I .

I N T R O D U C T I O N
a.Current trends about the disease condition Acute pyelonephritis can occur at any age. In neonates it is 1.5 times more common in boys and tends to be associated with abnormalities of the renal tract. Uncircumcised boys tend tohave a higher incidence than circumcised boys. Beyond that age girls have a 10 -fold higher incidence. In adult life it reflects the incidence of urinary tract infection (UTI) in that it is muchmore common in young women. Over 65 the incidence in men rises to match that of women.Glomerulonephritis (GN) comprises 25-30% of all cases of end-stage renal disease (ESRD).About one fourth of patients present with acute nephritis syndrome. Most cases that progress doso relatively quickly, and end-stage renal failure may occur within weeks or months of acute n e p h r i t i c syndrom onset. G e o g r a p h i c a n d s e a s o n a l v a r i a t i o n s i n t h e p r e v a l e n c e o f poststreptoc occal glomerulonephritis (PSGN) are more marked for pharyngeally associated GNthan for cutaneously associated disease. PGN has no predilection for any racial or ethnic group. A higher incidence (related to poor hygiene) may be observed in some s o c i o e c o n o m i c group. Acute GN predominantly affects males (2:1 male-to-female ratio). PGN can occur at anyage but usually develops in children. Outbreaks of PSGN are common in children aged 6 10 years . A c u t e g l o m e r u l o n e p h r i t i s r e f e r s t o a s p e c i f i c s e t o f r e n a l d i s e a s e s i n w h i c h a n immunologic mechanism triggers inflammation and proliferation of glomerular tissue that can result in damage to the basement membrane, mesangium, or capillary endothelium. Hippocratesoriginally described the manifestation of back pain and hematuria, which lead to oliguria or anuri a. Wi th t he devel opm ent of the mi croscope, Langhans was l at er abl e to descri be t hes e pathophysiologic glomerular changes. Most original research focuses on the poststreptococcal patient. Acute glomerulonephritis is defined as the sudden onset of hematuria, proteinuria, andred blood cell casts. This clinical picture is often accompanied by hypertension, edema, andimpaired renal function. Acute glomerulonephritis can be due to a primary renal or systemic disease. Glomerulonephritis represents 10-15% of glomerular diseases. Variable incidence has been report ed due in part to t he subcl ini cal nature of t he di sease i n m ore t han one half t hea f f e c t e d p o p u l a t i o n . D e s p i t e s p o r a d i c o u t b r e a k s , i n c i d e n c e o f p o s t s t r e p t o c o c c a l glomerulonephritis has fallen over the last few decades. Factors responsible for this decline may i nclude bett er healt h care del iver y and i mproved s oci oeconomi c condi ti ons . Wi th som eexceptions, a reduction in the incidence of poststreptococcal glomerulonephritis has occurred inmost western countries. It remains much more common in regions such as Africa, the Caribbean,India, Pakistan, Malaysia, Papua New Guinea, and South America. Immunoglobulin A (IgA) nephropathy glomerulonephritis (ie, Berger disease) is the most common c a u s e o f glomerulonephritis worldwide. Most epidemic cases follow a course ending in complete patientrecovery (as many as 100%). Sporadic cases of acute nephritis often progress to

a chronic form.Thi s progressi on occurs in as m an y as 30% of adult pat i ents and 10% of pedi atri c pati ent s. Glomerulonephritis is the most common cause of chronic renal failure (25%). The mortality rateof acute glomerulonephritis in the most commonly affected age group, pediatric patients, has been reported at 0-7% .A male-to-female ratio of 2:1 has been reported.Most cases occur in patients aged 5-15 years and only 10% occur in patients older than 40 years. Acute nephritis mayoccur at any age, including infancy. b. Reasons of choosing such case for presentation The group chose this study out of curiosity as it was our first time to encounter such caseand because of that, the group was interested in it. We were willing to undergo new experienceswhich would bring new learnings for the group as most of us have not been exposed yet to thePediatric ward. Another reason was that it was one of the suggestions of our clinical instructor to be used in making case study. c.Importance of the case study This case study will help the group in understanding the disease process of the patient.This would also help the group in identifying the primary needs of the patient with acute GN andacut e PN. B y i denti f yi ng such needs and heal th prob l em s of the pati ent as s oci at ed wit h t hedi sease and underst andi ng wh y s uch needs and health probl ems arise t he group can nowformul at e an indi vi dualiz ed care plan for t he pat i ent that would address t hese needs and problems effectively. Effective management of the problems identified will help the patient to recover faster and maintain a holistic sense of wellness even while in the hospital.This case study would also equip the group with knowledge, skills and attitude on how tomanage future patients with the same or similar disease. d. Objectives (Nurse Centered) - To gain new information about the patients disease and its etiology, pathophysiology,clinical manifestations as well as the standard medical and nursing management so that we mayapply this newly-acquired knowledge to our patient as well as similar situations in the future.- To learn new clinical skills as well as sharpen our current clinical skills required in themanagement of the patient with acute GN and acute PN.- To develop our sense of unselfish love and empathy in rendering nursing care to our patient so that we may be able to serve future clients with a higher level of holistic understandingas well as individualized care. NURSING PROCESS

A.ASSESSMENT
1.PERSONAL DATA A.Demographic Data Name: patient ex Age: 11 sex: male Religious Affiliation: RC Role position of the family:

Address: Campo 3 kita-kita

Date of Birth: 11-30-00

nationality: filipino
H e a l t h c a r e F i n a n c i n g : Usual source of medical care: B .En viron men tal S tatus: Their house structures are made of concrete and wooden materials which was build within a compound with their relatives. They have 2 bed rooms and their appliances are arranged properly in their divider as verbalized by the father.T h e y h a v e w a t e r p u m p w h i c h t h e i r p a r t i c u l a r s o u r c e o f w a t e r f o r b a t h i n g , cleaning cooking etc. but not a source of water to drink because the family usually bought mineral water for their source C .Person al Habits: He went to school every morning from 7:30 am to 11:30 am and play with hisuncle every afternoon. He usually eat variety of vegetables like sayote, papaya,carrots, kalabasa as verbalized by her mother, which are good for his heath. He loves to play holen and watched television. He usually play a long period of timeoutside with his friends D.Social: He is the second son of Mr. and Mrs. and an elementary student. E.Psychological: He loves to play outside with his friend so when his mother unable to permit him to go and to play outside he usually cries and make himself busy inside the house by playing in the room alone. 2.FAMILY HISTORY OF PAST ILLNESS 3.HISTORY OF PAST ILLNESSS Accordi ng t o the m ot her the pati ent has asthm a whi ch st art ed when he was 3 months old. Since then everytime the patient experiences the symptoms of asthma theytake salbutamol with the use of nebulizer to alleviate symptoms and improves airwayfunction. The patients asthma is usually triggered due to the weather changes, it usuallyoccurs during summer season or hot weather as the mother stated. When the patient hasfever, cough and col ds t he m ot her used OTC drugs li ke paracet amol for t he pat i ent condition. The patient had not experience other childhood illnesses. Boy X has completedhis childhood immunizations. The patient has no allergies to drugs, animals, or insects,and was never hospitalized due to serious illness.

4 .H I ST ORY OF PR ESENT IL LNESS

Present illness: came in due to n/v q after meals, with hypogastric pain, fever, U/A revealed UTI hence this admission
5.PHYSICAL ASSESSMENT

Nursing Responsibility for urinalysis : Ex pl ain t o the cli ent t hat the urine specim en is requi red, gi ve t he reason, and explain to be used to collect. Discuss how the results will be used in planningfurther care or treatments. Wash hands observe other appropriate infection control procedure. Provide client privacy. If uncircumcised, retract the foreskin slightly to expose the urinary meatus Routine urine examination is usually done on the first voided specimen in them orni ng because i t t ends t o have a higher, more uni form concent rat ion and a more acidic pH than specimens later in the day. At least 10 ml of urine is generally sufficient for a routine urinalysis. The specimen must be free of fecal contamination, so urine must be kept separatefrom feces. Female client should discard the toilet tissue in the toilet or in a waste bag rather than in the bedpan because tissue in the specimen makes laboratory specimen makes laboratory analysis more difficult.

 Put the lid tightly on the container to prevent spillage of th u r i n e a n d contamination of other objects,

Make sure that the specimen label and laboratory requisition carry the correctinformation and attach them securely to the specimen. Nursing responsibility for blood specimen collection. Place a tourniquet above the venepuncture site. Palpate and locate the vein. It is critical to disinfect the venepuncture site meticulouslywith 10% povidone iodine or 70% isopropyl alcohol by swabbing the skin concentricallyfrom the centre of the venepuncture site outwards. Let the disinfectant evaporate. Do notrepalpate the vein again. Perform venepuncture.

If withdrawing with conventional disposable syringes, withdraw 510ml of whole blood from adults, 25ml from children and 0.52ml for infants. If withdrawing using vacuum systems, withdraw the desired amount of blood directlyinto each transport tube and culture bottle. Remove the tourniquet. Apply pressure to site until bleeding stops, and apply sticking plaster (if desired). Using aseptic technique, transfer the specimen to the relevant cap transport tubes andculture bottles. Secure caps tightly. Be sure to follow manufacturers instructions on the correctamount and method for inoculation of blood culture bottles. Label the tube, including the unique patient identification number using indelible marker pen. Do not recap used sharps. Discard directly into the sharps disposal container C om pl et e t he case investi gat ion and the l aborat ory request forms usi ng t h e sam eidentification Number 7 .ANATO MY AND PHY SIO LOGY

the third lumbar vertebrae in adultThe average adult kidney weighs approximately 133 170g. (4.5 oz)and is 10-12 cm long 6 cm wide and 2.5 cm thick the right kidney is slight lower thanthe left due to the location of the liver K i d n e y a r e w e l l p r o t e c t e d b y t h e r i b s a n d b y t h e m u s c l e s o f t h e abdomen and back 3 LAYERS OF TISSUE SURROUNDING EACH KIDNEY

1.RENAL CAPSULE
- i n n e r m o s t l a y e r , i t i s a s m o o t h t r a n s p a r e n t f i b r o u s connective tissue membrane that connects with the outermost covering of the ureter at the hilum. It serves as a barrier against infection and trauma to the kidney

2.ADIPOSE CAPSULEsecond layer it is a mass of fatty tissue that protects thekidney from blows. It firmly holds the kidney in the abdominal activity

3.RENAL CAPSULEouter most layer which consist of a thin of a layer of fibrousconnective tissue that also anchors the kidney to their surrounding structures andto the abdominal wall. INTERNAL ANATOMY OF KIDNEY The renal parenchyma is divided into two parts the cortex and the medullaMEDULLAMedulla is approximately 5 cm wide which is the inner portion of the kidney. It containsthe loop of Henle, the Vasa Recta and the collecting ducts of the juxtamedullary nephrons thecollecting duct from

both the juxtamedullary and the cortical nephrons connect to renal pyramidswhich are triangular and are situated with base facins the concave surface of the kidney and the point (papilla)facins the hilum/pelvis. Each kidney contains approximately 8-18 pyramids. The pyramids drain into 4 to 13 minor calices which drain into 2 major calices that open directly intothe renal pelvis. The renal pelvis is the beginning of the collecting system and is composed of structures that are designed to collect and transport urine. Once the urine leaves The renal pelvis,the composition of urine does not change. CORTEX- It is approximately 2 cm wide, is located farthest from the center of the kidney andaround the outer most edges. It contains the nephrons. NEPHRONS- These are the functional units of kidney. It is microscopic renal tubule which functions asa filter. Each kidney has 1 million nephrons, which usually all ows for adequate renal functioneven if the opposite kidney is damaged or becomes nonfunctional. The structures are locatedwithin the renal parenchymas that are responsible for initial formation of urine. 2 KINDS OF NEPHRONS a. Cortical nephrons this makes up 80 to 85% of total number of nephrons in the kidney whichare located in the innermost part of the cortex. b. Juxtamendullary nephrons which make up the remaining 15 to 20% are located deeper in the cortex. There are distinguished by long loops of Henle, which are surrounded by long capillaryloops called Vasa Recta that dip into Medulla of the Kidney. Nephrons are made up of two basic components; a filtering element component of an encl osed capil l ar y net work and the att ach tubul e. The gl um erul us i s a unique net work of capillaries suspended between the afferent and efferent blood vessels, which are enclosed in anepithelial structure called Bowmans capsule. The glumerular membrane is composed of threefiltering layers: (a) Capillary endothelium, (b) basement membrane, and (c) epithelium. This membrane normally allows filtration of fluid and small molecules yet limits passage of larger molecules, such as blood cells and albumin.The tubular component of the nephrons begins in the Bowmans capsule. The filtratecreated in the Bowmans capsule travel first into the proximal tubule, then into loops of Henle,distal tubule, and either the cortical or medullary collecting ducts. The structural arrangement of the tubule allows the distal tubule to lie in close proximity to where the afferent and efferentarteriole respectively enter and leave the glumerulus. The distal tubular cells located in this area,known as the Macula Densa which functions with the adjacent afferent arteriole and

create whati s known as j uxt agl um erulus apparat us. Thi s is t he si t e of the renin producti on. R enin i s a hormone directly involved in the control of arterial blood pressure; it is essential for proper functioning of the glumerulus. The t ubul ar com ponent consi st s o f t he Bowm ans capsul e, the proxim al tubul e, the descending and ascending limbs of the loop of Henle, and the cortical and medullary collectingducts. This portion of the nephrons is responsible in making adjustments in the filtrate based onthe bodys needs. Changes are continually made as the filtrate travels through the tubules until itenters the collecting system and is expended from the body. BLOOD SUPPLY TO THE KIDNEY The hilum of pelvis is the concave portion of the kidney through which are renal arteryenters and ureters and renal vein exit. The kidney received 20 % t o 2 5 % of the total cardiac output, which means that all of the bodys blood circulates through the kidneys approximately 12 times per hour. The renal artery (arising from the abdomina l aorta) divided into smaller andsmaller vessels, eventually forming the afferent arterioles. Each afferent arterioles branches toform a glumerulus, which is the capillary bed responsible for glumerular filtration.

MANIFESTATION

EDEMA

(facial and bipedal) 08/30/08 HEMATURIA 08/30/08 HEADACHE 08/30/08

FEVER 08/30/08 09/04/08 09/05/08 NAUSEA AND VOMITING

NURSING RESPONSIBILITIES: BEFORE ADMINISTRATION

1.Explain to the patient and family on what is the effect of drug and its action 2.As s es s pat i ents i nfect ion before t herapy 3.Before gi vi ng fi rst dose do sensiti vi t y t est 4.Before giving the first dose , ask patient about previous reaction to cephalosporins or penicillin AFTER ADMINISTRATION 1.Be al ert for adverse reacti on and drug int eracti on 2.If adverse GI reaction occur, monitor patients hydration 3.Tell patient/ significant others to report adverse effect seen and experience 4.As s es s pat i ents i nfect ion aft er t he t herap y

NURSING RESPONSIBILITIES BEFORE ADMINISTRATION: 1.Explain to the patient and family on what is the effect of drug and its action 2.Assess patients underlying condition before administration 3.Monitor weight peripheral edema breath sounds blood pressure fluid intake and outputand electrolyte glucose BUN AFTER ADMINISTRATION: 1 .Be a ler t fo r ad ve rs e re act ion and drug intera cti on 2.Tell patient/ significant others to report adverse effect seen and experience. 3.Monitor weight peripheral edema breath sounds blood pressure fluid intake and outputand electrolyte glucose BUN

BEFORE ADMINISTRATION: 1.Explain to the patient and family on what is the effect of drug and its action 2 .Asse ss patie nt tem per atu re b efore the the rap y AFTER ADMINISTRATION: 1 .Asse ss patie nt tem per atu re afte r the th erap y 2 .Be a ler t fo r ad ve rs e re act ion and drug intera cti on 3.Tell patient/ significant others to report adverse effect seen and experience.

NURSING RESPOSIBILITIES BEFORE ADMINISTRATION 1. Assess if the patient has penicillin hypersensivity and cross sensitivity with other lactam antibiotic e.g cephalosporin 2.P reparati on of the m edi cati on >Direction of ReconstitutionTo make up to &0 ml first shake the bottle to loosen powder. Then ad 58 ml water and shake well. 3.Explain to the patient and family on what is the effect of drug and its action 4.S hake wel l before t he pat i ent t ake t he fi rst dose 5.Administer medication at the start of a meal to minimize potential gastrointestinalintolerance and to optimize drugs absorption AFTER ADMINISTRATION 1.Be al ert for adverse reacti on and drug int eracti on 2.Advice the patient to drink plenty of water to ensure proper ate of hydration and adequateurinary output 3.Advice the parents to maintain the take of medication at regular intervals4.Advice the parents to refrigerate the medication to maintain effectiveness

diabetes; glaucoma or increased pressure in your eye; an enlarged prostate or difficulty urinating; or liver or kidney disease.You may not be able to take phenylpropanolamine, or you may require a lower dose or specialmonitoring during treatment if you have any of the conditions listed above. 2.Explain to the patient and family on what is the effect of drug and its action 3.Shake well before the patient take the first dose

AFTER ADMINISTRATION 1 .Be a ler t fo r ad ve rse re act ion and drug inter a ction 2.Advice to store the medication on a less light and heat exposure place

III ACTIVITY/EXERCISE 1.For patient risk for impaired skin integrity r/t the presence of edema.

A.Change the childs position at least every 2 hours. Changing the position keeps pressure soresfrom appearing. B.Give bath daily and cleanse skin as needed. Attention to hygiene deters skin breakdown. C.Use lotion over areas of dry skin. Lotion help and moisture to the skin to decrease the chanceof skin breakdown. D.Use a support pillow under any edematous extremity. Support pillow will increase circulationand decrease pressure points that might lead to skin breakdown. 2.For patient experiencing fatigue r/t infectious process. A.Assess the child for signs of fatigue such as excessive sleepiness, yawning, or inability tohelp with activities of daily living. A child may show signs of fatigue in subtle ways such assleeping more than usual, yawning, or reluctance to help with bath or feeding activities. B.Ask the child what he wants to play with or what activities he wishes to engage in today. Achild of 5 years usually wants to play no matter how sick he is. If he has some choice he may play more than if he was told what to do. C .Obs erve t he chil ds act ivit y t o do activit i es even i f these are bed gam es. Obs ervati on wil l indicate the childs tolerance of an activity and level of fatigue. D.Rest periods during activities are important because the child will fatigue easily. 3.For patient who has pain r/t presence of infection and edema. A.Assess the child for signs of pain such as grimacing, crying, staying quiet, verbal complaintsof pain, or reluctance to move. Assessment of childs pain level allows for easily interventionto make the child, more comfortable. B.Gently move or reposition the child every 2 hours if he is to remain in a bed or chair position.Moving the child gently promotes circulation of the blood, lessens chance of pain, and helpscomfort the child. C.Position an edematous extremity on a support pillow. Supporting a swollen leg or arm willhelp decrease the pain.

DISCHARGE SUMMARY M: Take home medication instructed to the patient mother as follows:Coamixilae (Amocram) 150 g/mL 1 tsp 3x a day for 7 daysCarbocisteine syrup ( emyxer) 1 tsp 3x a dayPhenypropanolamine (coway) 1 tsp 3x a day E: Advised the mother to let his child continue his usual daily activities as tolerated T:

H: The following are advised to the patients mother: Increase the patients fluid intake to prevent dehydration Watch her child carefully for symptoms of asthma to prevent further complications Dont let her child to stay outside on hot environment for long period of time. O:Scheduled for OPD check up on September 08, 2008 at Tarlac provincial hospital D: Advised the mother to give her child nutritious food like fruits and vegetables to sustainthe needed nutrients of the body. Advised the mother not to let her child to eat junk foods. III CONCLUSION IV RECOMMENDATION P ati ent educati on i s di rect ed toward m aint ai ni ng ki dne y funct ion and prevent i n gcomplications. Fluid and diet restrictions must be reviewed with the patient, such as avoidingdietary protein when renal insufficiency and nitrogen retention (elevated BUN) develop, andsodium when the patient has hypertension, edema and heart failure. The importance of follow-upevaluations of blood pressure, urinalysis for protein and serum BUN and creatinine levels todetermine if the disease has progressed is stressed to the patient. A referral for home care may beindicated, a visit from a home care nurse provides an opportunity for careful assessment of the patients progress and detection of early signs and symptoms of renal insufficiency. Void every 2-3 hours during the day and completely empty the bladder. This prevents over distention of the bladder and compromised blood supply to the bladder wall. With regards to hygiene, shower rather than bathe in tub because bacteria in the bath water may enter the urethra. After each bowel movement, clean urethral meatus. Indicate that strenuous exercise should be avoided because exercise can induce proteinuria, hematuria, and cylindruria (renal cylinders or casts inthe urine). Some recommend other nutritional approaches such as consuming cranberry juice, blueberry juice, and fermented milk products containing probiotic bacteria, have been shown toinhibit adherence of bacteria to the epithelial cells of the urinary tract V. BIBLIOGRAPHY Website 2 New international Child Growth Standards for infants and young children (2006) by the WorldHealth Organization (retrieved from:http://www.who.int/growthref/en/)http://www.drugs.com/mtm/phenylpropanolamine.html http://www.chem-online.org/genericpharmaceutical.htmhttp://en.wikipedia.org/wiki/Carbocisteinehttp://en.wikipedia.org/wiki/Coamoxiclav( http://www.emedicine.com/med/topic879.htm )http://www.nlm.nih.gov/medlineplus/ency/article/003090.htm http://www.patient.co.uk/showdoc/40024643/ ) Book:

1 Health Assessment & Physical Examination (3rd Edition)by Mary Ellen Zator EstesPediatric Nursing (Caring for children and their families)by Nicki L Potts and Barbara LMandleco