Liceo de Cagayan University

College of Nursing

Individual Care Study

 Table of contents
I. Introduction
a.Overview of the Case
b.Objective of the Study
c.Scope and Limitation of the Study

II. Health History

a. Profile of patient
b. Personal Health History
c. History of Present Illness
d. Chief Complaint

III. Developmental Data

IV. Medical Management

a.Medical Orders and rationale
b.Drug study

V. Pathophysiology with Anatomy and Physiology

VI. Nursing Assessment (System Review & Nursing

Assessment II)

VII. Nursing Management

a.Ideal Nursing Management (NCP)
b.Actual Nursing Management (SOAPIE)

VIII.Referrals & Follow-up

 IX. Evaluation and Implications

X. Bibliography

I. INTRODUCTION

A. Overview of the Case

AcuteGlomerulonephritis is the disease of the kidney in which

there is an inflammation of the glomerular capillaries. In most cases,

the stimulus of the reaction is group A streptococcal infection, which

ordinarily precedes the onset of glomerulonephritis by 2 to 3 weeks.

B. Objective of the Study

The study generally aims to investigate the condition of an adult

man and further understand the extent of the case.

Specifically, the health care provider sought to;

 • Perform Physical Assessment,

• Data Base and History taking that solidifies the present diagnosis

of the client.

• Identify the development and changes encountered by the client.

• Identify the nursing problems which will be the basis of the care

plan.

• Develop Plan of the Care and Implement nursing interventions

relevant and suitable for the case.

As nursing students they will be able to improve their skills in

accordance to patient’s needs and condition.

The purpose of the study is to gather significant data to broaden

our knowledge with regards to the condition of the patient and to

improve our abilities as future health care providers. Moreover, this

case study will enable us to apply the acquired skills we obtained in

the classroom set-up.

C. Scope and Limitation of the Study

The study focuses only on one of the many problems of the

kidney, mainly the glomerulonephritis and its causes and effects on

patients that are being diagnosed to it. Also, the study tackles on how

this problem is being acquired.

II. HEALTH HISTORY

A. Client’s Profile
Name : Lisdan, Elpedio N.
Wife : Lisdan, Jemma
Address : San Rafael, Talakag, Bukinon province
Civil Status : Married
Sex : Male
Age : 42 years old
Religion : Roman Catholic
Educational Status : Elementary level
Income : 2,000 php/month
Nationality : Filipino
Date of Admission : January 27, 2009
Time of Admission : 9:10 am
Informant : Patient
Height : 158 centimetres
Weight : 52 kg
Vital Signs during Assessment
Temperature : 36.7 °C
Pulse Rate : 55 bpm
Respiratory rate : 20 cpm
Blood Pressure : 150/110 mmHg

Admitting Diagnosis : Acute Glomerulonephritis related to

nephritic syndrome; hypertension

Attending Physician : Dr. Joseph Borong

B. Family and Personal Health

Patient’s History

Allergies:
- No known allergies on foods and drugs.

Injuries/ Accident in the past:

 - Patient had not experience injuries or accident in the past.

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

Family health history:

- Experienced Hypertension and Kidney disorder (2006)

Social History

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

Tobacco use:
- Patient often smokes.

Home and Environment:

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

C. Chief Complaint and History of Present Illness

Noted to have edema; condition noted for a week – prior to

admission as onset of fever on and off associated with dysuria – tea

colored urine.

III. DEVELOPMENTAL DATA

• The Developmental Stages of Erik Erickson

Middle Adulthood: 35 to 65:

Generativity vs. Self absorption or Stagnation

Now work is most crucial. Erickson observed that middle-age is

when we tend to be occupied with creative and meaningful work and

with issues surrounding our family. Also, middle adulthood is when we

can expect to "be in charge," the role we've longer envied. The

significant task is to perpetuate culture and transmit values of the

culture through the family (taming the kids) and working to establish a

stable environment. Strength comes through care of others and

production of something that contributes to the betterment of society,

which Erikson calls generativity, so when we're in this stage we often

fear inactivity and meaninglessness.

• Freud's Psychosexual Stages of Development

The Genital Stage

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

genitals, interest turns to heterosexual relationships. The less energy

the child has left invested in unresolved psychosexual developments,

the greater his capacity will be to develop normal relationships with

the opposite sex. If, however, he remains fixated, particularly on the

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

further repression and defenses.

• Robert Havighurst Developmental Task Theory

Middle Adulthood (30-60 years)

Achieving adult social and civic responsibility; Reaching and

maintaining satisfactory performance in one’s occupational career;

Developing adult leisure time activities; Relating oneself to one’s

spouse as a person; To accept and adjust to the physiological changes

of middle age; Adjusting to aging parents. Assisting teenage children to

become responsible and happy adults; achieving adult social and civic

responsibility.

• Piaget's Theory of Cognitive Development

Formal operational stage (Adolescence and adulthood)

In this stage, intelligence is demonstrated through the logical use

of symbols related to abstract concepts. Early in the period there is a

return to egocentric thought. Many people do not think formally during

adulthood.

IV. MEDICAL MANAGEMENT

A. Medical Orders and Rationale

Doctor’s Order Rationale

01/27/09
➢ Please admit • To monitor patient’s medical
 condition and proper
➢ TPR q 4h management.

• To monitor any abnormal

➢ Full low salt, low fat diet changes in vital signs

• For proper nourishment and

for prevention of disease
➢ Give 1 egg white a day that may lead to severity of
the condition
➢ 0.9 NaCl @ KVO rate
• To promote good nutritional
status
➢ Furosemide i amp q 12h x
3doses • To monitor body fluids &
prevent dehydration

• For treatment of
➢ Cefuroxime 750 mg q 8h hypertension, edema
IVTT associated with CHF,
cirrhosis and renal disease

• For treatment of lower

➢ Omeprazole 20mg icap OD respiratory infection, UTI &
P.O. dermatologic infection

• First line treatment for

➢ Captopril 25mg itab BID P.O. heartburn and short term
treatment of active
duodenal ulcer

• Treatment for pulmonary

➢ I & O q shift tuberculosis that is not
responsible to 1st line
antituberculosis

01/28/09 • For proper hydration of the

patient and carefully
➢ IVF 0.9 NaCl @ KVO rate monitor the fluid losses

➢ Spironolactone 50mg itab

TID P.O.
• To monitor body fluids &
prevent dehydration
➢ Continue meds.
B. Drug Study
Generic Date Classi- Dose/ Mechanis Specific Contra- Side Nursing
Name of Ordere fication Frequen m of Indicati indication Effects/ Precauti
Ordered d cy/ Action on Toxic on
Drug Route Effects

Cefuroxi 01/27/0 Antibiotic 750 mg q Inhibits For Contra Hyperse Assess

me 9 (Cephalos 8h IVTT synthesis of lower indicated n- for
porin – 2nd bacterial respirato with allergy sitivity, hepatic
generatio cell wall, ry to nephrot or renal
n) causing cell infection cephalospori oxicity, impairme
death. , UTI & n or pain at nt
derma penicillins injection
tologic site Assess
infection for skin
status

Check for
sensitivit
y tests
Generic Date Classi- Dose/ Mechanism Specific Contra- Side Nursing
Name of Ordere ficatio Frequen of Action Indicati indication Effects/ Precauti
Ordered d n cy/ on Toxic on
Drug Route Effects

Furosemi 01/27/0 Loop Amp of Inhibits Hyperte Contraindic Polyuna, Assess

de 9 Diuretic 12h x 3 reabsoption n-sion, ates allergy Nocturia for
doses of Na and Cl Edema to , Rash, allergy to
from the associat furosemide; Anemia, furosemi
proximal and ed with anuria, Muscle de
distal tubules CHF, hepatic spasms,
and cirrhosis coma Cardiac Assess
ascending and arrythmi for skin
limb of the renal as color,
loop of disease lesions
Henle, and
leading to a edema
Na-reach CBC,
diuresis serium
electrolyt
es
Generic Date Classi- Dose/ Mechanism Specific Contra- Side Nursing
Name of Ordere ficatio Frequen of Action Indicati indication Effects/ Precauti
Ordered d n cy/ on Toxic on
Drug Route Effects

Omeprazo 01/27/0 Antisec 20mg Gastric acid First line Contra- Rash, Assess
le 9 retory icap OD pump treatme indicated alopecia for
drug; P.O. inhibitor: nt for with hyper- , hypersen
Proton Supresses heartbur sensitivity nausea, sitivity to
Pump gastric acid n and to vomiting omepraz
Inhibito secretion by short omeprazole Epistasis ole
r specific term or its , fever
inhibition of treatme component. Assess
hydrogen- K nt of Use for skin
ATPase active cautiously lesions
enzymes duodena pregnancy Assess
system at l ulcer lactation for
secretory urinary
surface of output
the gastric
parietal cells.
Generic Date Classi- Dose/ Mechanism Specific Contra- Side Nursing
Name of Ordere ficatio Frequen of Action Indicati indication Effects/ Precauti
Ordered d n cy/ on Toxic on
Drug Route Effects

Captropil 01/27/0 ACE 25mg Polypeptide Treatme Contra- Polyuria, Assess

9 inhibito itab Antibactic; nt indicated Tachy- for
r BID P.O. against hyper- allergy to cardia, allergy to
Mycobacteriu tension capreomyci proteinu captropil
m n; pre- riacough
tuberculosis existing dry Assess
auditory mouth for skin
impairment color and
lesions

For CBC
and
differenti
al
Generic Date Classi- Dose/ Mechanism Specific Contra- Side Nursing
Name of Ordere ficatio Frequen of Action Indicati indication Effects/ Precauti
Ordered d n cy/ on Toxic on
Drug Route Effects

Spirono- 01/28/0 Diuretic 50mg Cause loss of To Hyper- Clumsy Monitor

lactone 9 s itab TID sodium counter sensitivity; Headach intake &
P.O. bicarbonate act Hyperkalem e output
and calcium potassiu ia Dyscrasi
while saving m loss as Daily
potassium caused weight
and by other during
hydrogen diuretics therapy
ions
Monitor
BP
before
adminis-
tering
V. PATHOPHYSIOLOGY
VI. ASSESSMENT
GASTRO INTESTINAL TRACT:
EENT:
[ ] obese [ ] distension [ ] mass
[ ] impaired vision [ ] blind
[ ] dysphagia [ ] rigidly [ ] pain
[ ] pain [ ] reddened [ ] drainage
[x] no problem
[ ] gums [ ] hard of hearing

[ ] deaf [ ] burning [x] edema

[ ] lesion [ ] teeth [ ] no problem

GENITO URINARY and GYNE:

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

RESPIRATORY: bleeding
[ ] asymmetric [ ] tachypnea [ ] hermaturia [ ] discharge [ ]
nocturia
[ ] apnea [ ] rales [x] cough
[ ] no problem
[ ] barrel chest [ ] bradypnea

[ ] shallow [ ] rhonchi [x] sputum

NEUROLOGICAL:
[ ] diminished [ ] dyspnea
[ ] paralysis [ ] stuporous [ ]
[ ] orthopnea [ ] labored [ ]
unsteady
wheezing
[ ] seizures [ ] lethargic [ ]
[ ] pain [ ] cyanotic [ ] no
comatose
problem
[ ] vertigo [ ] tremors [ ]
confused
CARDIO VASCULAR:
[ ] vision [ ] grip [x] no
problem
[ ] arrhythmia [ ] tachycardia [ ]
numbness

[ ] diminished pulses [ ] edema [ ]

MUSCULOSKELETAL:
fatigue
[ ] appliance [ ] stiffness [ ]
[ ] irregular [ ] bradycardia [ ]
itching
murmur
[ ] petechiae [ ] hot [ ]
[ ] tingling [ ] absent pulses [x] pain
drainage
[ ] no problem
[ ] prosthesis [ ] swelling [ ] [ ] no problem
lesion

[ ] poor turgor [ ] cool [ ]

deformity

[ ] wound [ ] rash [ ] skin

color

[ ] flushed [ ] atrophy [x]

pain

[ ] ecchymosis [ ] diaphoretic[ ]
moist
 NURSING ASSESSMENT II
SUBJECTIVE OBJECTIVE
COMMUNICATION:
[ ] Hearing Loss Comments: [ ] Glasses [ ] Language
“wala [ ] Contact lens [ ] Hearing
[ ] Visual Changes man – Aide
wala
[x] Denied R L
gihapon” Pupil Size: 3-5 mm [ ] Speech
As difficulties
verbalized by Reaction: PERRLA
the
husband
OXYGENATION:
[ ] dyspnea Respiratory: [x] regular [ ]
Comments: “Nah! irregular
[ ] smoking history Describe: regular breathing but
gapanigarilyo associated with pain
Oftentimes mana
siya -giubo Right: Right lung is symmetrical to left
[x] cough pd siya lung.
karon oh.’ Left: Left lung is symmetrical to right
[x] sputum As lung.
verbalized by
[ ] denied the
wife
CIRCULATION: Heart Rhythm [x]regular [ ]
[ ] chest pain irregular
Comments: “Sakit! Ankle Edema: present in lower
[x]leg pain bug- extremities
at… Pulse Carotid Radial DP
[x]numbness of extremities Femoral
nanghubag na Right: 62 65 60 not
[ ] denied man assessed
gni ako Left: 62 65 60 not
mga assessed
tiil” As
verba Comments: Pulse sites are palpable and
lized by its rate are within normal range.
the
patient
NUTRITION:
Diet: DAT but decreased fluid intake [ ] dentures [x] none
[ ]N [ ]V
Comments: “Wala Full Partial With
Character Patient
man…perma- Upper [√] [ ] [ ]
[ ] recent charge
nente nay gana” Lower [√] [ ] [ ]
in weight, appetite As
verbalized
[ ] swallowing by
the patient
 Difficulty
[x] denied
ELIMINATION:
Usual bowel pattern [ ] urinary Comments: urinate once Bowel
frequency Sounds:
Once a day once daily due to pain Audible
daily sounds
[ ] constipation [ ] urgency and excrete small Abdominal
Remedy [x] dysuria Distention:
[ ] amount. Present [ ]
hematuria Yes [x] No
January 27, 2009 [ ] Urine
incontinence (color,
Date of last BM [ ] polyuria consistency
, odor)
[ ] diarrhea character [ ] foly in tea color of
place urine,
[ ] denied inconsistent

MANAGEMENT OF HEALTH &

ILLNESS:
[x] alcohol [ ] denied Briefly describe the patient’s
(amount, frequency) ability to follow treatments (diet,
Occasionally – once in 2 months
meds, etc.) for chronic health
[ ] SBE Last Pap Smear: N/A problems (if present):
LMP:
The patient is properly following her
medications

SUBJECTIVE OBJECTIVE
SKIN INTEGRITY:
[ ]dry Comments: “ [ ] dry [x] cold
wala man [ ] pale
[ ] itching - nanghupong [ ] flushed [] warm
[x] other - edematous lang ko” as [ ] moist [ ] cyanotic
[ ] denied verbalized by
the * rashes, ulcers, decubitus (describe
Patient. size, location, drainage): No presence
of any ulcers, decubitus or rashes.
ACTIVITY/SAFETY:
[ ] convulsions Comments: “ [ ] LOC and orientation: Oriented to
dili man time and
[ ] dizziness hinuon, bug- space
at lang Gait: [ ] walker [ ] cane
[ ] limited motion of joints gyud ako tiil [ ] other
Kay
nanghupong [x] steady [ ] unsteady
Naman – [ ] sensory and motor losses in face
kaya or extremities
Limitation in man hinuon None
nako.”
ability to as verbalized [ ] ROM limitations: patient can
by the performed range
[ ] ambulate patient of motion
[ ] bathe self
[ ] other
[x] denied

COMFORT/SLEEP/AWAKE:
[ ] pain Comments: [ ] facial grimaces
“ok [ ] guarding
(location, raman [ ] other signs of pain
hinuon” Edema on both extremities
Frequency, As verbalized
Remedies) by the [ ] siderail release form signed (60 +
patient. years)
[ ] nocturia None
[ ] sleep difficulties
[x] denied

COPING:
Occupation : Farmer Observed non-verbal behavior
Members of household: None
6
Most supportive person: The person and his phone number
Wife that can be reached any time

SPECIAL PATIENT INFORMATION

_______________ Daily weight _______________ PT/OT
_________________
_______________ BP q shift _______________ Irradiation
_______________ Neuro VS ______________ Urine test
_______________
_______________ CVP/SG. Reading ________ ______________ 24 hour urine
collection
Date Diagnostic/labor Date Date I.V. Date
Ordered atory exams done ordered Fluids/Blo disc.
od
01/27/09 CBC 01/27/09 01/27/09 0.9 Nacl iL
@ KVO
rate
01/27/09 Urinalysis
VII. NURSING MANAGEMENT
A. Ideal Nursing Management
Nursing Diagnosis:
➢ Excessive fluid volume related to glomerulonephritis

INTERVENTIONS RATIONA
• Monitor intake and output • To check fluid balance an
• Observe for fever • To check for infection sin

greater risk
• Elevate edematous extremities, change • To reduce tissue pressure

position frequently breakdown

• After elevating, place in semi-fowlers position • To facilitate movement o
improving respiratory eff
• Provide quiet environment • To promote ventilation an

stimuli
• Administer furosemide I amp of 12h as • For the treatment for ede

prescribed by the physician

Nursing Diagnosis:
➢ Ineffective airway clearance related to productive cough

INTERVENTIONS RATIONA
• Assess the airway patency • To check the effectivity o

for further management

• Elevate the head part of the bed/change • To enhance drainage of/v
 position q 2h lung segments
• Encourage deep-breathing and coughing • To mobilize secretions

exercise
• Monitored the fluid intake • To help liquefy secretions
edema
• Instruct to have proper clothing, not too tight • To provide warm body/en

and not too loose

Nursing Diagnosis:
➢ Acute pain related to edema

INTERVENTIONS RATIONA

• Monitor vital signs • Because vital signs are a

experienced

• Acknowledge patient’s verbalization of pain & • Pain is subjective experie

allow him to describe it no other one can felt abo

• Perform pain assessment each time occurs • To rule out worsening of

condition/developing com

• Elevate edematous extremities, change • To reduce tissue pressure

position frequently breakdown

• Provide quiet environment • To promote ventilation an

stimuli

• Administer Spironolactone 50mg itab TID P.O. • For the treatment for ede
as prescribed by the physician
B. Actual Nursing Management

S “Bug-at lang akong tiil kay nanghupong naman

ko.”
As verbalized by the patient

• Edema
O • Oliguria
• Restlessness

Fluid volume excess related to Glomerulonephritis

A

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

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

1) Monitor vital signs especially temperature

➢ To check & assess for infection since the pt.
has a higher risk
2) Monitor intake & output
I ➢ To monitor & check fluid volume & prevent
dehydration
3) Elevate the edematous extremities
➢ To reduce tissue pressure & risk in skin
breakdown
4) Place in a semi-fowlers position, change position
frequently
➢ To facilitate movement of diaphragm &
improve respiratory effort
5) Administer furosemide 1 ampule every 12h as
prescribed by the physician
➢ For the treatment of edema
 E At the end of 8 hrs, the pt reduces the excess fluid in his
body thru excretion of stored fluids.

HEALTH TEACHINGS

Name of Patient: Gloria Yabo

Encourage to follow the dosages and proper

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

Encourage bed rest and frequent changes of

EXERCISE position, early ambulation, and deep breathing
exercise.

Encourage/instruct to keep the edematous

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

OUT-PATIENT Encourage pt. that when his discharged, he

(Check-up) must have a regular check-up to his physician
until it’s needed. To evaluate the progress of his
condition.

Instruct to limit intake of salty & fatty foodsand

DIET enrich/increase the intake of foods rich in
potassium such as bananas…
VIII. REFERRALS AND FOLLOW-UP

Since the patient is suffering from Acute Glomerulonephritis, it is

advised for him to stay in the hospital for a better and thorough

management regarding on her condition. Acute Glomerulonephritis are

very critical in a man’s condition that is why the patient needs an

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

If the doctor has already approved the release or discharge of

the patient from the hospital, the patient is highly advised to have a

regular check-up on her personal physician to take out the risk from

the said ailment.

If the patient will again suffer the Acute Glomerulonephritis, it is

best for him to be admitted to a tertiary-leveled hospital for better

monitoring of his critical condition, knowing that even a single mistake

worsen his condition.

IX. EVALUATION AND IMPLICATIONS

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

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

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

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

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

that cannot be merely taken for granted.

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

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

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

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

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

X. BIBLIOGRAPHY

 Doenges, Marilyn E. et.al Nurses Pocket

Guide: Diagnoses, Interventions and
Rationale. 9th edition pages 278-279,
472-477, 576-578 F. A Davis Company
Philadelphia, 2004.

 Lippincott Williams & Wilkins, Manual of

Nursing Practice, 8th edition, volume 1.

 Deglin, et al. Davis’s Drug Guide for

nurses, 9th edition.

 Smeltzer, Suzanne C. et al. Textbook of

Medical-Surgical Nursing, 11th edition,
volume 2.