I.

INTRODUCTION

A. Current trends about the disease condition

In United States Glomerulonephritis represents 10-15% of glomerular

diseases. Variable incidence has been reported due in part to the subclinical
nature of the disease in more than one half the affected population. Despite
sporadic outbreaks, incidence of poststreptococcal glomerulonephritis has fallen
over the last few decades. Factors responsible for this decline may include better
health care delivery and improved socioeconomic conditions (accessed at
http://www.emedicine.com/emerg/topic219.htm#section~Introduction)

Glomerulonephritis is an inflammation of the kidney’s filtering

mechanisms, called the glomeruli. Glomerulonephritis can be acute, which
means it occurs suddenly, or chronic, meaning symptoms develop gradually and
continue over a number of years. Acute glomerulonephritis is more common in
children between the ages of 2 and 12, particularly boys. Children with frequent
streptococcal infections are at a higher risk of developing acute
glomerulonephritis. Chronic glomerulonephritis is more common in people with
diseases such as hepatitis, lupus, or diabetes. Acute glomerulonephritis often
occurs after a streptococcal infection, such as strep throat. When this is the
cause, the condition is called acute poststreptococcal glomerulonephritis
(APSGN), or postinfectious glomerulonephritis. It can also occur when certain
toxins, such as paints or glues, are inhaled and then excreted through the urine.
While chronic glomerulonephritis occurs as a symptom of certain diseases, its
cause is not known. (accessed at
http://www.hmc.psu.edu/healthinfo/g/glomerulonephritis.htm)

According to science daily.com (may 1 2007) Fish Oil May Help Kidney
Disease Sufferers because fish oils had known anti-inflammatory properties due
to their high concentration of Eicosapentaenoic Acid (EPA). "EPA has been used
successfully in other population groups with chronic inflammation including

1
people with osteoarthritis and cancer cachexia, however the anti-inflammatory
effects have not yet been applied to patients on dialysis "While fish oil won't cure
kidney disease, it may provide a better quality of life for sufferers." (Accessed at
http://www.sciencedaily.com/releases/2007/04/070430094018.htm)

B. Reasons for choosing such case for presentation

As nurses, the ultimate goal is to provide care for all our clients. In this
case study, we were fortunate enough to be in a hospital that emphasizes the
unique aspect of rendering service and that provides us the opportunity to apply
our skills and knowledge while delivering essential health care to patients
reaching out for our care.

With the improved and effective application of knowledge of the health

care provider, the physical, emotional, mental, and social well being will be
augmented and enhanced.

This is the reason why the researchers chose Acute Gromerulonephritis

for a case study, to trace the lifestyle of the client that could have attributed to the
occurrence of the disease on how the outcome of the study would be a great
help in health promotion and prevention of the said kidney disease.

This case study elicited interest among the group most especially that it
provides opportunity to develop their knowledge on Acute Gromerulonephritis
and in the future given the opportunity to handle client with the same condition,
the researchers can take care of their client with competence.

The group also chose this case study because the group is exposed to the
pediatric ward wherein Acute glomerulonephritis is common to children as
mentioned in the statement above. And the group believes that a deeper

2
exploration to the said disease it will give the group a better understanding and to
know a more systematic way of providing care and treatment for patients with the
acute gromerulonephritis.

NURSE CENTERED OBJECTIVES

 Gather pertinent data regarding the patient ands family.
 Perform a thorough physical assessment to help confirm diagnosis of patient
and identify the different signs and symptoms manifested by the patient.
 Explain the different diagnosis and laboratory procedures done by the patient.
 Recognize the different modifiable and non-modifiable factors that led to the
development of brain tumor
 Explain the medical management of acute glomerulo nephritis and identify the
appropriate nursing interventions for each medical management.
 Evaluate the success of condition and different medical and nursing
management.
 Identify and implement the appropriate nursing care plan.
 Document the client’s daily progress.
 Particularize the conclusion and learning derived from working of the case
study.
 Give recommendation based from what was learned in the study.

PATIENT CENTERED OBJECTIVES

At the end of the case study, the patient will be able to:

 Identify the different factors that led to the development of her disease
condition.
 Gain knowledge on the disease condition.
Demonstrate improvement the condition on the different nursing interventions
implemented by the student nurses.

3
II. NURSING PROCESS

A. ASSESSMENT

1. Personal Data
The researchers have interviewed the patient and gathered the following
information. Mrs. U, the patient’s mother, speaks in the behalf of Sushi, the
patient, which is why the researchers were able to collect the data presented.
Sushi is a 10 year old male, the son of Mr. U and Mrs. U. He is a natural
born Filipino and a pure Catholic. Sushi was born on April 8, 1999 in a hospital at
Guagua. The family currently resides in Dau, Lubao Pampanga. According to
Mrs. U, Sushi was admitted on February 21, 2010 in a hospital at Guagua and
was diagnosed with AGN/ Acute Glomerulonephritis.

2. Pertinent Family History

Mr. U is the son of Mr. Z and Mrs. Z. Mr. Z is a hypertensive individual.

Mr. U is married to Mrs. U, the daughter of Mr. Y and Mrs. Y. The couple, Mr. U
and Mrs. U, has 5 children: Elmer, 16 years old was the eldest among the
children, born on June 27, 1993. The mother was hospitalized by the time she
was conceiving because of vaginal bleeding and pre- term contractions. But the
child was born on a normal delivery in the hospital during his term. The mother
stated that it was difficult and painful during the delivery because it was her first
child. The second to the eldest was named Ryan, 13 years old born on May 24,
1996. The child was born as normal delivery in the hospital. The mother stated
that she did not experience any complications while she was conceiving the
child. She stated that it was less painful delivering the baby compared to the first.
The third child was Erika, 13 years old, was also born as normal delivery in the
hospital on February 9, 1997. The fourth child was Sushi, 10 years old, born on
April 8, 1999 and was also a normal delivery. The youngest is Clarence, 6 years
old, born on November 21, 2004, but he was delivered at home. Mrs. U stated

4
that she did not experience any complications with the four children except for
the first child.

The family currently resides in Dau, Lubao. Mrs. U described that their
house was made up of concrete with 2 rooms and a comfort room. Their family is
classified as poor because Mr. U is a Security Guard and Mrs. U is a plain
housewife. All the expenses of the family come from the money earned by Mr. U
from his job.

The family still believes in hilots and albularyos. Their current practice
towards health is that they don’t restrict their children from buying and eating junk
foods and soft drinks since they are not aware of the effects of these foods on
their children’s health. And their source of drinking water comes from a pitcher
pump, which they do not boil for 15- 30 minutes. This means that the water
coming from the pitcher pump may contain microorganisms that may increase
the possibility of acquiring water-borne diseases.

Based from these data gathered, the family can be classified as having a
poor practice towards health.

5
Family Diagram

PATERNAL MATERNAL

Mr. Z Mrs. Z Mr. Y Mrs. Y

Hypertension No known illness No known illness No known illness

Mr. U Mrs. U
No known illness No known illness

Ryan Erika Sushi

13 years old AGN
13 years old 10 years old

Elmer Clarence
LEGEND:
16 years old 6 years old
- Male

- Female

- Patient

- Married 6
3. Personal History

During Mrs. U’s pregnancy on Sushi, she habitually sleeps during

afternoon and she avoids going out at night because she believes that evil spirits
are lurking around at night such as aswang, tiktik, and tikbalang. She always
make use of a blanket whenever she sleeps or takes a nap believing this will
prevent her form having “manas” or edema.

Mrs. U did not experience any complications or difficulties during

conception. She delivered Sushi easier compared to her first delivery. Sushi
weighed 5.5 lbs when he was brought out from her mother’s womb at 4:36 a.m.
of April 8, 1999.

Growth and Development

 Erik Erikson
Sushi, being 10 years of age, is in the Industry vs. Inferiority stage of
Erikson’s psychosocial conflict wherein he expresses his independence with his
actions. At this stage children are eager to learn and accomplish more complex
skills: reading, writing, telling time. They also get to form moral values, recognize
cultural and individual differences and are able to manage most of their personal
need and grooming with minimal assistance (Allen and Marotz, 2003). At this
stage, children might express their independence by being disobedient, using
back talk and being rebellious. Children at this age are becoming more aware of
themselves as individuals." They work hard at "being responsible, being good
and doing it right." They are now more reasonable to share and cooperate. This
stage is shown by his feeling of competence and belief in his own skills.

 Jean Piaget
Sushi is in the Concrete Operational stage of Piaget’s Theory of cognitive
development wherein During this stage, children begin to reason logically,

7
 and organize thoughts coherently. However, they can only think about actual
physical objects, and cannot handle abstract reasoning. They have difficulty
understanding abstract or hypothetical concepts. This stage is also
characterized by a loss of egocentric thinking. One of the most important
developments in this stage is an understanding of reversibility, or awareness
that actions can be reversed. In Sushi’s eating pattern, He learned to feed
himself using a spoon, when his mother gives him a fork, he also knows that
he can feed himself using a fork.

 Sigmund Freud
Based on the patient’s age, he falls under the Latency stage of Freud’s
Psychosexual stages This is a period during which sexual feelings are
suppressed to allow children to focus their energy on other aspects of life. This is
a time of learning, adjusting to the social environment outside of home, absorbing
the culture, forming beliefs and values, developing same-sex friendships,
engaging in sports, etc. This period of sexual latency lasts five to six years, until
puberty, upon which children become capable of reproduction, and their sexuality
is re-awakened. Upon observation, there were no manifestations of this stage
noted from Sushi’s behaviour.

4. History of Past illness

Sushi has no history of recent hospitalization due to sickness. As

verbalized by Mrs. U, he only had fever, cough, and common colds in his past
illness. It was managed by frequent check ups in the health center and by self
medication.

5. History of Present Illness

The reason why the parents rushed Sushi to the hospital was because the
child experienced dizziness in the morning of February 21, 2010. The common
foods eaten by Sushi are junk foods that are rich in sodium or salt content, such

8
as Tempura, Lala crackers, cup noodles, and so on. He also prefers to drink
carbonated drinks like colas or Sprite, and he has minimal water intake
amounting to 300-400mL per day, as cited by Mrs. U. He urinates at a maximum
of 3 times a day. And the color of her urine is tea colored but he has negative
dysuria. Tracing the possibility why he experienced this kind of condition is
because he always buys and eats junk foods and soft drinks from the store. Mrs.
U also stated that the water as their means of drinking comes from a pitcher
pump, wherein they don’t practice boiling the water for at least 15 to 30 minutes.
This is because they lack awareness that the water coming from the pitcher
pump may contain harmful microorganisms that may be the cause why the child
experienced these kinds of complications. He was diagnosed of Acute
Glomerulonephritis (AGN), and was confined in the hospital.

6. Physical Examination

 Initial Assessment (February 23, 2010)

A. GENERAL APPEARANCE:
Sushi, a ten year old male, was born on April 8, 2010. His body built,
height and weight are proportionate to age and health. The group first met Sushi
during the third day of his admission. He was wearing a red shirt and white shorts
upon assessment. He was seen conscious, coherent, but most of the time
uncooperative, unresponsive and hostile with nurses and speech is sometimes
not understandable because He is shy and has very soft voice that is difficult to
hear.

9
Vital Signs are as follows

Time Blood Pressure Pulse Rate Respiration Temperature

8: 00 am 120/80 88 21 36.ºc
12: 00 pm 120/80 85 20 36.5ºc
2:00 pm 120/80 - -
-
4: 00 pm 120/80 107 20 37.ºc

B. PHYSICAL ASSESSMENT:
SKULL AND FACE:
Sushi has round normocephalic shape skull with absence of nodules or
masses. He has symmetrical facial features and facial movements as he was
able to smile, frown, close eyes, show teeth and raise eyebrows. Hair is black
and evenly distributed without flaking.

EYES AND VISON:

Eyebrows are evenly distributed and symmetrically aligned with equal
movements. Eye lashes are also equally distributed and curled slightly outward
and upward. Eyelids close symmetrically with skin intact and no discharges or
discoloration. Bulbar conjunctiva is transparent. Palpebral conjunctiva is shiny,
and pale pink in color. Lacrimal ducts have no edema or tearing upon palpation.
Cornea is transparent, shiny and smooth with visible details of iris. Pupils are
black in color, are round and reactive to light accommodation.

EARS AND HEARING:

Ears are same as the color of facial skin, symmetric and aligned with outer
canthus of eye. Ears are mobile, firm and recoil after being folded. No discharges

10
and obstructions noted upon inspection. He can hear normal voice tones, was
able to hear ticking in both ears.

NOSE AND SINUSES:

Nose is symmetric and straight, with no presence of secretions and no
flaring. It has uniform color and not tender. Nasal septum is intact and in midline.
Facial sinuses are not tender.

MOUTH AND OROPHARYNX:

Maxillary and frontal sinuses are not tender. Lips are pale pink in color,
soft and symmetrical. There is no presence of dental carries. Gums are pink.
Tongue is at the center and pink in color with no lesions or tenderness.

NECK AND JUGULAR VEINS:

Neck muscles are equal in size. He can move head smoothly with no
discomfort. He can shrug shoulders against the resistance of student nurse’s
hands. Lymph nodes are not palpable and trachea is in the midline of neck.
Thyroid gland is not visible upon inspection and ascends during swallowing.
Carotid artery and jugular veins are not distended or visible.

THORAX AND LUNGS:

Symmetrical chest expansion. No bruises or lesions upon inspection. No
lumps noted upon palpation. He has quiet, rhythmic, and effortless respirations.
Full, symmetric excursion,

HEART:
He has normal heart rate and rhythm, no abnormal heart sounds upon
auscultation.

ABDOMEN:

11
 Skin is unblemished and uniform in color. He has audible bowel sounds.
There no masses, lesions and tenderness noted.

UPPER EXTREMITIES:
Skin is uniformly dark brown in color. Muscles are generally equal in size
on both sides with no tremors or contractures. There are no bone deformities or
joint swelling and tenderness. He has normal muscle strength, and minimal
movement against resistance. He can repeatedly and rhythmically touch the
nose. Performs with coordination and rapidity when asked to do the finger to
nose movement. He can rapidly touch each finger to thumb. There is presence of
edema on both hands.

LOWER EXTREMITIES:
Skin color is the same with the upper extremities. The muscles are
generally equal in size on both sides with no tremors or contractures. He was
able to determine ‘sharp’ and ‘dull’ sensations.

NEUROLOGICAL ASSESSMENT
NORMAL ACTUAL
CRANIAL NERVE PROCEDURE
FINDINGS FINDINGS
CN I : Olfactory Ask the client to Client must be Sushi was able to
Type: Sensory identify aromas able to identify the identify the scent
Function: Smell with eyes closed. scent of an agent of alcohol with
with eyes closed eyes closed.
when asked to
smell it.
CN II: Optic Ask the client to Client must be Sushi was able to
Type: Sensory read a number able to read a read the number
Function: Vision written on a piece number correctly correctly and
of paper at a written on a piece clearly at a given
given distance. of paper at a distance
given distance.

12
CN III: Make use of Pupils should Sushi pupils
Oculomotor penlight in order constrict (+ constricted
Type: Motor to test papillary PERRLA ) consensually. He
Function: Pupil reaction and consensually was able to open
constriction and instruct the client once light passes and close her
raising eyelids to open and close through. Eyelids eyelids.
eyelids. should open and
close.
CN IV: Trochlear Instruct client to Client must be Sushi was able to
Type: Motor move eyes able to follow the follow the pen’s
Function: Oblique downward and pen’s movement movement
movement of the upward without downward and downward and
eye moving head. upward without upward without
moving head. moving his head.
CN VI: Abducens Tell the client to Client should be Sushi was able to
Type: Motor devoid his head able to follow the follow the lateral
Function: Lateral steadily and follow lateral movement movement of the
eye movement the pen’s direction of the pen pen.
CN VII: Facial Ask client to Client should be Sushi was able to
Type: Motor smile, frown, and able to smile, smile, frown and
Function: raise the frown, and raise raise eyebrows
Movement of eyebrows. the eyebrows without difficulty.
muscles of the face without difficulty.
CN IX: Instruct client to Client should be Sushi was able to
Glossopharyngea swallow. able to swallow swallow without
l without difficulty. difficulty.
Type: Motor
Function:
Pharyngeal
movement and
swallowing
CN XI: Accessory Ask the client to Client should be Sushi was able to
Type: Motor shrug shoulders able to shrug shrug shoulders

13
 Function: against shoulders against against
Movement of resistance. resistance. resistance.
shoulder muscles
CN XII: Instruct the client Client should be Sushi was able to
Hypoglossal to protrude tongue able to protrude protrude his
Type: Motor and move it tongue and move tongue and move
Function: laterally, it laterally, it laterally,
Movement of downward and downward and downward and
tongue, strength of upward. upward. upward.
the tongue

7. DIAGNOSTIC AND LABORATORY PROCEDURES

a. Blood Chemistry – a study composition of materials

suspended in blood plasma (e.g., glucose, urea nitrogen,
bilirubin, creatinine and cholesterol) can be used to assess
the functioning of the body systems. It is routinely done
when blood is taken and additional tests are available
(http://en.wikipedia.org).

DATE
DIAGNOSTIC
ORDERED INDICATIONS
OR NORMAL ANALYSIS AND
DATE OR RESULTS
LABORATORY VALUES INTERPRETATION
RESULTS PURPOSES
PROCEDURES
IN

BLOOD
CHEMISTRY

Serum creatinine
♥ Serum Date >> to assess and BUN level is
Creatinine Ordered: glomerular BUN: 14.5 BUN: 7-18 not affected. This
-provides a February filtration indicates that there
more sensitive 22, 2010 >> to screen Creatinine: Creatinine: is no significant
measure of Date for renal 1.1 0.7-1.3 kidney damage that

14
renal damage Results In: damage has occurred.
than BUN February
levels 22, 2010

NURSING RESPONSIBILITIES:
Before:
 Check for the doctor’s order.
 Inform the patient/SO before doing the procedure. Explain the importance
and uses of such procedure.
 Inform the patient/SO that there is a need to restrict food or fluids for about
6 to 8 hours before the test.
 Tell the patient that she may experience transient discomfort from the
needle puncture.
 Fill up the laboratory request form properly and send it to the laboratory
technician during the collection of sample or specimen.

During:
 Explain that the test measures substances that are suspended in the
blood which may serve as important parameters for diagnosing different
illnesses.
 Explain that the test will help evaluate if these are within normal range in
the blood.
 Adhere to standard precautions.

After:
 Apply pressure to the venipuncture site.
 Encourage enough rest if she is experiencing fatigue.
 Observe for signs of further bleeding on the venipuncture site.
 Chart time of collection of blood specimen.

15
  Attach result to the chart as soon as they are available.

b. Serum Electrolyte Analysis - measurement of electrolytes

is a commonly performed diagnostic procedure, performed
via blood testing or urinalysis (http://en.wikipedia.org).

DATE
DIAGNOSTIC OR ORDERED INDICATIONS
NORMAL ANALYSIS AND
LABORATORY DATE OR RESULTS
VALUES INTERPRETATION
PROCEDURES RESULTS PURPOSES
IN

MISCELLANEOUS Date ♥ Sodium 148.2 F: 135- Result is within

SEROLOGICAL Ordered: >> to monitor 150mEq/L normal range. This
TEST February detect Na may indicate that
22, 2010 level and kidney damage is
imbalance not severe and the
Date >> this serum sodium
Results In: test for Na reabsorption and
February levels excretion is not
22, 2010 evaluate fluid compromised.
and
electrolyte
balance as
well as renal
or adrenal
disorder.

♥ Potassium
>> to check 4.31 F: 3.5- Result is within
potassium 5.2mEq/L normal value.
level There is no
and to detect presence of
presence of hypokalemia or
hypokalemia hyperkalemia. This
or may indicate that
hyperkalemia kidney damage is
and to monitor not severe
potassium
level during
health

16
 problems.
>> this serum
test for K
levels
evaluate fluid
and
electrolyte
balance as
well as renal
or adrenal
disorder.

NURSING RESPONSIBILITIES:
Before:
 Check for the doctor’s order.
 Inform the patient/SO before doing the procedure. Explain the importance
and uses of such procedure.
 Inform the patient/SO that there is no need to restrict food or fluids before
the test.
 Tell the patient that she may experience transient discomfort from the
needle puncture.
 Fill up the laboratory request form properly and send it to the laboratory
technician during the collection of sample or specimen.

During:
 Explain that the test will help evaluate if there are enough electrolytes
within the body and if supplementation may be indicated.
 Adhere to standard precautions.

After:
 Apply pressure to the venipuncture site.
 Encourage enough rest if she is experiencing fatigue.

17
  Observe for signs of further bleeding on the venipuncture site.
 Chart time of collection of blood specimen.
 Attach result to the chart as soon as they are available.

c. Hematology – is the branch of pathology, clinical laboratory

medicine, and pediatrics that is concerned with the study of
blood, the blood-forming organs and blood diseases.
Hematology includes the study of etiology, diagnosis,
treatment, prognosis, and prevention of blood diseases. The
laboratory work that goes into the study of blood is
performed by a medical technologist
(http://en.wikipedia.org).

DATE
DIAGNOSTIC
ORDERED INDICATIONS
OR NORMAL ANALYSIS AND
DATE OR RESULTS
LABORATORY VALUES INTERPRETATION
RESULTS PURPOSES
PROCEDURES
IN

18
 COMPLETE Hemoglobin level is
BLOOD within the normal
COUNT (CBC) range. This reflects
OR that fluid excess
HEMATOLOG >> to monitor may not be that
Y Hgb value in severe and the
the RBC renal function in the
>> to suggest production of rbc is
Date the presence not affected since
♥ HgB Ordered: of body fluid 120 F: 120- this may indicate
-is a component February deficit or 170gm/L that there are
or red blood cell 22, 2010 excess due to enough rbc which
that carries elevated or is the oxygen
oxygen and decreased carrying capacity of
CO2 to and form Date Hgb level the blood
tissues Results In: >> to monitor
composed of February the iron status
alpha and beta 22, 2010 and oxygen-
protein carrying
components capacity of the
necessary to blood
pick up and .
release Oxygen Hematocrit level is
Date >> to aid within normal
Ordered: diagnosis of .36 F: 0.37- range.
♥ Hct February abnormal 0.47 L/L This indicates that
-measures the 22, 2010 states of there is no
percentage by hydration hemodilution due to
volume of Date (dilution or possible presence
packed red Results In: concentration) of fluid excess
blood cells in a February and anemia.
whole blood 22, 2010 >>It measures
sample the
concentration
of RBC within
the blood
volume and is
expressed as
a percentage

Date >> to detect

♥ WBC Count Ordered: infection or 13.3 F:5- WBC count is
-it measures February inflammation 10x109 above normal

19
 the number of 22, 2010 >>this blood range. An
white bleed test evaluates increased count
cells (WBC) or the number of (leukocytosis)
leukocytes in a Date condition and commonly signals
cubic millimeter Results In: differentiates infection, such as
of blood February causes of an abscess,
22, 2010 alteration in meningitis,
the total WBC appendicitis, or
count tonsillitis; or may
including result from
inflammation, leukemia,and
infection and tissue necrosis
tissue caused by burns,
necrosis. myocardial
infarction, or
gangrene

Date >> to
♥ Lymphocytes Ordered: determine 0.20-0.40
-are produced February bacterial 0.21
by the lymphoid 22, 2010 infection
tissue and they >> produces
participate in antibodies; There is no
humoral Date responsible increase in
response; Results In: for allergic concentration as
produces April 12, reactions per lymphocyte
antibodies; 2008 count.
responsible for
allergic
reactions

20
NURSING RESPONSIBILITIES:
Before:
 Check for the doctor’s order.
 Inform the patient/SO before doing the procedure. Explain the importance
and uses of such procedure.
 Inform the patient/SO that there is no need to restrict food or fluids before
the test.
 Tell the patient that she may experience transient discomfort from the
needle puncture.
 Fill up the laboratory request form properly and send it to the laboratory
technician during the collection of sample or specimen.

During:
 Explain that the test measures a part of the blood that carries oxygen.
 Explain that the test will help evaluate if there are enough RBC in the
blood.
 Adhere to standard precautions.

After:
 Apply pressure to the venipuncture site.
 Encourage enough rest if she is experiencing fatigue.
 Observe for signs of further bleeding on the venipuncture site.
 Chart time of collection of blood specimen.
 Attach result to the chart as soon as they are available.

d. Urinalysis - (or "UA") is an array of tests performed on

urine and one of the most common methods of medical
diagnosis. A part of a urinalysis can be performed by using

21
 urine dipsticks, in which the test results can be read as color
changes (http://en.wikipedia.org).

DATE
DIAGNOSTIC
ORDERED INDICATIONS
OR NORMAL ANALYSIS AND
DATE OR RESULTS
LABORATORY VALUES INTERPRETATION
RESULTS PURPOSES
PROCEDURES
IN

URINALYSIS Date This is done Color: yellow Yellow- Slightly abnormal in

Ordered: as a general orange color. Suggests
February screening to signs of
21, 2010 check for concentration of
early signs of urine
Date disease. It
Results In: may also be
February used to
21, 2010 monitor Transparency: Turbidity in urine
kidney slightly turbid Turbid transparency may
disease. indicate presence
of RBC , albumin
and bacteria.

Specific Result within

gravity: 1.020 1.003- normal range.
1.035 Urine is not
concentrated or
packed with other
element such as
proteins.

Pus cells: Should May indicate

6-8 HPF be infection.
negative

Albumin: Negative Proteinuria

Positive suggests renal
affectation
specifically
impairment in the
permeability of the
glomelular

22
 capillaries.

Sugar: Negative Normal finding.

negative

R B C: NONE This indicates

14-18 damage in the
kidney. It could
indicate formation
of lesions in the
kidney and
increased in the
permeability of the
glomelular
membrane.

NURSING RESPONSIBILITIES:
Before:
 Check for the doctor’s order
 Inform the patient/SO before doing the procedure. Explain to the patient’s
SO the importance of the test.
 Inform the patient/SO that there is no need to restrict food or fluids before
the test.
 Explain to the patient’s So that the laboratory procedure is non-invasive;
no pain will be felt.

During:
 Assist patient in going to bathroom or CR.

23
  Describe the procedure for collecting a clean-catch or midstream
specimen.
 Advise the patient’s SO to wash patient’s genitalia prior to collection of
specimen.

After:
 Chart time of collection of urine specimen.
 Attach result to the chart as soon as they are available.
 Record and document findings.

 Renal Ultrasound
Date Ordered: February 22, 2010
Date Results Received: February 22, 2010
Indication: The kidney is ultrasonographically evaluated to diagnose and locate
renal cysts, to differentiate renal cyst from solid renal tumors, to demonstrate
renal and pelvic calculi, to document hydronephrosis, and to guide a
percutaneously inserted needle for cyst aspiration or biopsy. Ultrasound of the
urologic tract is also used to detect malformed or or ectopic kidneys and
perinephric abscesses.
Result:
Both kidneys normal in size and parenchymal echogenecity with intact central
echo complexes. The right kidney measures 8.6x4.2x4.0 cm with cortical
thickness of 1.2 cm while the left measures 8.8x3.9x3.6 cm with cortical
thickness of 1.5 cm. The renal parenchyma thickness is within normal limits. No
mass, lesions or calculus noted.

Impression:
Normal kidneys

Nursing Responsibilities:

24
PRIOR TO:
1. Explain the procedure to the patient.
2. Tell patient that fasting may or may not be required, depending on the
organ to be examined. No fasting is required for ultrasonography of the
kidneys.
DURING:
1. Note the following procedural steps:
 The patient is placed on the ultrasonography table in prone or supine
position depending on the organ to be exmined.
 A greasy conductive paste is applied to the patient’s skin to enhance
sound wave transmission.
 A ttransducer is placed over the skin.
 Instruct the patient to be still or instruct the SO to keep the client calm.
2. The test is completed in approximately 20 minutes.
3. Tell the patient that no discomfort is associated with the procedure.

AFTER:
1. Remove the coupling agent (grease) from the patient’s skin.
2. Note that if a biopsy is done, refer to biopsy of the specific organ.

III. ANATOMY AND PHYSIOLOGY

The Human Renal System

The human renal system is made up of two
kidneys, two ureters, the urinary bladder,
and the urethra. In addition to the production
of urine the renal system has many other
functions.

One quarter to one fifth of cardiac output

passes through the kidneys at all times. This

25
means that the kidneys filter approximately 1.2 liters of blood every minute. It is
therefore not surprising that even slight abnormalities of renal function quickly
lead to electrolyte disturbances. If left untreated death will occur.

The Kidneys
The kidneys are two bean shaped organs of the renal system located on the
posterior wall of the abdomen one on each side of the vertebral column at the
level of the twelfth rib. The left kidney is slightly higher than the right. Human
kidneys are richly supplied with blood vessels which give them their reddish
brown color. The kidneys measure about 10cm in length and, 5cm in breadth and
about 2.5 cm in thickness.

The kidneys are protected by three highly specialized layers of protective tissues.
The outer layer consists mainly of connective tissue which protects the kidneys
from trauma and infection. This layer is often called the renal fascia or fibrous
membrane. The technical name for this layer is the renal capsule. The next layer
(second layer from the exterior) is called the fascia and it makes a fibrous
capsule around the kidneys. This layer connects the kidneys to the abdominal
wall. The inner most layer is made up of adipose tissue and is essentially a layer
of fatty tissue which forms a protective cushions the kidney; and the renal
capsule (fibrous sac) surrounds the kidney and protects it from trauma and
infection.

Blood and Nerve

Supply:
The kidneys receive their
oxygenated blood supply
from the renal arteries
which come off the
abdominal portion of the
aorta. Venous blood from
the kidneys drains into
the renal veins to join the
abdominal portion of the
inferior vena cava.

26
The hilum of the kidneys is located toward the smaller curvature. The opening in
the hilum allows for the entry and exit of blood vessels and nerves. The funnel
shaped extension of the kidneys is called the renal pelvis and it connects the
kidneys to the two ureters. This structure facilitates the collection of the urine
from the kidneys and drainage to the urinary bladder.

The ureters are tubes that are 25-30cm long and lined with smooth muscle.
These tubes help carry urine to the bladder. The muscular tissue helps force
urine downwards. They enter the bladder at an angle, so urine doesn't flow up
the wrong way.

The functional parts of the kidneys are divided into two distinct regions. The outer
region is reddish brown in color and is called the renal cortex. This is where the
nephrons of the kidney are located. The inner layer of the kidney is more pinkish
in color and is called the renal medulla. The renal cortex houses the functional
units of the kidneys called nephrons. The inner area of the kidneys is supplied by
a small blood vessel network called the vasa recta.

The Nephron
The nephron is a functional part of the kidneys. The Glomerulus is a collection of
capillaries which are surrounded by the Bowman's capsule. The afferent arteriole
enters this capsule and the efferent arteriole leaves it. In the glomerulus the
blood pressue is high and it pushes small structured molecules out (water, salts,
glucose and urea). However larger molecules (Proteins and glycogen) stay within
the capillary network. The particles which are pushed out with water (filtrate)
enter the proximal convoluted tubule. This portion is convoluted and broad. The
following portion is straight and narrow; hence it is called the straight collecting
tubule, also referred to as the Loop of Henle. This portion is located in the renal
medulla.

The collecting tubule upon re-entry into the renal cortex passes by the efferent
arteriole. The macula densa is the final part of the ascending collecting tubule
very closely. The filtrate is selectively reabsorbed in the distal broad convoluted
and the proximal narrow straight tubules. Water and salts are reabsorbed in the
Loop of Henle. Urine concentration occurs here.

27
Proximal tubule is broad and convoluted. It is located in the renal cortex. Distal
tubule is narrow and straight. It forms the Loop of Henle and is located in the
renal medulla.

When the filtrate arrives in the distal tubule water is reabsorbed. However,
hydrogen ions, ammonia, histamines, and certain antibiotics are excreted into the
distal tubule. This process is selective and involves the expansion of energy i.e.
ATP is used up. It is called tubular excretion.

THE URINARY BLADDER

The urinary bladder is located midline in

the abdominal pelvis. It is a pyramid
shaped muscular organ. The main function
of the bladder is to collect and store urine.
The stored urine will be excreted through
the urethra when the controlling sphincters
are relaxed after receiving signals from the
brain. In men the urethra is much longer, is
surrounded by the prostate gland and the
enlargement of this gland can cause
problems with the excretion of urine. The
normal bladder can hold up to 500 mls of
urine. In patients with urinary retention the
bladder may be larger. The bladder has
three openings, two ureteral openings to receive urine from the kidneys and one
urethral opening to drain the urine. These openings form the trigone of the
bladder. This area is smooth and triangular shaped.

The trigone is sensitive to expansion (stretch) which occurs as the bladder fills
with urine. When stretched to a certain degree, the urinary bladder signals the
brain to empty its contents. When there are problems with the control or
sphincter muscles the patient many experience urinary incontinence. As the
bladder fills more the signals become more intense.

28
The smooth muscle of the bladder is called the detrusor muscle. The urethral
sphincter at the base of the bladder consists of ring like muscles which facilitate
its opening and closing. When the bladder is full stretch receptors in the bladder
send signals to the brain. When the brain receives these signals (indicating that
the bladder is full) the sphincter relaxes and urination occurs. For urination to
occur the detrusor muscle must contract and the urethral sphincter muscle must
relax at the same time.

The detrusor muscle is unique in the sense that it is capable of distension to

accept large quantities or urine without increasing the internal pressure. This
allows much larger volumes of fluids to be collected in the bladder (700 to
1000ml) without causing back pressure and damage to the kidneys.

The urinary bladder is supplied with arteries to supply oxygenated blood vessels.
The common arteries which supplies the bladder are the vesical, the obturator,
uterine, gluteal and vaginal arteries. A venous network drains the blood to the
abdominal iliac vein.

The voluntary muscles of the bladder are under the control of the Central
Nervous system. The controls are located in the brain (voluntary) and in the
spinal cord (involuntary).

The Urethra
The urethra is a tube like organ which drains urine from the bladder to the
exterior. It is lined with endothelium and surrounded by involuntary muscles. In
females it is about 5 to 6 cm long. Generally it is 6mm wide in healthy patients. In
males it is 15 to 22 cm long. It begins at the base of the bladder and extends to
the tip of the penis. Since the female urethra is shorter and located close to the
vagina it is subjected to frequent urinary tract infections.

The internal pudendal and vaginal arteries supply arterial blood to the urethra in
females. In males the blood supply is slightly different. The inferior vesical and
middle rectal arteries supply the bulk or arterial blood. The venous return follows
these blood vessels. Nerve innervation: the pudendal nerve.

Functions of the Renal System

29
The renal system has many functions. The following are the best known. Each is
discussed under a separate subtitle because the functions are varied and
complex:

1. Excretion of urea, a by product of protein metabolism

2. Regulations of the amount of water which stays in the body
3. Kidneys maintain the pH balance of the human body
4. Produce EPO hormone which has a role in the production of Red
blood cells and s like
5. Produce the enzyme rennin. This enzyme has a role in the
maintenance of blood pressure.

a. Urine production and

b. water regulation:
These are important
functions of the different
parts of the nephrons.
They filter blood of its small
molecules and ions and
make urine. During this
process it reclaims useful
minerals and sugars. In
one day (24hrs) the
kidneys reclaim 1,300 g of
NaCl, 400 g of NaHCO3
and 180 g of glucose and
180 liters of water. These are the constituents which entered the tubules during
the filtration process.

c. Maintain pH value of human body: The human body is designed to function

optimally at a pH value of 7.35 to 7.45. Death will occur if pH drops below 6.8 or
rises above 7.8. It is for this reason that pH values are checked frequently during
acute illnesses. pH is maintained by buffers dissolved in the blood. However, the
kidneys and the lungs play a vital role in removing the H+ ion from the body.
Metabolic Acidosis occurs when the kidneys fail to remove the H+ ions.

30
Respiratory acidosis occurs when the lungs fail to remove the excess of CO2
from circulation.

d. Hormone production: Kidneys produce two hormones known as

erythropoietin (EPO), and calcitriol. They also produce the enzyme known as
rennin.

Erythropoietin (EPO): Is a hormone which is produced by the kidneys. It is

needed in the bone marrow for the formation of red blood cells. Chemically EPO
is a glycoprotein with a molecular weight of 34,000. A glycoprotein is a protein
with an attached sugar molecule.

Highly specialized cells of the kidney which are sensitive to low oxygen levels in
the blood produce EPO. The EPO subsequently stimulates the bone marrow to
produce RBCs to increase O2 carrying capacity. This also leads to greater
production of hb. Hb is the molecule which facilitates the transport of oxygen by
the cardiovascular system.

The EPO gene is located on chromosome 7, band 7q21. Some EPO is also
produced in the liver. Normal levels of EPO are 0 to 19mU/ml (milliunits per
milliliter). Elevated levels of EPO indicate polycythemia. Lower levels are seen in
chronic renal failure. EPO is often prescribed to Renal Failure Patients.

Kidneys have a role in the manufacture of vitamin D (Calcitriol)

 Calcitriol is 1,25[OH]2 = Vitamin D3, the active form of vitamin D.
 Vitamin D3 (Cholecalciferol): Is synthesized in skin when it is exposed to
sunlight.
 Vitamin D2 (Ergocalciferol) is a synthetic vitamid D derivative
 Both vitamin D2 and D3 are hydroxylated in the kidneys into Calcitriol.

Vitamin D regulates Calcium and Phosphorus levels in blood by promoting their

absorption from the food in the intestines and promoting re absorption of Calcium
in the kidneys.

31
Deficiency Disorders: Insufficient calcitriol prevents normal deposition of calcium
in bone. In childhood, this produces the deformed bones characteristic of rickets.
In adults, it produces weakened bones causing osteomalacia.

The commonest causes for vitamin D deficiency are inadequate dietary intake
and insufficient exposure to the sun. A rare inherited mutant gene also interferes
with the production of the enzyme which converts 25[OH] vitamin D3 into
calcitriol. Some inherited rickets are also caused by two defective genes for the
calcitriol receptor.

e. Renin : Is an enzyme which is in the juxtaglomerular cells of the

juxaglomerualr apparatus of the renal system. This occurs when: a. the
circulating blood volume is low or b. or serum NaCl concentrarion is low.
Overproduction causes hypertension and underproduction causes hypotension.

Sympathetic stimulation of Beta 1 and Alpha 1 adrenergic receptors on the JGA

cells also bring about the production of renin. Normal concentration is 1.0 to 2.5
mg/ml.

Male Urethra
In males, the urethra is a common outlet for the reproductive system and
urinary elimination. The prostate gland, although not a direct part of the urinary
system, is a major cause of urinary dysfunction in men. Located below the
bladder neck, the prostate completely enlarges, it constrict the urethra and
obstruct the outflow of urine.
The male urethra is about 20 cm long and is divided into three main
sections. The prostatic urethra extends about 3 cm below the bladder neck, the
ejaculatory ducts of the membranous urethra is about 1 to 2 cm in length and
ends where the muscle layer forms the external sphincter. The distal portion is
the cavernous (penile) urethra. Approximately 15 cm long, it travels through the
penis to the urethra orifice at the tip of the penis; it is also lined with epithelial
cells.

32
 IV. THE PATIENT’S ILLNESS
a. Pathophysiology
Book-centered

Predisposing Factors: Antigen (group A beta-hemolytic

streptococcus) Precipitating Factors:
- common among
children older than 2 - diet: high sodium
years old but can occur
- poststreptococcal infxn
at any age
- predominantly among - skin infection
males Antigen-antibody product
- heredity

Deposition of antigen- antibody

complex in the glomerulus

Increased production of epithelial

cells lining the glomerulus

Leukocyte infiltration of the

glomerulus

Thickening of the glomerular filtration

membrane

Scarring and loss of glomerular

filtration membrane
33
Decreased
Acute
glomerular
Renal Failure
filtration rate
 Client-centered PACHECK KE PA KANG KUYA KU

b. Synthesis of the Disease

b.1. Definition of the Disease

Acute glomerulonephritis is a kidney disease that results from

inflammation of the glomerulus, a small condensed group of blood vessels, which
serves to filter the blood. Acute glomerulonephritis results in compromised kidney
function and, at times, overt kidney failure. An immunologic response to an
infection (usually streptococcal) which damages the renal glomeruli. It can be
initiated by other bacterial and viral infections. This is an immune complex,
hypocomplementemic glomerulonephritis. Most common in children.
Characterized by diffuse inflammatory changes in the glomeruli and clinically by
the abrupt onset of hematuria with red blood cell casts, and mild proteinuria.
Accompanied in many cases by hypertension, edema, and azotemia. AGN is the
most serious and potentially devastating form of various renal syndromes

To further understand, what AGN is, we have to take a look of what might be the
cause for the said disease; Glomerulonephritis is an important cause of renal
impairment accounting for 10%–15% of cases of end stage renal failure in the
USA, following only diabetes and hypertension in importance. In defining acute
glomerulonephritis, we have chosen to discuss those glomerular diseases that
may present with a nephritic syndrome—that is with haematuria, proteinuria, and
impaired renal function together with hypertension, fluid overload, and oedema.

34
Their pathology involves intraglomerular inflammation and cellular proliferation
with secondary renal impairment over days to weeks. This definition excludes
glomerular diseases without cell proliferation or nephritic presentations, such as
minimal change disease, membranous nephropathy, and focal segmental
glomerulosclerosis that can, none the less, chronically compromise renal
function. In primary glomerulonephritis, disease is almost entirely restricted to the
kidneys (as in IgA nephropathy or post-streptococcal glomerulonephritis) while in
secondary glomerulonephritis it occurs in association with more diffuse
inflammation (as in systemic lupus erythematosus or systemic vasculitis). Prompt
diagnosis of glomerulonephritis is vital as patients with even mildly impaired renal
function, hypertension, and urinary abnormalities may rapidly lose kidney function
if not treated urgently.

Although our understanding of the causes of glomerulonephritis is still at a basic

level, inflammation is thought to be autoimmune mediated and involve both
cellular and humoral immune systems. In each case a unique initiating stimulus
(occurring by one of at least four different mechanisms) is followed by a common
pathway of inflammatory and subsequently fibrotic events. In antiglomerular
basement membrane disease, patients produce antibodies that react directly with
the specialised basement membranes of the lung and glomerulus. In post-
streptococcal glomerulonephritis antibodies are formed not to an endogenous
antigen but to an exogenous streptococcal antigen planted in the glomerulus at
the time of infection. In systemic lupus erythematosus and IgA nephropathy, the
antigen antibody reaction occurs not only in situ in the glomerulus but also
systemically with subsequent trapping of complexes in the kidney. Finally in the
glomerulonephritis seen in small vessel vasculitis, cellular rather than humoral
immune responses are thought to be stimulated, with inflammation often
originating in organs distant to the kidney with a subsequent renal influx of T-cells
and macrophages as crescentic glomerulonephritis evolves.

Whatever the initial events, common inflammatory pathways follow with activation
of the coagulation and complement cascades and production of proinflammatory

35
cytokines.Activation of complement components leads to chemotaxis of
inflammatory cells and cell lysis (via the membrane attack complex). The
coagulation cascade leads to fibrin deposition. Cellular proliferation of parietal
epithelial cells in Bowman’s space together with an influx of inflammatory cells
such as macrophages and neutrophils results in acute glomerular crescent
formation. Cytokine release leads to activation of the glomerular cells themselves
and a change in endogenous cell phenotype results in cell proliferation,
overproduction of proteases and oxidants, and laying down of extracellular matrix
with subsequent fibrosis, perhaps stimulated by factors such as platelet derived
growth factor and transforming growth factor beta. Failure of apoptosis (the
normal mechanism allowing resolution of inflammation) is also important. Finally
in a chronic phase of damage, haemodynamic alterations lead to hyperfiltration
and intraglomerular hypertension with subsequent development of glomerular
sclerosis and chronic interstitial damage. Thus a process that is initially
inflammatory with the potential to resolve may progress to fibrosis and
irreversible scarring. This dynamic picture may partly explain why in post-
streptococcal glomerulonephritis where antigen is rapidly cleared, even acute
renal failure can be expected to resolve spontaneously. By contrast in hepatitis C
associated mesangiocapillary glomerulonephritis (MCGN) where viral infection is
chronic, antigen cannot be cleared and renal damage may chronically progress.

b.2. Modifiable/ Non – Modifiable Factors

Modifiable Factors:
Streptococcal Infection
Acute glomerulonephritis results from entrapment and collection of
antigen-antibody complexes (produced as an immunologic mechanism in
response to streptococci) in the glomerular capillary membranes, inducing
inflammatory damage and impeding glomerular function.
High Sodium Diet
Poor Hygiene

36
Non – Modifiable Factors:
Age
Acute glomerulonephritis can occur at any age. However, it is most
common in children older than two years old.
Gender
Acute glomerulonephritis is most common in males.
b.3. Signs and Symptoms with rationale

[Book Based]

Hematuria - occurs the RBC leaves the capillary due to the increase
permeability on the glomerular capillary. Decrease RBC in the body can lead
to Anemia.

Proteinuria - Protein is not normally found in the urine of healthy persons, but
because of the abnormal permeability of the glomeruli due to damages
protein enters to the glomerolus and excretes through urine.

Edema - Usually occurs because of buildup of salt and water, Fluid and salt
overload from decreased GFR, decline in urine output.

Fever - Due to the inflammation of the kidney tubules (glomeruli) that filters
waste products from the blood following streptococcal infection such as
tonsillitis, there will be a release of chemical mediators which stimulates the
hypothalamus to regulate body temperature.

Hypertension - is a result of increased sodium in the body and the

released of renin causing the release of Angiotensin.

Decrease tissue perfusion - due to the effect of rennin-angiotensin system

which causes vasoconstriction.

37
 [Patient – Centered]

The patient manifested the following Hematuria (+), Protenuria, elevated

blood pressure.

b.4. Health Promotion and Preventive Aspects of the Disease

o Antibiotic therapy
Antibiotic therapy (penicillin) is the agent choice to treat poststreptococcal
glomerulonephritis. It is also used prophylactically after streptococcal infections
to prevent further damage.
o Teaching patients self-care
 Upon discharge, patient education should emphasize the importance of
close follow-up care.

 Indicate that strenuous exercise should be avoided because exercise can

induce proteinuria, hematuria, and cylindruria (renal cylinders or casts in
the urine) in healthy individuals.

 The patient should avoid high-potassium foods. Fluid and diet restrictions
must be reviewed with the patient to avoid worsening of edema and
hypertension.
 Instruct patient to notify physician if symptoms of renal failure occur
(fatigue, nausea, vomiting, diminishing urine output) or at the first sign of
any infection.
o Continuing Care
The importance of follow-up evaluation of blood pressure, urinalysis for
protein and BUN and serum creatinine levels to determine if the disease has
progressed is stressed to the patient and SO. A referral for home care may be
indicated; a visit from a home care nurse provides an opportunity for careful

38
assessment of the patient’s progress and detection of early signs and symptoms
of renal insufficiency. If corticosteroids, immunosuppressants or antibiotic
medications are prescribed, the home care nurse or the nurse in the outpatient
setting uses the opportunity to review the dosage, desired actions and adverse
effects of medications and the precautions to be taken.
V. THE PATIENT AND HIS CARE
A. MEDICAL MANAGEMENT
a. Intravenous Fluid

Medical Date ordered, General Indications or Client’s

Management/ date Description Purposes response to
Treatment performed, the treatment
date changed
D5W 500 cc to Bottle # 1: D5W is The patient
KVO Date Ordered: hypertonic to remain on bed
February solutions but complains
21,2010 (10:20 containing less of pain in the IV
PM) than 5% site.
dextrose. This
Date medication is a
Performed: solution given
February 21, by vein
2010 (through an IV).
Time started: It is used to
9:15 PM supply water
and calories to
the body. It is
Date Changed: also used as a
February 23, mixing solution
2010 (diluent) for
1: 50 AM other IV

39
 medications.
Dextrose is a
natural sugar
found in the
body and
serves as a
major energy
source. When
used as an
energy source,
dextrose allows
the body to
preserve its
muscle mass.

D5 LRS 500 cc Bottle # 2: Lactated When The patient

x KVO Date Ordered: Ringer’s administered remains relaxed
February Solution is a intravenously, with adequate
23,2010 sterile, these solutions hydrating
Time started: nonpyrogenic, provide sources status.
1:50 AM isotonic of water and
solution in a electrolytes.
Date single dose Their
Performed: ARTHROMATI electrolyte
February C plastic content
23,2010 container for resembles that
use as an of the principal
arthroscopic ionic

40
 irrigating constituents of
solution. Each normal plasma
liter contains and the
6.0 g Sodium solutions
Chloride, USP, therefore are
(NaCl), 3.1 g suitable for
Sodium Lactate parenteral
(C3H5NaO3), replacement of
300 mg extracellular
Potassium losses of fluid
Chloride, USP, and
(KCl), and 200 electrolytes,
mg Calcium with or without
Chloride, USP, carbohydrate
(CaCl2•2H2O). calories.
pH 6.5 (6.0 to
7.5).
Milliequivalents
per liter:
Sodium - 130,
Potassium - 4,
Calcium - 3,
Chloride - 109,
Lactate - 28.
Osmolarity 273
mOsmol/L
(calc.).

D5W 500 cc x Bottle # 3:

KVO Date Ordered:
February 23,

41
 2010 (10:30
AM)

NURSING RESPONSIBILITIES:
Prior to the procedure:
 Introduce yourself to the patient and explain the procedure.

 Check the doctor’s order

 Prepare the necessary materials

 Proper hand washing

 Observe sterile technique before performing the insertion

During the Procedure:

 Use the appropriate gauge

 Check for a good site for IVF insertion

 Set the IV regulation on its appropriate drop factor

After the Procedure:

 Secure the placement of IVF infusion

 position the hand in proper position

 Regulate IVF

 Check the IV level

 Perform proper documentation of the procedure

42
 b. Drugs

Name of Date Route of General Action, Indications or Client’s

Drugs, ordered, Administration, Functional purposes response to
Generic Date Dosage, Classification, meds w/ ac
Name, Performed, frequency of Mechanism of S/E
Brand Date Administration action
Name Changed
Generic Date Furosemide 20 General Action: May be used The patient
Name: ordered: mg IV STAT for not manifes
Furosemide Rapid-acting management side effects
February Furosemide 20 potent of than decrea
21, 2010 mg 1 tab now sulfonamide hypertension, blood press
Brand
then BID “loop” diuretic alone or in
Name:
February 22, and combination
Fumide ,
2010 antihypertensive with other
Furomide ,
with antihypertensiv
Lasix,
Date pharmacologic e agents such
Luramide
Performed: effects and uses as Catapres. It
almost identical makes the
February 21, to those of kidneys
2010(9:20 ethacrynic acid. eliminate
PM) Exact mode of larger amounts
action not of electrolytes
February 22, clearly defined; (especially
2010 (4:00 decreases renal sodium and
AM, 6:00 vascular potassium

43
PM) resistance and salts) and
may increase water than
February 23,
renal blood flow. normal
2010 (6:00
(diuretic
PM)
Functional effect). Loop
Classification: diuretics are
useful for
Loop Diuretic treating many
conditions in
Mechanism of which salt and
Action: water retention
(eg, edema,
Each of the swelling) is a
sodium- problem.
transporting
cells contains
Na-K-ATPase
pumps in the
basolateral
membrane.
These pumps
perform two
major functions:
they return
reabsorbed
sodium to the
systemic
circulation; and
they maintain
the cell sodium
concentration at

44
 relatively low
levels. The latter
effect is
particularly
important, since
it allows filtered
sodium to
passively enter
the cells down a
favorable
concentration
gradient.

Captopril is
General Action: used to lower
the blood
Lowers blood pressure It is
pressure by effective alone
specific and in
inhibition of the combination
angiotensin- with other
converting antihypertensiv
enzyme (ACE). e agents, The patient
Captopril 25 mg ½ This interrupts especially participative
tab BID conversion thiazide-type taking the
Generic Date sequences diuretics. The medication
Name: ordered : initiated by renin blood pressure did not com
that lead to lowering on any adve
Captopril February 23, formation of effects of effects.
2010 angiotensin II, a captopril and

45
 potent thiazides are
endogenous approximately
vasoconstrictor. additive.
ACE inhibition
Brand Date alters
Name: Performed: hemodynamics
without
Capoten February 23, compensatory
2010 (7:00 reflex
PM) tachycardia or
changes in
cardiac output
(except in
patients with
CHF).
Peripheral
vascular
resistance is
lowered by
vasodilation.
Inhibition of ACE
also leads to
decreased
circulating
aldosterone.
Reduced
circulating
aldosterone is
associated with
a potassium-
sparing effect. In

46
heart failure,
captopril
administration is
followed by a fall
in CVP and
pulmonary
wedge pressure;
hypotensive
action appears
to be unrelated
to plasma renin
levels.

Functional
Classification:

ACE inhibitor
Anti-
hypertensive

Mechanism of
Action:

The mechanism
of action of
captopril has not
yet been fully
elucidated. Its
beneficial effects
in hypertension Nifedipine

and heart failure reduces

47
appear to result arterial blood
primarily from pressure
suppression of involves
the renin- peripheral
angiotensin- arterial
aldosterone vasodilatation
system. and the
resulting
reduction in
peripheral
vascular
General Action: resistance.

Nifedipine is a
calcium-channel
antagonist with
effective
antihypertensive
activity and has
been suggested
for the treatment
of high blood
pressure as an
alternative to
vasodilators.

Functional
Classification:

Antianginal
Antihypertensive

48
 Calcium channel
Blocker
Throughout
Mechanism of administrati
Action: the medicat
Nifedipine 5 mg ½ the client
Nifedipine
tab now then q 8° complies wi
blocks the slow
treatment.
calcium
Date
channels thus
Generic ordered:
preventing the
Name:
flow of calcium
February 21,
ions into the cell.
Nifedipine 2010
It produces
peripheral and
Brand Date
coronary
Name: performed:
vasodilatation,
reduces
Calci bloc, February 23
afterload,
Adalat, 2010 ( 7:00
peripheral
Nifediac AM, 3:00
resistance and
CC, PM)
BP, increases
coronary blood
flow and causes
reflex
tachycardia. It
has little or no
effect on cardiac
conduction and
rarely has
It has also
negative
been used as

49
 follow-up
inotropic activity.
prophylactic
therapy for
rheumatic
General Action: heart disease
and acute
an acid-sensitive
glomeruloneph
form of penicillin
ritis.
prepared as
penicillin G
benzathine and
penicillin G
procaine used
for deep
intramuscular
administration. It
is slowly
released,
resulting in
prolonged
effective blood
levels.

Functional
Classification:

Antibiotic

Mechanism of
Action:

50
 penicillin G
inhibits cell wall
The patient
synthesis that
showed
causes cell
conformity w
death.
the adminis
penicillin G of the medic
800,000 “u” IV Q
6° (-) ANST

Date
ordered:
Generic
Name: February 22,
2010
Penicillin G
benzathine Date
Performed:
Brand
Name: February 22,
2010 (10:00
Bicillin L-A AM, 4:00
Permapen PM, 10:00
PM)

February 23,
2010 (4:00
AM, 10:00
AM, 4:00
PM)

51
NURSING RESPONSIBILITIES:

Prior to the procedure:

 Check the doctor’s order

 Introduce yourself and explain the procedure

 Prepare the necessary materials

 Read the label of medication before administering it.

 Check the expiration date of each medication.

 Know the right patient

During the Procedure:

 Check the BP

 Give with food to prevent GI upset(Furosemide)

 State the therapeutic actions and side effects of each

medication

 Stay with the patient until he/she drinks the medication

 Provide health teachings about the prohibited foods to eat

while on the therapy

52
 After the procedure:
 Observe the effectiveness of the drug

 Immediately report to the physician when adverse effect or

anaphylactic reaction occurs.

 Monitor VS

 Monitor UO

 Document the procedure

 Dispose the materials used in the procedure properly

 Perform proper hand washing

c. Diet

Type of Diet Date General Indication or Specific Client’s

ordered, description purposes Foods Response
Date Taken and or
performed, reaction to
date the diet
Changed
Low fat, February 21, a diet that It is indicated Foods to be The patient
Low Salt 2010 restricts the in avoided demonstrated
use of hypertension, include fresh compliance to
sodium edematous or canned the diet by
chloride plus states shellfish, eating
other (especially ham, bacon, nutritious
compounds when frankfurters, foods.
containing associated luncheon
sodium, with meats,
such as cardiovascular sausage,

53
baking disease), renal cheese,
powder or or liver salted butter
soda, disease, and or
monosodium therapy with margarine,
glutamate, corticosteroids any breads
sodium . or cereals
citrate, made with
sodium salt, and
propionate, most canned
and sodium or frozen
sulfate. foods,
except those
prepared
without
sodium (for
example,
frozen fruits
and
vegetables).
Also to be
avoided are
many drugs
that contain
sodium,
such as
laxatives,
sedatives,
and
alkalizers,
and drinking
water from a

54
 source using
a water
softener that
adds
sodium.

NURSING RESPONSIBILITIES:
Prior to the procedure:
 Check the physician’s order

 Introduce yourself and explain the procedure to the patient and

to the significant others

 Perform hand washing

During the procedure:

 Observe the patient’s reaction to the diet.

 Impart health teachings, example of such are the disadvantages

that salty and fatty foods may take effect on the patient’s health

After the procedure:

 Monitor I/O

 Perform hand washing

 Document the procedure

B. SURGICAL MANAGEMENT

Acute glomerulonephritis refers to 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.

55
 Surgical management that can be used to treat a worst case is kidney
transplant. One donated kidney is needed to replace the work previously done by
the kidneys. The donated kidney may be from aLiving related donor -- related to
the recipient, such as a parent, sibling, or child, living unrelated donor -- such as
a friend or spouse or deceased donor -- a person who has recently died and who
has no known chronic kidney disease.

The healthy kidney is transported in cool salt water (saline) that preserves
the organ for up to 48 hours. This gives the health care providers time to perform
tests that match the donor's and recipient's blood and tissue before the
operation.

If you are donating a kidney, you will be placed under general anesthesia
before surgery. This means you will be asleep and pain-free. People receiving a
kidney transplant are given general anesthesia before surgery. The surgeon
makes a cut in the lower belly area.Your surgeon places the new kidney inside
your lower belly. The artery and vein of the new kidney are connected to the
artery and vein in your pelvis. Your blood flows through the new kidney, which
makes urine just like your own kidneys did when they were healthy. The tube that
carries urine (ureter) is then attached to your bladder. Your own kidneys are left
in place, unless they are causing high blood pressure, infections, or are too large
for your body. The wound is then closed.

Kidney transplant surgery takes about 3 hours.

NURSING RESPONSIBILITIES

Prior to the procedure:

56
 Have everything ready in advance

 Instruct the patient to take all medicines that the doctor have
been prescribed. Report changes in your medications and any
new or worsening medical problems to the transplant team.

 Instruct the patient to keep his weight in the range that has been
recommended and follow any recommended exercise program.

 Ask the patient to avoid vices such as smoking and drinking

alcohol.

 Put the patient on a diet in accordance with the doctor’s order.

During the procedure:

 Explain to the S.O. about the procedure

 Prepare the patient for surgery

After the procedure:

 Assist the patient in fulfilling his/her needs

 Assess for signs of infection

 Perform proper cleaning of wound

 Give medications on time as ordered

 Apply the appropriate diet ordered by the physician/dietitian

57
 C. NURSING MANAGEMENT

1. Nursing Care Plan

Problem #1: Excess Fluid Volume

Nursing Scientific Expected

Assessment Objectives Interventions Rationale
Diagnosis Explanation Outcome
S:  Excess Fluid Fluid Volume Short term: >Establish >To gain pt.'s Short term:
Volume r/t excess is After 4 hours of rapport trust and The patient shall
O: The patient inflammation of characterized nursing cooperation have
manifested: glomerular by an increase intervention, demonstrated
membrane in the ECF, the pt.'s SO will >Monitor and >To obtain behaviors to
-slightly pale inhibiting including the demonstrate record VS baseline data monitor fluid
colored lips filtration circulating behaviors to status and
blood volume. monitor fluid >Monitor urine >Provides reduce
-pale Protein is status and output information recurrence of
conjunctiva responsible in reduce about overall fluid excess
oncotic recurrence of fluid balance
-edema on pressure since fluid excess Long term:
hands there is a >Monitor >Indicator of The patient shall
decrease in Long term: client's weight overall fluid have stabilized
Patient may protein as a After 3 days of and nutritional fluid volume as
manifest: result colloid nursing status evidenced by
oncotic intervention, >Maintain oral balance I/O, VS
-weight gain pressure will the pt. will restrictions and >To promote within normal
decrease, fluid stabilize fluid bed rest fluid limits, stable
-oliguria then escapes volume as management weight and free
from IVS going evidenced by >Administer from signs of

58
 to interstitial IVF as
-restlessness spaces balance I/O, prescribed >To maintain edema
resulting to VS within fluid balance
-altered edema. normal limits
electrolyte

Problem #2: Risk for Imbalance Nutrition: Less Than Body Requirements

Nursing Scientific Expected

Assessment Objectives Interventions Rationale
Diagnosis Explanation Outcome
S:  Imbalanced Imbalanced Short term: > Establish >To gain pt.'s Short term:
nutrition: less nutrition: less After 4 hours rapport trust and The SO shall
O: The patient than body than body of nursing cooperation have
may manifest: requirements requirements intervention, demonstrate
r/t increased occurs when the SO will >Monitor and >To obtain understanding
-dry buccal metabolic there is demonstrate record VS baseline data on ways to
cavity demand insufficient intake understanding regain and
secondary to of nutrients to on ways to >Assess pt.'s >Provides maintain
-poor muscle disease meet metabolic regain and weight, age comparative appropriate
tone condition needs due to the maintain and baseline weight of
dietary appropriate activity/rest
patient
-sore, inflamed restrictions and weight of level >To enhance
the condition. patient intake
Long term:
>Encourage

59
 Long term: SO to give The patient
buccal mucosa After 4 days of appropriate shall have
nursing foods to pt. as demonstrate
-capillary intervention, ordered >To emphasize weight gain
fragility patient will importance of towards goal
demonstrate >Provide SO well balanced
-body weight weight gain with diet and
20% or more towards goal information nutritional
under ideal regarding pt.'s intake
nutritional
needs >To promote
adequate
nutritional
intake
>Encourage
SO to give
nutritious and >To monitor
Vitamin rich effectiveness
foods of efforts
towards goal
>Encourage
SO to weigh
daily

60
Problem #3: Activity Intolerance

Nursing Scientific Expected

Assessment Objectives Interventions Rationale
Diagnosis Explanation Outcome
S:  Activity Acute Short term: > Establish >To gain pt.'s Short term:
Intolerance r/t Glomerulonephritis After 4 hours rapport trust and The pt. shall
O: The pt. may bed rest is an inflammation of nursing cooperation have
manifest: of the kidney's intervention, demonstrated
filtering the pt. will be >Monitor and >To obtain decrease in
-generalized mechanism called able to record VS baseline data physiological
weakness glomeruli. Due to demonstrate signs of
the disease decrease in >Note >Has potential intolerance
-fatigue condition, there is physiological presence of for interfering
a need to signs of medical with clients Long Term:
-listlessness increases the intolerance diagnosis ability to The pt. shall
body’s oxygen perform at a have
-loss of thus increasing Long Term: desired level participated in
appetite metabolic After 2 to 3 of activity conditioning/
demands. This days of rehabilitation
-inability to results to a nursing >Determine >Provides program to
perform ADL's decrease in intervention, baseline opportunity to enhance ability
activity intolerance the pt. will be activity level to perform
track changes
that is why there is able to and physical
insufficient energy participate in condition
to endure daily conditioning/
activities. rehabilitation
>Promote or >To
program to
implement prevent/limit
enhance ability
conditioning deterioration
to perform
program

61
 >Identify and >To provide for
discuss timely
symptoms interventions

>Administer >To promote

medications as wellness
ordered

Problem #4: Deficient Diversional Activity

Nursing Scientific Expected

Assessment Objectives Interventions Rationale
Diagnosis Explanation Outcome
S:  Deficient The client’s Short term: > Establish >To gain pt.'s trust Short term:
Diversional recommended After 4 hours rapport and cooperation The pt. shall
O: The pt. may Activity may activity is bed of proper have
manifest: be related to rest that’s why nursing >Monitor and >To obtain recognized own
treatment there is a intervention record VS baseline data psychological
-disinterest modality/ decreased the pt. will response and
restrictions stimulation recognize own >Validate >To assess initiate
- and malaise, from psychological reality of precipitating/etiolo appropriate

62
 possibly recreational or response and coping action
inattentiveness evidenced by leisure initiate environment gi-cal factors
statements of activities. appropriate mental Long Term:
-restlessness boredom, coping action deprivation The pt. shall
restlessness have engaged
-hostility and irritability Long Term: >Determine >Presence of in satisfying
After 2-3 days ability to depression, activities within
-lethargy of proper participate/ problems of personal
nursing interest in mobility, protective limitations
intervention activities that isolation or
the pt. will are available sensory
engage in deprivation may
satisfying interfere with
activities desired activity
within >Acknowledge
personal reality of >To establish
situation and therapeutic
feelings of the relationship
client

>Encourage >Client’s sense of

client to assist control is
in scheduling enhanced
required and
optional
activity
choices

>Suggest >To stimulate

activities observation as

63
 well as
participation in
activity

Problem #5: Readiness for Enhanced Therapeutic Regimen Management

Nursing Scientific Expected
Assessment Objectives Interventions Rationale
Diagnosis Explanation Outcome
S:  Readiness for A pattern of Short term: > Establish >To gain pt.'s
Enhanced regulating and After 4 hours rapport trust and
O: The pt. may Therapeutic integrating into of nursing cooperation
manifest: Regimen daily living a intervention,
Management program for the pt. will >Monitor and >To obtain
-no treatment of demonstrate record VS baseline data
unexpected illness and its proactive
acceleration of sequelae that management >Verify client’s >Provide
illness is sufficient for by anticipating level of opportunity to
symptoms meeting health knowledge assure
and planning
-choices of related goals accuracy and
for
daily living are and can be completeness
eventualities of
appropriate for strengthened.
condition
meeting the >Identify steps >Understanding
goals of Long term: necessary to the process
treatment of After 2-3 days reach desired enhances

64
prevention
of nursing health goal commitment
intervention,
the pt. will >Assist in >Promotes
assume implementing proactive
responsibility strategies for problem solving
for managing monitoring
treatment for progress
regimen
>Identify >Provides
additional additional
community opportunities
resources/suppor
t groups

65
2. Actual SOAPIER

February 23, 2008

S> Ø

O> received patient in supine position conscious and coherent with an ongoing
IVF of #2 D5W 500 cc x KVO @ 250 cc level infusing well over right dorsal
aspect of the hand.

> With edema on the hands, with decreased HCT, with proteinuria and Hematuria
upon reviewing the UA.

> VS taken and recorded as follows:

T- 37 ˚ C

P- 107 bpm

R- 20 bpm

BP- 120/80 MmHg

A>Excess fluid volume related to failure of regulatory mechanism as evidenced

by edema and increase in BP secondary to glomerulonephritis.

P> After 6 hours of NI, the patient shall stabilize fluid volume as evidenced by
normal VS and free of signs of edema.

I> Established rapport

> Monitored and recorded VS

>Monitored BP q 1

> weighed the patient

> Reviewed lab data

66
> Instructed to avoid fatty and salty foods

> Elevated edematous extremities

> Discussed importance of low fat low sodium diet

> Administered medications as ordered

E>Goal partially met as evidenced by a decrease in blood pressure.

67
 VI. CLIENT’S DAILY PROGRESS IN THE HOSPITAL

1. CLIENT DAILY PROGRESS CHART (FROM ADMISSION TO DISCHARGE)

NURSING DIAGNOSES
Problems Admission 02/21/10 DAY 2 DAY 3
02/22/10 02/23/10
1. excessive fluid
volume
2. risk for
imbalanced body
nutrition less that
body requirements
3.activity
intolerance
4. deficient
diversional activity
5. .readiness for
enhanced
therapeutic
management

68
 VITAL SIGNS Admission DAY 2 DAY 3
02/21/10 02/22/10 02/23/10
Body Temperature 8:00pm- 36.6°c 8:00 am- 36.5°c 12:00 mn- 36°c
1:00pm- 37°c 10:00 am- 36.5°c 4:00 am- 36.3°c
3:00pm- 36. 2°c 12:00 nn- 36.4°c 8:00 am- 36.6°c
5:00 am- 36.7°c 4:00 pm- 36.1°c 12:00 nn- 36.5°c
8:00 pm- 36.1°c
Respiratory rate 8:00pm- 24cpm 8:00 am- 22cpm 12:00 mn- 20cpm
1:00 am- 20cpm 10:00 am- 22cpm 4:00 am- 21cpm
3:00am- 20cpm 12:00 nn- 21cpm 8:00 am- 21cpm
5:00 am- 24cpm 4:00 pm- 28cpm 12:00 nn- 20cpm
8:00 pm- 24cpm
Cardiac Rate 8:00 pm- 100 bpm Ø Ø
Pulse rate 8:00pm- 84bpm 1:00 am- 8:00 am- 85bpm 12:00 mn- 70bpm
84bpm 10:00 am- 86bpm 4:00 am- 73bpm
3:00am- 83bpm 12:00 nn- 95bpm 8:00 am- 88bpm
5:00 am- 76bpm 4:00 pm- 92bpm 12:00 nn- 85bpm
8:00 pm- 86bpm
Blood pressure 8:00pm- 150/90mmHg 8:00 am- 130/80mmHg 12:00 mn- 110/70mmHg
1:00 am- 130/90mmHg 10:00 am- 130/80mmHg 4:00 am- 120/70mmHg
3:00am- 130/90mmHg 12:00 nn- 140/90mmHg 8:00 am- 120/80mmHg
5:00 am- 130/90mmHg 4:00 pm- 140/90mmHg 12:00 nn- 120/80mmHg

69
 8:00 pm- 130/80mmHg
DIAGNOSTIC/ LABORATORY PROCEDURES
COMPLETE BLOOD COUNT February 21, 2010 Results
Hemoglobin 120 g/L (NR: 120-170g/L)
Hematocrit 4.2 (NR: 4.0-5.0x10)
Erythrocytes 0.36 (NR: 0.37-0.54)
Leucocytes 13.3 g/L (NR: 5-10xg/L)
Platelet count 360x10/L (NR: 150-450x10/L
Segmenters 0.74 (NR: 0.50-0.70)
Lymphocytes 0.21 (NR: 0.20-0.40)
Eosinophils 0.03 (NR: 0.0-0.05)
Monocytes 0.02 (NR: 0.0-0.05)
URINALYSIS February 21, 2010 Results
Color Yellow
Transparency Slightly turbid
Albumin Positive
P.H 6.5
Specific gravity 1.020
RBC 14-18/hpf
PCS cells 6-8
A-urates Few
BLOOD CHERMISTRY February 21, 2010 Results
BUN 14.5 (NR: 7-18)
Creatinine 1.1 (NR: 0.7-1.3)
MISCELLANEOUS SEROLOGICAL TEST February 22, 2010 Results
Anti- streptolycin-o Reactive;400 iu/ml
(NR: <200 iu/ml)
Sodium 48.2mmol/L
(NR: 3.5-5.3mmol/L)

70
 Potassium 4.31mmol/L
(NR: 3.5-5.3mmol/L)
CBC- ESR 4.5mmHr
(NR: 0-10mmHr)

RENAL ULTRASOUND FEBRUARY 22, 2010

Both kidneys Normal in size and parenchymal echogenicity with intact central
echocomplexes.
Right kidney Measures 8.6x4.2x4.0cm with cortical thickness of1.2 cm
Left kidney Measures 8.8x3.9x3.6cm with cortical thickness of1.5 cm
Renal parenchyma Thickness is within normal limits. No mass lesions or calculus
noted.

DAY 2 DAY 3
MEDICAL MANAGEMENT Admission 02-21-10
02/ 22/10 02/23/10
D5W 500cc x KVO D5LRS 500cc x KVO D5W500cc x KVO
INTRAVENOUS FLUID
9:15 pm 10:10 pm 1:50 am
Day 2 DAY 3
DRUGS Admission 02/21/10
02/22/10 01/23/10
Furosemide 20 mg IV Stat- 9:00 pm 20 mg 1 tab now then 20 mg 1 tab now then
TID TID
4:00 am, 6:00 pm 6:00 pm

71
 5 mg ½ tab now then q
Nifedipine 8 7:00 am, 3:00
Pm
Mg ½ tab BID - 7:00
Captopril
pm
800,000 “u” IV q 6 (-)
800,000 “u” IV q 6 (-)
ANST
Penicillin ANST
4:00 am, 10:00 am,
4:00 pm, 10:00 pm
4:00 pm
Admission DAY 2 DAY 3
DIET
02/21/10 02/21/10 02/21/10
Low fat, low salt
ACTIVITY/EXERCISE Admission DAY 2 DAY 3
02/21/10 02/21/10 02/21/10
Complete bed rest Complete bed rest Complete bed rest Complete bed rest

72
VII. CONCLUSION AND RECOMMENDATION (Learning Derived)

The researchers, as future nurses, have a lot of things to learn and one of
this is their ability to provide proper management needed by the patient to assure
continuity of healthy life. The researchers have learned new things on how to
provide proper management and care to patients especially to those with AGN.
AGN can progress to even more sever cases if ignored. Medical management
and proper interventions should be applied in order to prevent and alleviate the
disease itself.

The researchers recommend this study to those patients suffering from

AGN so that they may be aware of the proper health promotion and preventive
aspects of the disease. And also to all health care providers to let them know of
the proper management of the disease so they may be able to provide health
teachings to patients with AGN to help them prevent further complications and
promote their overall well being.

VIII. BIBLIOGRAPHY

a. BOOKS

 Textbook of Medical Surgical Nursing by Brunner and Suddarth

 Diagnostics: A to Z Guide to Laboratory Test and Diagnostics

Procedure. Springhouse 2001

 Nursing Drug Handbook 1993

 2008 Edition PDR Nurse’s Drug Handbook by George R. Spratto,

PhD and Adrienne L. Woods, MSN, ARNP, NP-C

 Nurse’s Pocket Guide Diagnoses, Prioritized Interventions, and

Rationales by Marilynn E. Doenges, Mary Frances Moorhouse, and
Alice C. Murr

73
  Maternal and Child Nursing by Pillitteri

b. INTERNET

http://lifesci.rutgers.edu/~babiarz/kid.htm
http://training.seer.cancer.gov/module_anatomy/unit11_1_uri_functions
.html
http://www.kidneyinfectionhub.com/parts/nephron/
http://en.wikipedia.org/wiki
http://www.answers.com
http://en.wikipedia.org
http://www.diagnose-me.com/treat/T161687.html
http://www.medicalnewstoday.com/articles/104660.php
http://family.go.com/parentpedia/preteen-teen/eating-nutrition/teen-
junk-food/
http://www.pia.gov.ph/?m=12&fi=p080602.htm&no=58

74