our abilities as future health care

providers. Moreover, this case study will enable us to apply the acquired skills we

obtained in the classroom set-up.

C. Scope and Limitation of the Study

The study focuses only on one of the many problems of the kidney, mainly the

glomerulonephritis and its causes and effects on patients that are being diagnosed to it.

Also, the study tackles on how this problem is being acquired.

II. HEALTH HISTORY

A. Client’s ProfileName : Lisdan, Elpedio N.Wife : Lisdan, Jemma Address : San Rafael, Talakag, Bukinon provinceCivil Status : MarriedSex : MaleAge : 42 years oldReligion : Roman CatholicEducational Status : Elementary level

Income : 2,000 php/monthNationality : FilipinoDate of Admission : January 27, 2009Time of Admission : 9:10 amInformant : PatientHeight : 158 centimetresWeight : 52 kgVital Signs during AssessmentTemperature : 36.7 °CPulse Rate : 55 bpmRespiratory rate : 20 cpmBlood Pressure : 150/110 mmHg

Admitting Diagnosis : Acute Glomerulonephritis related to nephritic syndrome; hypertension

Attending Physician : Dr. Joseph Borong

B. Family and Personal Health

Patient’s History

Allergies:- No known allergies on foods and drugs.

Injuries/ Accident in the past:- Patient had not experience injuries or accident in the past.

Blood Transfusion:- Patient didn’t receive blood in the past.

Family health history:- Experienced Hypertension and Kidney disorder (2006)

Social History

Alcohol use:- Patient occasionally drinks alcoholic beverages, as seldom as once in 2 months.

Tobacco use:- Patient often smokes.

Home and Environment:- Resides at San Rafael, Talakag- Living status is just enough for their family needs

C. Chief Complaint and History of Present Illness

Noted to have edema; condition noted for a week – prior to admission as onset of

fever on and off associated with dysuria – tea colored urine.

III. DEVELOPMENTAL DATA

The Developmental Stages of Erik Erickson

Middle Adulthood: 35 to 65:

Generativity vs. Self absorption or Stagnation

Now work is most crucial. Erickson observed that middle-age is when we tend to

be occupied with creative and meaningful work and with issues surrounding our family.

Also, middle adulthood is when we can expect to "be in charge," the role we've longer

envied. The significant task is to perpetuate culture and transmit values of the culture

through the family (taming the kids) and working to establish a stable environment.

Strength comes through care of others and production of something that contributes to the

betterment of society, which Erikson calls generativity, so when we're in this stage we

often fear inactivity and meaninglessness.

Freud's Psychosexual Stages of Development

The Genital Stage

In the genital stage, as the child's energy once again focuses on his genitals,

interest turns to heterosexual relationships. The less energy the child has left invested in

unresolved psychosexual developments, the greater his capacity will be to develop

normal relationships with the opposite sex. If, however, he remains fixated, particularly

on the phallic stage, his development will be troubled as he struggles with further

repression and defenses.

Robert Havighurst Developmental Task Theory

Middle Adulthood (30-60 years)

Achieving adult social and civic responsibility; Reaching and maintaining

satisfactory performance in one’s occupational career; Developing adult leisure time

activities; Relating oneself to one’s spouse as a person; To accept and adjust to the

physiological changes of middle age; Adjusting to aging parents. Assisting teenage

children to become responsible and happy adults; achieving adult social and civic

responsibility.

Piaget's Theory of Cognitive Development

Formal operational stage (Adolescence and adulthood)

In this stage, intelligence is demonstrated through the logical use of symbols

related to abstract concepts. Early in the period there is a return to egocentric thought.

Many people do not think formally during adulthood.

IV. MEDICAL MANAGEMENT

A. Medical Orders and Rationale

Doctor’s Order Rationale

01/27/09

Please admit

TPR q 4h

Full low salt, low fat diet

Give 1 egg white a day

0.9 NaCl @ KVO rate

Furosemide i amp q 12h x 3doses

To monitor patient’s medical condition and proper management.

To monitor any abnormal changes in vital signs

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

To promote good nutritional status

To monitor body fluids & prevent dehydration

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

For treatment of lower respiratory

Cefuroxime 750 mg q 8h IVTT

Omeprazole 20mg icap OD P.O.

Captopril 25mg itab BID P.O.

I & O q shift

01/28/09

IVF 0.9 NaCl @ KVO rate

Spironolactone 50mg itab TID P.O.

Continue meds.

Weight patient daily pre-breakfast

01/29/09

Continue meds.

IVF of D5nm iL @ KVO rate

infection, UTI & dermatologic infection

First line treatment for heartburn

and short term treatment of active duodenal ulcer

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

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

To monitor body fluids & prevent dehydration

To counteract potassium loss caused by other diuretics

To treat the disease & remove the symptoms

To monitor if the symptoms are relieved

To treat the disease & remove the symptoms

To monitor fluids

B. Drug StudyGeneric Name of Ordered

Drug

Date Ordered

Classi-fication

Dose/Frequency/

Route

Mechanism of Action

Specific Indication

Contra-indication

Side Effects/Toxic

Effects

Nursing Precaution

Cefuroxime 01/27/09 Antibiotic(Cephalos porin – 2nd

generation)

750 mg q 8h IVTT

Inhibits synthesis of bacterial cell wall, causing

cell death.

For lower respiratory infection,

UTI & dermatologic

infection

Contra indicated with

allergy to cephalosporin or penicillins

Hypersen-sitivity,

nephrotoxicity, pain

at injection site

Assess for hepatic or

renal impairment

Assess for skin status

Check for sensitivity

tests

Generic Name of Ordered

Drug

Date Ordered

Classi-fication

Dose/Frequency/

Route

Mechanism of Action

Specific Indication

Contra-indication

Side Effects/Toxic

Effects

Nursing Precaution

Furosemide 01/27/09 Loop Diuretic

Amp of 12h x 3 doses

Inhibits reabsoption of Na and Cl from

the proximal and distal tubules and ascending

limb of the loop of Henle,

leading to a Na-reach diuresis

Hyperten-sion,

Edema associated with CHF, cirrhosis and renal disease

Contraindicates allergy to

furosemide; anuria, hepatic

coma

Polyuna, Nocturia,

Rash, Anemia, Muscle spasms, Cardiac

arrythmias

Assess for allergy to

furosemide

Assess for skin color, lesions and edemaCBC, serium electrolytes

Generic Name of Ordered

Drug

Date Ordered

Classi-fication

Dose/Frequency/

Route

Mechanism of Action

Specific Indication

Contra-indication

Side Effects/Toxic

Effects

Nursing Precaution

Omeprazole 01/27/09 Antisecretory drug;

Proton Pump

Inhibitor

20mg icap OD P.O.

Gastric acid pump inhibitor:

Supresses gastric acid secretion by

specific inhibition of hydrogen- K

ATPase enzymes system

at secretory surface of the gastric parietal

cells.

First line treatment

for heartburn and short

term treatment of active duodenal

ulcer

Contra-indicated with

hyper-sensitivity to

omeprazole or its component. Use cautiously

pregnancy lactation

Rash, alopecia, nausea,

vomitingEpistasis,

fever

Assess for hypersensit

ivity to omeprazole

Assess for skin lesionsAssess for

urinary output

Generic Name of Ordered

Drug

Date Ordered

Classi-fication

Dose/Frequency/

Route

Mechanism of Action

Specific Indication

Contra-indication

Side Effects/Toxic

Effects

Nursing Precaution

Captropil 01/27/09 ACE inhibitor

25mg itabBID P.O.

PolypeptideAntibactic;

against Mycobacterium

tuberculosis

Treatment hyper-tension

Contra-indicated allergy to

capreomycin; pre-existing

auditory impairment

Polyuria, Tachy-cardia,

proteinuriacough

dry mouth

Assess for allergy to captropil

Assess for skin color and lesions

For CBC and

differential

Generic Name of Ordered

Drug

Date Ordered

Classi-fication

Dose/Frequency/

Route

Mechanism of Action

Specific Indication

Contra-indication

Side Effects/Toxic

Effects

Nursing Precaution

Spirono-lactone

01/28/09 Diuretics 50mg itab TID P.O.

Cause loss of sodium

bicarbonate and calcium while

saving potassium and hydrogen ions

To counteract potassium

loss caused by

other diuretics

Hyper-sensitivity;

Hyperkalemia

ClumsyHeadacheDyscrasias

Monitor intake & output

Daily weight during therapy

Monitor BP before adminis-

tering

V. PATHOPHYSIOLOGY

Post-streptococcal infection (group-A, beta hemolytic)

Release of material from the organism, into the circulation (antigen)

Formation of antibody

Immune complex reaction in the glomerular capillary

Inflammatory response

Proliferation of epithelial cells lining glomerolus & cells between

endothelium & epithelium of capillary membrane

Swelling capillary membrane & infiltration with leukocytes

↑ Permeability of base membrane

↓ Glomerular filtration rate

Occlusion of the capillaries of the glomeruli vasospasm of afferent

ventrioles

↓ Ability to form filtrate from glomeeruli plasma flow

Retention of H2O & Na; hypovolemia; circulatory congestion

Edema Hypertension

↓ urinary outputUrine dark in color

AnorexiaIrritability lethargy

ACUTE GLOMERULO-

NEPHRITIS

VI. ASSESSMENT

EENT:

[ ] impaired vision [ ] blind

[ ] pain [ ] reddened [ ] drainage

[ ] gums [ ] hard of hearing

[ ] deaf [ ] burning [x] edema

[ ] lesion [ ] teeth [ ] no problem

RESPIRATORY:

[ ] asymmetric [ ] tachypnea

[ ] apnea [ ] rales [x] cough

[ ] barrel chest [ ] bradypnea

[ ] shallow [ ] rhonchi [x] sputum

[ ] diminished [ ] dyspnea

[ ] orthopnea [ ] labored [ ] wheezing

[ ] pain [ ] cyanotic [ ] no problem

CARDIO VASCULAR:

[ ] arrhythmia [ ] tachycardia [ ] numbness

[ ] diminished pulses [ ] edema [ ] fatigue

[ ] irregular [ ] bradycardia [ ] murmur

[ ] tingling [ ] absent pulses [x] pain

[ ] no problem

GASTRO INTESTINAL TRACT:

[ ] obese [ ] distension [ ] mass

[ ] dysphagia [ ] rigidly [ ] pain

[x] no problem

GENITO URINARY and GYNE:

[x] pain [x] urine color [ ] vaginal bleeding

[ ] hermaturia [ ] discharge [ ] nocturia

[ ] no problem

NEUROLOGICAL:

[ ] paralysis [ ] stuporous [ ] unsteady

[ ] seizures [ ] lethargic [ ] comatose

[ ] vertigo [ ] tremors [ ] confused

[ ] vision [ ] grip [x] no problem

MUSCULOSKELETAL:

[ ] appliance [ ] stiffness [ ] itching

[ ] petechiae [ ] hot [ ] drainage

[ ] prosthesis [ ] swelling [ ] lesion

[ ] poor turgor [ ] cool [ ] deformity

[ ] wound [ ] rash [ ] skin color

[ ] flushed [ ] atrophy [x] pain

[ ] ecchymosis [ ] diaphoretic [ ] moist

[ ] no problem

dysuria

Edema wit pain in both

extremities

Infusion site

NURSING ASSESSMENT IISUBJECTIVE OBJECTIVE

COMMUNICATION:[ ] Hearing Loss Comments: “wala [ ] Visual Changes man – wala [x] Denied gihapon” As verbalized by the husband

[ ] Glasses [ ] Language[ ] Contact lens [ ] Hearing Aide

R L Pupil Size: 3-5 mm [ ] Speech difficultiesReaction: PERRLA

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

Respiratory: [x] regular [ ] irregularDescribe: regular breathing but associated with

pain

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

CIRCULATION:[ ] chest pain Comments: “Sakit! [x] leg pain bug-at… [x] numbness of extremities nanghubag na [ ] denied man gni ako mga tiil” As verbalized by the patient

Heart Rhythm [x]regular [ ] irregularAnkle Edema: present in lower extremitiesPulse Carotid Radial DP FemoralRight: 62 65 60 not assessedLeft: 62 65 60 not assessed

Comments: Pulse sites are palpable and its rate are within normal range.

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

[ ] dentures [x] none

Full Partial With PatientUpper [√] [ ] [ ]

Lower [√] [ ] [ ]

ELIMINATION:Usual bowel pattern [ ] urinary frequency Once a day once daily [ ] constipation [ ] urgency Remedy [x] dysuria [ ] hematuria January 27, 2009 [ ] incontinence Date of last BM [ ] polyuria

[ ] diarrhea character [ ] foly in place [ ] denied

Comments: urinate once Bowel Sounds: daily due to pain Audible sounds and excrete small Abdominal Distention: amount. Present [ ] Yes [x] No Urine (color, consistency, odor) tea color of urine, inconsistent

MANAGEMENT OF HEALTH & ILLNESS:[x] alcohol [ ] denied (amount, frequency) Occasionally – once in 2 months

[ ] SBE Last Pap Smear: N/A LMP:

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

The patient is properly following her medications

SUBJECTIVE OBJECTIVE SKIN INTEGRITY:[ ] dry Comments: “ wala man [ ] itching - nanghupong[x] other - edematous lang ko” as [ ] denied verbalized by the Patient.

[ ] dry [x] cold [ ] pale[ ] flushed [ ] warm [ ] moist [ ] cyanotic

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

ACTIVITY/SAFETY:[ ] convulsions Comments: “ dili man[ ] dizziness hinuon, bug-at lang [ ] limited motion of joints gyud ako tiil Kay nanghupong Naman – kaya Limitation in man hinuon nako.” ability to as verbalized by the[ ] ambulate patient [ ] bathe self[ ] other[x] denied

[ ] LOC and orientation: Oriented to time and space Gait: [ ] walker [ ] cane [ ] other

[x] steady [ ] unsteady[ ] sensory and motor losses in face or extremities None

[ ] ROM limitations: patient can performed range of motion

COMFORT/SLEEP/AWAKE:[ ] pain Comments: “ok (location, raman hinuon” Frequency, As verbalized Remedies) by the patient.[ ] nocturia [ ] sleep difficulties[x] denied

[ ] facial grimaces[ ] guarding[ ] other signs of pain Edema on both extremities

[ ] siderail release form signed (60 + years) None

COPING:Occupation : Farmer Members of household: 6Most supportive person: Wife

Observed non-verbal behavior None

The person and his phone number that can be reached any time

SPECIAL PATIENT INFORMATION_______________ Daily weight _______________ PT/OT ________________________________ BP q shift _______________ Irradiation _______________ Neuro VS ______________ Urine test ______________________________ CVP/SG. Reading ________ ______________ 24 hour urine collection

Date Ordered

Diagnostic/laboratory exams

Date done Date ordered

I.V. Fluids/Blood

Date disc.

01/27/09 CBC 01/27/09 01/27/09 0.9 Nacl iL @ KVO rate

01/27/09 Urinalysis

VII. NURSING MANAGEMENT

A. Ideal Nursing Management

Nursing Diagnosis:

Excessive fluid volume related to glomerulonephritis

INTERVENTIONS RATIONALE

Monitor intake and output To check fluid balance and prevent dehydration

Observe for fever To check for infection since the patient has a greater risk

Elevate edematous extremities, change position frequently To reduce tissue pressure and risk of skin breakdown

After elevating, place in semi-fowlers position To facilitate movement of diaphragm, thus improving respiratory effort

Provide quiet environment To promote ventilation and limits external stimuli

Administer furosemide I amp of 12h as prescribed by the

physician

For the treatment for edema

Nursing Diagnosis:

Ineffective airway clearance related to productive cough

INTERVENTIONS RATIONALE

Assess the airway patency To check the effectivity of the airway & to plan for further

management

Elevate the head part of the bed/change position q 2h To enhance drainage of/ventilation to different lung

segments

Encourage deep-breathing and coughing exercise To mobilize secretions

Monitored the fluid intake To help liquefy secretions and not to severe the edema

Instruct to have proper clothing, not too tight and not too

loose

To provide warm body/environment

Nursing Diagnosis:

Acute pain related to edema

INTERVENTIONS RATIONALE

Monitor vital signs Because vital signs are altered in acute pain experienced

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

Pain is subjective experience of a person that no other one can felt about it

Perform pain assessment each time occurs To rule out worsening of underlying condition/developing complication

Elevate edematous extremities, change position frequently To reduce tissue pressure and risk of skin breakdown

Provide quiet environment To promote ventilation and limits external stimuli

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

For the treatment for edema

B. Actual Nursing Management

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

O

Edema Oliguria Restlessness

A Fluid volume excess related to Glomerulonephritis

P

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

Short term: At the end of 8 hours, the pt. will be able to reduce the excessive fluid volume.

I

1) Monitor vital signs especially temperature To check & assess for infection since the pt. has a higher

risk2) Monitor intake & output

To monitor & check fluid volume & prevent dehydration3) Elevate the edematous extremities

To reduce tissue pressure & risk in skin breakdown4) Place in a semi-fowlers position, change position frequently

To facilitate movement of diaphragm & improve respiratory effort

5) Administer furosemide 1 ampule every 12h as prescribed by the physician

For the treatment of edema

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

HEALTH TEACHINGS

Name of Patient: Gloria Yabo

MEDICATIONSEncourage to follow the dosages and proper timing of his meds. Such as the Furosemide 1 ampule every 12hours x 3doses, Omeprazole 20mg 1capsule once a day, Captopril 25mg 1tablet twice a day, & Spironolactone 50mg 1 tablet thrice a day. As prescribed by his physician.

EXERCISEEncourage bed rest and frequent changes of position, early ambulation, and deep breathing exercise.

TREATMENT

Encourage/instruct to keep the edematous extremities to elevate as often; limit of water intake; monitor intake and output; provide warm environment; provide egg white a day; weight the pt. daily, at the same time.

OUT-PATIENT(Check-up)

Encourage pt. that when his discharged, he must have a regular check-up to his physician until it’s needed. To evaluate the progress of his condition.

DIETInstruct to limit intake of salty & fatty foodsand enrich/increase the intake of foods rich in potassium such as bananas…

VIII. REFERRALS AND FOLLOW-UP

Since the patient is suffering from Acute Glomerulonephritis, it is advised for him

to stay in the hospital for a better and thorough management regarding on her condition.

Acute Glomerulonephritis are very critical in a man’s condition that is why the patient

needs an urgent hospital service for him to be monitored every now and then.

If the doctor has already approved the release or discharge of the patient from the

hospital, the patient is highly advised to have a regular check-up on her personal

physician to take out the risk from the said ailment.

If the patient will again suffer the Acute Glomerulonephritis, it is best for him to

be admitted to a tertiary-leveled hospital for better monitoring of his critical condition,

knowing that even a single mistake worsen his condition.

IX. EVALUATION AND IMPLICATIONS

After conducting this care study, I was able to appreciate more the

essence of utilizing the nursing process in the care and management of my

patient. It was indeed a tough job on conducting this study yet, it gave me a

big impact regarding how useful it is in my chosen profession. Nursing really

demands a tender loving care attitude. It demands patience and it is calling

that cannot be merely taken for granted.

Moreover, this care study taught us to stand on our own by not depending

on others just to make this. This provides us, the students, a big learning

regarding on how well we take care of or patients in the real clinical setting.

Most of all, this study teaches the students to provide clients care more

efficiently and competently to achieve an effective and quality nursing care.

X. BIBLIOGRAPHY

Doenges, Marilyn E. et.al Nurses Pocket Guide: Diagnoses, Interventions and Rationale. 9th edition pages 278-279, 472-477, 576-578 F. A Davis Company Philadelphia, 2004.

Lippincott Williams & Wilkins, Manual of Nursing Practice, 8th edition, volume 1.

Deglin, et al. Davis’s Drug Guide for nurses, 9th edition.

Smeltzer, Suzanne C. et al. Textbook of Medical-Surgical Nursing, 11th edition, volume 2.