case study - agn 2

7/27/2019 Case Study - AGN 2

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NURSING PROCESS

I. PATIENT ASSESSMENT DATA BASE

A. GENERAL DATA

1. Patients name: Ms. AF

2. Address: Libueg Camiling, Tarlac

3. Age: 14 years old

4. Sex: Male5. Birthdate: August 1, 1997

6. Rank in the family: 3rd

child

7. Nationality: Filipino

8. Civil Status: Child

9. Date of Admission: September 12, 2011

10. Order of Admission: > Please admit to peadia ward under Dr. Gerardo Tamayo

> Low salt, low fat diet

> Please insert heplock

> Monitor urine output

> Monitor vital signs and record

11. Attending Physician: Dr Gerardo Tamayo

B. CHIEF COMPLAINT: Bipedal Edema

C. HISTORY OF PRESENT ILLNESS:

> 4 days prior to admission patient ha abdominal pain accompanied by decreased urine output and tea-colored urine. No consultation done, no

medication given

> 3 days prior to admission due to above symptoms with bipedal edema consult was done at health center, no medicine given , advice for admission but

patient did not comply.

> Few hours prior to admission persistent of above symptoms prompted consult at TPH and was subsequently admitted.

D. PAST HEALTH HISTORY/STATUS

1. Childhood Illnesses: mumps, sore eyes, chicken pox, measles

2. Immunization: Hepa1, Hepa2, BCG, OPV, DPT

3. Major Illnesses: Glomerulonephritis

4. Current medications: Penicillin, Furosemide, Nifedipine, Cloxacillin

5.Allergies: no know allergies


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E. FAMILY ASSESMENT

Name Relation Age Sex Occupation Educl Attainment

Mr. ROS

Mrs. MYS

Ms. APS

Mr. CHS

Mr. RES

Father

Mother

Sister

Brother

Brother

39

42

22

18

9

Male

Female

Female

Male

Male

Tricycle driver

Housewife

Student

High school

graduate

High school

graduateHigh school

graduate

High school under-

graduate

Grade 4 student

F. SYSTEM REVIEW- GORDONS 11 FUNCTIONAL HEALTH PATTERNS ASSESMENT

1. Health perception Health Management Pattern

> Patient RMS believes that he could achieve health by taking care of himself. Illnesses occurs when you forgot to give importance to your body. If

ever patient RMS is sick his mother gave him medicine, but ever it become worst they would admit him to the hospital.

2. Nutritional Metabolic Pattern

> Mr. RMS eats 3x a day and usually eats snacks

> Usual Daily Menu

> Food rice, meats, vegetables and fish

> Water drinks 5 glasses of water a day

> Beverages softdrinks, juice


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3. Elimination Patterns

> Bowel habits: patient RMS usually defecates once a day.

> Color: Brownish in color and semi formed

> Odor: Foul in odor

> Consistency: soft

> Laxative use if any: Patient RMS is not using any laxatives

> Bladder: Patient RMS usually urinate 5x a day.

> Color: Tea- colored Urine> Odor: Aromatic

> Alteration if any:

4. Activity Exercise Pattern

O Feeding O Dressing O Grooming

O Bathing O Toileting O Cooking

O Bed mobility O Home maintenance

Legend:

O -Full care

I -Requires use of equipment

II -Requires assistance of supervision of others

III -Requires assistance or supervision of others, and equipment and a device

IV -Dependent; doesnt participate

5. Cognitive Perceptual Pattern

> Hearing: Patient RMS perceives sounds.

> Vision: Patient RMS can see clearly

> Sensory Perception: Patient RMS

> Learning Style: Patient RMS can supervise his learning abilities and level of understanding through reading books, going to school and watching

television.

6. Sleep Rest Pattern

> Patient RMS usually sleep 11 oclock in the evening then wake up 8 in the morning. He says that he has no difficulty in sleeping. He watch

television or stare at a blank things to make himself asleep.


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7. Self- Perception and Self concept Pattern

> Our patient accepts his present health status, through he know the complications of the disease in his body. He sees himself as a brave man and

feels like he can survive the crisis that his going through even though he was a little bit afraid of injection.

8. Role Relationship Pattern

> Patient RMS is a responsible son in his family because he usually help their mother in preparing their food and sometimes he cook for them.

9. Coping Stress Tolerance Pattern> Whenever Mr. RMS got bull by his classmates, he would cry and tell it to his mother. If ever he was scolded by his parents he take their word as a

motivation to do good.

10. Value Belief Pattern

> Patient RMS is a Roman Catholic who usually goes to church together with his family every Sunday. He truly believes in God as the Father and our

Creator.

G. HEREDO FAMILIAL ILLNESS

MATERNAL unremarkable

PATERNAL unremarkable

I. PHYSICAL ASSESSMENT

A. General Survey

> Patient is well groomed and appropriately dress. He has an actual height of 115 cm and a weight of 35 kg. he is a little bit worried in his

condition but has a moderately good mood. He is also alert upon interviewing.

B. Vital Signs:

> BP 120/90 mmHg

> CR 88 beats per minute

> RR 22 breath per minute

> Temp 37.2 Degrees Celsius


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C. Regional Exam:

1. Hair, head and face - Thick evenly distributed hair

- normocephalic with a symmetrical facial movement

2. Eyes - presence of pustule in his lower left eye, edema

3. Nose - Normal nasal congestion

4. Ears - Normal hearing acuity

5. Mouth and Throat - Dry mouth, free from lesion

6. Neck and Lymph nodes - can move his neck freely and not tender

7. Skin - Light deep brown, moist due to warm room8. Nails - Intact epidermis

9. Thorax and Lungs - Normal breath sound

10. Cardiovascular - rhythmic pattern

11. Breast and Axilla - symmetrical, non tender

12. Abdomen - Symmetrical, Umbilicus inverted

13. Genitals - Not assess

14. Rectum and Anus - Not assess

15. Neurological/Cranial nerves - patient is alert, oriented to time and place and he has an appropriate behavior.

II. PERSONAL/ SOCIAL HISTORY

A. HABITS/VICES

a. Caffeine not drinking

b. Smoking not drinking

c. Alcohol not drinking

d. Tea not dringking

e. Drugs not using drugs

B. LIFESTYLE

> Go to school and playing around with friends.

C. RANK IN THE FAMILY> 3

rdChild

D. EDUCATIONAL ATTAINMENT

> Second year high school


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III. ENVIRONMENT HISTORY

> Living in a concrete house along the hi-way

XII. DISCHARGE PLAN

Medications> Nifedipine 10 mg PO TID

> Furosemide 20 mg x 1 tab PO OD

Exercise

> Advise client to have a non-strenous and non jarring exercise such as walking.

> Tell client to initiate exercise through repetitive low intensity exercise first.

> As time and experiences increases the client can move to higher intensity exercise.

Treatment

> Ensure follow up and self care.

> Advice client or significant others to take in time prescribe medicines specially high blood pressures.

> Ensure dietary restrictions and salt, fluids protein and other substances max be recommended.

> Tell significant others to closely watched and monitor for signs of developing kidney failure.

Diet

> Assure a low sodium, low protein diet.

> Limitation of fluid and salt intake to minimize vascular overload and hypertension.


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V. INTRODUCTION

Glomerulonephritis is a condition where the small structures inside the kidneys, known as glomeruli, become inflamed. There are two kidneys in

the body. These organs have a very important function. They remove waste products from the blood, which are then passed out of the body in urine. In each

kidney, there are about one million tiny filters called glomeruli. Glomerulonephritis occurs when the glomeruli become inflamed (swollen). If the kidneys become

inflamed, they are unable to work properly. Salt and excess fluid can build up, leading to complications, such as high blood pressure (hypertension). In some cases,

kidney disease or kidney failure can occur. Glomerulonephritis is the name given to a range of conditions that affect the kidneys. There are a number of different

types of glomerulonephritis. However, the condition can be broadly categorised into two main types: primary glomerulonephrit is and secondary

glomerulonephritis. Primary glomerulonephritis: where the condition develops on its own, and is not related to another pre-existing condition. Secondary

glomerulonephritis: where the condition develops as a result of another, pre-existing condition such as Hodgkin's disease, or Goodpasture's syndrome (an

autoimmune disorder that affects the lungs and kidneys). Glomerulonephritis can vary in severity. It can be short-lived (acute) and need minimal treatment or be

more serious and last for a long time (chronic).

VI. ANATOMY AND PHYSIOLOGY

1. Renal pyramid- are cone-shaped tissues of the kidney.2. Interlobular artery- The first set of renal bloodvessels

3. Renal artery - normally arise off the side of the abdominal aorta, immediately below the superior mesenteric artery, and supply the kidneys with blood.

4. Renal vein - The renal veins are veins that drain the kidney. They connect the kidney to the inferior vena cava.

5. Renal hilum - or renal pedicle of the kidney is the recessed central fissure.

6. Renal pelvis - The renal pelvis or pyelum is the funnel-like dilated proximal part of the ureter in the kidney.

7. Ureter - are muscular tubes that propel urine from the kidneys to the urinary bladder.
http://www.webmd.boots.com/hypertension-high-blood-pressure/default.htmhttp://en.wikipedia.org/wiki/Renal_pyramidhttp://en.wikipedia.org/wiki/Biological_tissuehttp://en.wikipedia.org/wiki/Kidneyhttp://en.wikipedia.org/wiki/Interlobular_arteryhttp://en.wikipedia.org/wiki/Renal_arteryhttp://en.wikipedia.org/wiki/Abdominal_aortahttp://en.wikipedia.org/wiki/Superior_mesenteric_arteryhttp://en.wikipedia.org/wiki/Kidneyhttp://en.wikipedia.org/wiki/Bloodhttp://en.wikipedia.org/wiki/Renal_veinhttp://en.wikipedia.org/wiki/Veinhttp://en.wikipedia.org/wiki/Kidneyhttp://en.wikipedia.org/wiki/Inferior_vena_cavahttp://en.wikipedia.org/wiki/Renal_hilumhttp://en.wikipedia.org/wiki/Renal_pelvishttp://en.wikipedia.org/wiki/Ureterhttp://en.wikipedia.org/wiki/Kidneyhttp://en.wikipedia.org/wiki/Ureterhttp://en.wikipedia.org/wiki/Urinehttp://en.wikipedia.org/wiki/Kidneyhttp://en.wikipedia.org/wiki/Urinary_bladderhttp://en.wikipedia.org/wiki/File:KidneyStructures_PioM.svghttp://en.wikipedia.org/wiki/Urinary_bladderhttp://en.wikipedia.org/wiki/Kidneyhttp://en.wikipedia.org/wiki/Urinehttp://en.wikipedia.org/wiki/Ureterhttp://en.wikipedia.org/wiki/Kidneyhttp://en.wikipedia.org/wiki/Ureterhttp://en.wikipedia.org/wiki/Renal_pelvishttp://en.wikipedia.org/wiki/Renal_hilumhttp://en.wikipedia.org/wiki/Inferior_vena_cavahttp://en.wikipedia.org/wiki/Kidneyhttp://en.wikipedia.org/wiki/Veinhttp://en.wikipedia.org/wiki/Renal_veinhttp://en.wikipedia.org/wiki/Bloodhttp://en.wikipedia.org/wiki/Kidneyhttp://en.wikipedia.org/wiki/Superior_mesenteric_arteryhttp://en.wikipedia.org/wiki/Abdominal_aortahttp://en.wikipedia.org/wiki/Renal_arteryhttp://en.wikipedia.org/wiki/Interlobular_arteryhttp://en.wikipedia.org/wiki/Kidneyhttp://en.wikipedia.org/wiki/Biological_tissuehttp://en.wikipedia.org/wiki/Renal_pyramidhttp://www.webmd.boots.com/hypertension-high-blood-pressure/default.htm


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8. Minor calyx - n the kidney, surrounds the apex of the renal pyramids. Urine formed in the kidney passes through a papilla at the apex into the minor calyx

then into the major calyx.

9. Renal capsule - is a tough fibrous layer surrounding the kidney and covered in a thick layer ofperinephric adipose tissue. It provides some protection from

trauma and damage.

10.Inferior renal capsule

11.Superior renal capsule

12.Interlobular vein - veins that drain the arcuate veins, pass down between the renal pyramids, and unite to form the renal vein.

13.Nephron - is the basic structural and functional unit of the kidney. Its chief function is to regulate the concentration ofwater and soluble substances like

sodium salts by filtering the blood, reabsorbing what is needed and excreting the rest as urine.

14.Minor calyx

15.Major calyx - in the kidney, surrounds the apex of the renal pyramids.

16.Renal papilla - is the location where the medullary pyramids empty urine into the minor calyx.

17.Renal column- is a medullary extension of the renal cortex in between the renal pyramids. It allows the cortex to be better anchored.

VII. PATHOPHYSIOLOGY

The initial reaction is usually either an upper respiratory infection or skin infection due to group A beta-hemolytic streptococcus. This leads to

the formation of an antigen-antibody reaction. It is followed by the release of a membrane-like material from the organism into the bodys circulation. Antibodies

produced to fight the invading organism also react against the glomerular tissue, thus forming immune complexes. The immune complexes become trapped in the

glomerular loop and cause an inflammatory reaction in the affected glomeruli. Changes in the glomerular capillaries reduce the amount of the glomerular filtrate,

thereby allowing passage of blood cells and protein into the infiltrate, and reducing the amount of sodium and water that is passed into the tubules for

reabsorption. This affects the vascular tone and permeability of the kidney, resulting to tissue injury.
http://en.wikipedia.org/wiki/Minor_calyxhttp://en.wikipedia.org/wiki/Renal_pyramidhttp://en.wikipedia.org/wiki/Urinehttp://en.wikipedia.org/wiki/Kidneyhttp://en.wikipedia.org/wiki/Major_calyxhttp://en.wikipedia.org/wiki/Renal_capsulehttp://en.wikipedia.org/wiki/Kidneyhttp://en.wikipedia.org/wiki/Perinephrichttp://en.wikipedia.org/wiki/Perinephrichttp://en.wikipedia.org/wiki/Adipose_tissuehttp://en.wikipedia.org/wiki/Inferior_renal_capsulehttp://en.wikipedia.org/wiki/Inferior_renal_capsulehttp://en.wikipedia.org/wiki/Superior_renal_capsulehttp://en.wikipedia.org/wiki/Superior_renal_capsulehttp://en.wikipedia.org/wiki/Interlobular_veinhttp://en.wikipedia.org/wiki/Interlobular_veinhttp://en.wikipedia.org/wiki/Nephronhttp://en.wikipedia.org/wiki/Nephronhttp://en.wikipedia.org/wiki/Kidneyhttp://en.wikipedia.org/wiki/Waterhttp://en.wikipedia.org/wiki/Bloodhttp://en.wikipedia.org/wiki/Urinehttp://en.wikipedia.org/wiki/Minor_calyxhttp://en.wikipedia.org/wiki/Minor_calyxhttp://en.wikipedia.org/wiki/Major_calyxhttp://en.wikipedia.org/wiki/Major_calyxhttp://en.wikipedia.org/wiki/Renal_pyramidhttp://en.wikipedia.org/wiki/Renal_papillahttp://en.wikipedia.org/wiki/Renal_papillahttp://en.wikipedia.org/wiki/Minor_calyxhttp://en.wikipedia.org/wiki/Renal_columnhttp://en.wikipedia.org/wiki/Renal_columnhttp://en.wikipedia.org/wiki/Renal_cortexhttp://en.wikipedia.org/wiki/Renal_pyramidhttp://en.wikipedia.org/wiki/Renal_pyramidhttp://en.wikipedia.org/wiki/Renal_cortexhttp://en.wikipedia.org/wiki/Renal_columnhttp://en.wikipedia.org/wiki/Minor_calyxhttp://en.wikipedia.org/wiki/Renal_papillahttp://en.wikipedia.org/wiki/Renal_pyramidhttp://en.wikipedia.org/wiki/Major_calyxhttp://en.wikipedia.org/wiki/Minor_calyxhttp://en.wikipedia.org/wiki/Urinehttp://en.wikipedia.org/wiki/Bloodhttp://en.wikipedia.org/wiki/Waterhttp://en.wikipedia.org/wiki/Kidneyhttp://en.wikipedia.org/wiki/Nephronhttp://en.wikipedia.org/wiki/Interlobular_veinhttp://en.wikipedia.org/wiki/Superior_renal_capsulehttp://en.wikipedia.org/wiki/Inferior_renal_capsulehttp://en.wikipedia.org/wiki/Adipose_tissuehttp://en.wikipedia.org/wiki/Perinephrichttp://en.wikipedia.org/wiki/Kidneyhttp://en.wikipedia.org/wiki/Renal_capsulehttp://en.wikipedia.org/wiki/Major_calyxhttp://en.wikipedia.org/wiki/Kidneyhttp://en.wikipedia.org/wiki/Urinehttp://en.wikipedia.org/wiki/Renal_pyramidhttp://en.wikipedia.org/wiki/Minor_calyx


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VIII. LABORATORY AND DIAGNOSTIC EXAMINATIONS

TYPE OF EXAMINATION: COMPLETE BLOOD COUNT

RESULTS NORMAL VALUES SIGNIFICANCE

RBC Count: 4.03

WBC Count: 11.

Hematocrit: .318

Hemoglobin: .112

MCV: 78.9 fL

MCH: 27.8 pg

MCHC: 35.2

PLATELET: 368.

Male:4.7 to 6.1 million cells/mcL

44,500 to 10,000 cells/mcL

Male: 40.7 to 50.3 %

Male: 13.8 to 17.2 gm/Dl

80 to 95 femtoliter

27 to 31 pg/cell

32 TO 36 GM/Dl

150,000 TO 400,000 per mm3

-The cells that carry oxygen to the body. Low results can indicate

blood loss, problems with the bone narrow, leukemia and

malnutrition. High results can indicate heart problems, kidneydisease, over transfusion and dehydration.

-This cells are the infection fighting portion of the blood and play

a role in inflammation. A low count can indicate bone narrow

problems, chemical exposure, autoimmune disease, and

problem with the liver or spleen. High level can indicate the

presence of tissue damage(burn), leukemia and infection

disease.

-This is the percentage of the blood that is composed of red

blood cells, low hematocrit level can indicate anemia, blood loss,

bone marrow problems, malnutrition and more.-Hemoglobin is a protein on red blood cells that carries oxygen.

Low levels may indicate blood loss or anemia.

-The MCV shows the size of the red blood cells. The MCV value is

the amount of hemoglobin in an average red blood cell.

-Mean corpuscular hemoglobin (MCH) is a calculation of theaverage amount of oxygen-carrying hemoglobin inside a redblood cell.

-The MCHC measures the concentration of hemoglobin in an

average red blood cell. These numbers help in the diagnosis of

different types of anemia.

-The platelet count is the number of platelets in a given volume

of blood. Both increases and decreases can point to abnormalconditions of excess bleeding or clotting.
http://labtestsonline.org/understanding/analytes/platelethttp://labtestsonline.org/understanding/analytes/platelet


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TYPE OF EXAMINATION: URINALYSIS


COLOR: Yellow

APPEARANCE: Cloudy

pH: 5.0

Specific gravity: 1.026

PROTEIN: +2

GLUCOSE: Negative

Pale yellow

Clear

4.6 to 8.0

1.003 to 1.030

0

0

-color is influence by urine concentration and ingredients.

-Bacteria, excessive crystals, or cells cause cloudiness.

-Urine becomes alkaline(pH more than 7) with urinary tract

infection or severe alkalosis.

-Specific gravity is elevated in dehydration as kidney try to

conserve fluid, and decreased in over hydration as they try to rid

the body of fluid.

-Due to inflammation, protein molecules pass into urine.

-Glucose in urine occurs most frequently as a symptom of

diabetes mellitus.

TYPE OF EXAMINATION: BLOOD CHEMISTRY(ELECTROLYTES)


SODIUM: 139.6

POTASSIUM: 4.53

CHLORIDE: 108.7

135 TO 145 mEq/L

3.5 to 5 mEq/L

100 TO 106 mEq/L

-plays a major role in regulating the amount of water in thebody. Also, the passage of sodium in and out of cells is necessary

for many body functions, like transmitting electrical signals in the

brain and in the muscles. The sodium levels are measured to

detect whether there's the right balance of sodium and liquid in

the blood to carry out those functions.

-is essential to regulate how the heart beats. Potassium levels

that are too high or too low can increase the risk of an abnormal

heartbeat. Low potassium levels are also associated with muscle

weakness.

-Like sodium, helps maintain a balance of fluids in the body. Ifthere's a large loss of chloride, the blood may become more

acidic and prevent certain chemical reactions from occurring in

the body that are necessary it to keep working properly.


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X. LIST OF IDENTIFIED PROBLEMS

1. Excess fluid volume related to compromised regulatory mechanism as manifested by AGN.

2. Imbalanced nutrition: less than body requirements related to increased glomerular fermeability as evidenced by proteinuria.

XI. NURSING CARE PLAN

ASSESSMENT NURSING DIAGNOSIS GOALS INTERVENTION RATIONALE EVALUATION

S-

O-

Periorbital and

pedal edema

Irritable when

awake

VS:

T- 37.2 degrees

Celsius

P-88R- 22

BP- 120/90

Excess fluid volumerelated to

compromised

regulatory mechanism

as manifested by AGN.

After nursingintervention, the

patient will:

Display

appropriate

urinary output

with normal

specific gravity

and laboratory

status within

normal range

Minimizepresence of

edema

Achieve stable

weight and

vital sigs.

Record accurateintake and

output(I&O)

Monitor urine

specific gravity

Weigh daily at the

same time of the

day

Monitor heart rate

and BP.

Elevate edematous

body part.

Low output(lessthan 400 ml/24

hr) is the first

indicator of

acute renal

failure.

To measure the

kidneys ability to

concentrate

urine

Daily body

weight is bestmonitor of fluid

status. A weight

gain of more

than 0.5 kg/day

siggest fluid

retention.

Tachycardia and

hypertension can

occur because of

failure of the

kidney to excreteurine

To promote

venous return

After nursing intervention,the patient has:

Displayed

appropriate urinary

output with normal

specific gravity and

laboratory status

within normal

range.

Absence of edema

and body weight

returns to normal Vital signs within

normal range.


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ASSESSMENT NURSING DIAGNOSIS GOALS INTERVENTION RATIONALE EVALUATION

S- andaming bawal

ipakain sa kanya as

verbalized by the

mother.

O- Protein = +2

Imbalanced nutrition:

less than body

requirementsrelated

to increased

glomerular

fermeability as

evidenced by

proteinuria.

After nursing

intervention, the

patient will:

Comply with

dietary

restrictions

Have increased

energy levelsand appetite

Prevent

symptoms

associated

with protein

deficiency.

Assess

nutritional

status. Assess

body weight

and lab values(

UA protein)

Promote a diet

based oncurrent

nutritional

status.

Promote a

low-sodium,

low-potassium,

high-calorie,

protein

restricted but

albumin-rich

diet.

Assist client

and the family

to cope with

the discomfort

caused by

restrictions in

the diet.

Explain the

rationale

behind dietary

restriction.

Monitor and

record clients

progress,

weigh patient

daily.

Obtain baseline for

comparison.

Reduces the sources

of restricted foods,at the same time

provides the calorie

and nutritional

needs of the client

and spares protein.

Understanding and

comforts promotes

compliance and also

increases appetite.

To evaluate

progress and to

detect

complications early.

After nursing

intervention, the

patient had:

Observably

increased

energy levels.

Consumed

high-caloriefood within

restrictions.

Reported

increase

appetite

Complied and

actively

participated in

the

interventions

presented.


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PANPACIFIC UNIVERSITY NORTH PHILIPPINES(Urdaneta City)

CASE STUDY(PEDIA WARD)

SUBMITTED BY:

RUSSEL M. TALIO

ROBIN M. UMIPIG SUBMITTED TO:

Mr. ALVIN BERNARDO

case study - agn 2

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