Professional Documents
Culture Documents
Morayta, Manila
Case Presentation
(Acute Glomerulonephritis)
Submitted by:
BSN122
Group 87
April 30, 2010
Gratuito, Rachel S.
Jacinto, Arvie D.
Jornacion, Catrisha Elaine T.
Macaballug, Katrina B.
Maningding, Marvic S.
Mariano, Lalaine B.
Matibag, Michelle A.
Mendoza, Kristeen Frieda O.
Mislang, Angel Marie P.
Mora, Danica V.
Muñoz, Joseph James J.
Submitted to:
Mrs. Rosalie Catanghal R.N.
Table of contents
I. BIOGRAPHIC DATA
II. NURSING HEALTH HISTORY
a. Past Health History
b. Present Health History
c. Family History
III. PATTERNS OF FUNCTIONING
IV. ACTIVITIES OF DAILY LIVING
V. PHYSICAL ASSESSMENT
VI. COURSE IN THE WARD
1. Diagnostics and Laboratories
2. Medications/Drug Study
VII. PATHOPHYSIOLOGY
VIII. ECOLOGIC MODEL
IX. PROBLEMS IDENTIFIED
X. NCP
XI. DISCHARGE PLAN
I. Biographic Data
Name: Mr. L.R.
Address: Valenzuela City Age: 18 yrs. old Gender: Male
Religious Affiliation: Christian
Marital Status: Single Occupation: N/A
(Student)
Room and Bed #: Rm. 311
Chief Complaint: Abdominal pain, DOB, cough
Provisional Diagnosis: Acute Glomerulo Nephritis (AGN), UTI,
Bilateral pleural effusion
Attending Physician: Dr. Mary Calalang
Coping Patterns
According to the client the most stressful event that happen to him is
his situation today because he cannot do what he want and also because it is
his first time to be confined in a hospital. The client stated that “yung mga
hobbies ko katulad ng basketball di ko na magawa dahil nga nandito ako sa
ospital atsaka yung mga sakit ko naman dati e sipon at ubo lang, ngayon
lang ako nagkaron ng ganitong sakit na kailangan iconfine pa.” The client
stated the he manage his stress by just watching DVD and playing basketball
but since he is in the hospital, he manage his stress by texting to his
girlfriend to visit him in the hospital, walking in the hallway and watching TV.
The client also said that he is more open to his mother than to his father. The
client verbalize “mas open ako kay mommy kasi mas kasundo ko si mommy
sa mga bagay pwera lang sa babae.” The client said that he frequently do
have mood swings because of family problems. The client also state that
when he is not in the mood he just kept quiet and eventually his mood
becomes better even without sharing it to any person.
Interaction Pattern
The client said that he is very sociable. The client said that “madali
naman ako makapaghalubilo sa ibang tao kasi sanay naman ako
makipagusap sa mga tao dahil nag part-time model ako dati.” In his family,
the client usually talks to her mother in Dubai atleast 3-4 times a day and
that is the way of his communication to his mother. The client seldom talks
to his father. The client said that “minsan lang kami magusap ni daddy kasi
nagkakasundo lang kami kapag ang topic ay babae pero sa iba hindi na
lalong lalo na pagdating sa luho ko.”
Self-concept
The client said that he feels good about himself even he is confined in
the hospital. He stated that “ok naman ako wala naman nagbago sa
pagtingin ko sa sarili ko kahit na nandito ako sa ospital.” The client says that
he is a pessimistic kind of person because he is going to perform or do
something he always thinks that he cannot do it. The client stated that
“kapag mag peperform o may gagawin sa school ang naiisip ko kagad yung
negative side na mangyayari pero kapag gagawin na nagagawa ko naman
talaga lang na negative ako magi sip sa umpisa.” He rates himself as 9 when
we asked about his self-confidence as 10 being the highest and 1 being the
lowest.
Cognitive Pattern
The client goes to the hospital together with his father for regular
check-up especially for the signs of hypertension because her father does
have hypertension. The client also had a check-up for his tonsillitis because
he frequently had tonsillitis even before he was just a kid.
Emotional Pattern
The client frequently has mood swings because of family problems.
The client stated that he is easily hurt emotionally than physically. When
someone or his classmates teases him he just kept quiet and the suddenly
his anger subsides. He usually shares his problem to his mother than to his
father.
Sexuality
When it comes to the sexual activity the client sated that he do have
sex with his girlfriend before his hospitalization. They do it atleast twice a
week and they both feel satisfied or solved. They practice withdrawal and
10days after the menstruation. The client is not aware of the testicular self
examination.
B. Socio-cultural patterns
Cultural Patterns
The culture of their family is respecting the one who is older than to
him. And his parents usually give them punishment if they do something
wrong. They are not active in any community celebrations.
Significant relationships
The client states that he has a girlfriend that is very supportive to him
and he loves her very much although her mother does not agree to their
relationship.
Recreation patterns
The client stated that his recreational activities are playing basketball
atleast 4 times a week before his hospitalization and watching DVD until
1am.
Environment
The client said that the only problem with their environment before his
hospitalization is the unfinished project of maynilad. The client states that
“ang problema lang naman sa lugar naming e yung mga bungkal na ginawa
ng maynilad tapos hindi naman sinasara basta na lang tinatabunan ng
buhangin. Puro bungkal nga dun sa amin e at ok naman yng lugar naming e
hindi naman magulo o mausok.”
Economic
The client states that his mother works as staff nurse in Dubai while his
father is a supervisor in a company near North station MRT. According to the
client the income of his parents are enough to meet the need of the family.
Reference:
Kozier and Erb’s Fundamentals of Nursing 8th Edition Volume 2 page 1004
C. Spiritual Patterns
Nutrition
Before hospitalization, the client said that he has a good appetite. The
client verbalized “ for breakfast usually 1 cup of milk muna then kakain
ako ng corned beef or tuna pero hindi ko na yun niluluto tapos yung rice
sasabawan ko ng toyo, yung nasa pack, mga ¼ nun pag hindi ako
nakuntento nilalagyan ko pa sya ng suka hangggang sa maghalo yung
alat at asim. Sa lunch, mga 2 gatang ng kanin nauubos ko yung 1 ½ inch
per gatang, half square, ganon din may toyo at suka, pero sa dinner 1 cup
of rice nalang. Tapos mahilig ako sa mga masasabaw na pagkain,
paborito ko yung sinigang lalo na yung taba non tapos may ketchup, mga
kalahating bote ng ketchup nauubos ko.” Mr. L.R said that he only eats
vegetables once a week and fruits at least twice a week. The client also
added that he is consuming at least 1 liter of softdrinks (coke) each meal
and 6 liters of water per day.
Reference:
Kozier and Erb’s Fundamentals of Nursing 8th Edition Volume 2
page 1242-1243
Elimination
Exercise
Reference:
Kozier and Erb’s Fundamentals of Nursing, 8th Edition Volume 2
Hygiene
Substance Abuse
Before hospitalization, the client verbalized “wala po akong bisyo,
hindi po ako umiinom or naninigarilyo. Yung sa gamot naman po,
nagvivitamins lang ako.”
During hospitalization, Mr. L.R. said that since the day he was admitted
in the hospital he sleeps at 9pm and wakes up at 5am. The client
verbalized “mababaw lang yung tulog ko, masakit pa sa ulo.” He said that
he takes a nap for 30 minutes.”
Reference:
Kozier and Erb’s Fundamentals of Nursing 8th Edition Volume 2
Sexual Activity
Reference:
Black and Hawks Medical Surgical Nursing 8th edition p. 858
Predisposing Factors:
Infections: (Post-streptococcal
infection, Viral infections)
Antigen-Antibody product
Deposition of antigen
antibody complex in the
glomerulus
Increased production of
epithelial cell lining the
glomerulus
Medicine:
a.) Encouraged client to take medications as prescribed by his physician, if
any.
b.) Teach patient or the significant others of the different side and adverse
effects of the drugs.
c.) Report any adverse effect when taking the prescribed drug such as
nausea and vomiting or skin allergies.
d.) Instruct him and significant others not to take other medications without
consulting with the physician to prevent any harmful drug-drug
interactions.
Exercise:
a.) Encouraged the patient to engage in at least 30 minutes of moderate-
level activity on most, and preferably all, days of the week, this can lower
or reduced blood pressure.
b.) Encouraged patient to have adequate rest periods and sleep to promote
faster recovery.
Treatment:
a.) Encouraged to decrease fluid intake
b.) Encouraged the patient to comply with the medication as ordered by his
physician.
c.) Explain the importance of adhering to his treatment regimen.
Health Teaching:
a.) Encouraged to elevate the part where there is edema
b.) Tell the patient to notify the physician immediately if there are
unusualities.
c.) Teach the client to follow all the instructions including medications, diet
regimen and do’s and don'ts that was instructed to him by the physician.
d.) Teach the patient to ensure rest for himself as much as possible.
Out- patient referral:
a.) Inform the patient to have follow-up check-ups to prevent further
complications and to update the medical team concerning the progress
of the patient’s condition and to promote continuity of care.
c.) Encourage him to comply with all the modifications and instructions
given to him.
Diet:
a.) Limit fluid intake, Do not consume more than 48 oz.
b.) encouraged Low calorie diet , Low protein , Low sodium diet , Low
potassium diet , Low phosphorus diet , Calcium supplements , Vitamin B
supplements.