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NCP - Poststreptococcal Glomerulonephritis

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Nursing Care

Plan
Group 1 and 4

Case Scenario
A case of 2 year old male brought
by his mother at the emergency room
due to dyspnea , puffy eyelids, flank
pain and tea-colored urine. Upon
assessment, patient was noted to
have scabies at both lower
extremities . The following are the
doctors order:
1. CBC, urinalysis, BUN, creatinine,
total protein AG ratio, chest x-ray
2. Strictly monitor intake and output
3. Weigh daily

Patients Name: KAV

Rm. #: Pediatric Ward

Age: 2 years old


C/C: Dyspnea

Diagnosis:Acute Poststreptococcal Glomerulonephritis

Doctor: Dr. U.

General Objective:
To facilitate the maintenance of oxygen
supply to all body cells

Subjective Cues
As

verbalized by the mother:

Di siya mayo kaginhawa


Di siya mayo katulog
Pirme lang siya gahibi
Gahungag ang iya ilong
Ginahapo siya biskan wala siya may gin
ubra.

Objective Cues
Pale

skin
Restlessness
Nasal Flaring
Temp. 37.9C (37.5 C)
RR: 72 cpm (32-60 cpm)
HR: 135 bpm (app. 80-110 bpm)
Weight: 11.5 lbs or 5 kg; increasing to 0.3
lbs/day (approx.11.7 lbs)
BP: 110/80 mmHg (105/55-70 mmHg)

Others:
Chest

x-ray result revealed pulmonary edema with


leakage of fluid into the interstitium, alveoli and pleural
space

Hgb- 10.2 g/dL (12.5 g/dL) 2-6 yrs old


Hct- 29.6% ( 34-40%) 2-6 yrs old
BUN- 22 mg/dL (5-18 mg/dL)
Creatinine- .9 mg/dL ( under .5 mg/dL)
WBC- 11,100 WBCs/mL (4,500-11,000 WBCs/mL
Total protein AG ratio - 5.9 g/dL (6.3-8.2 g/dL)
U/O- 20 mL/hr (500-600 mL/day or approx. 23 mL/hr)

NURSING
DIAGNOSIS

RATIONALE

SPECIFIC
GOAL

Altered breathing
pattern: Dyspnea
related to fluid
retention
secondary to Acute
Poststreptococcal
Glomerulonephritis

Due to Sarcoptes Scabiei infestation skin


integrity is compromised causing bacterial
growth streptococcus in the bodys
systemic circulation. Inflammation of the
glomeruli of the kidney occurs as an
immune complex disease after infection
with nephritogenic streptococci. Tissue
damage occurs from a complement
fixation reaction a cascade of protein
activated by antigen-antibody reaction
plugs and obstructs the glomeruli causing
kidney damage leading to water retention
increasing systemic blood volume and
cardiac workload thus increase in heart
rate resulting inefficient pumping of the
heart leading to the lungs causing
pulmonary congestion during respiratory
congestion there would be insufficient gas
exchange resulting dyspnea, low O2
saturation, restlessness and increase
respiratory rate.

Within 4
days of
rendering
nursing care
the client will
display
normal
breathing
pattern

INTERVENTION

RATIONALE

INDEPENDENT
Assess the level of consciousness and skin tone.

Note

for respiratory rate, depth, use of accessory


muscles, pursed-lip breathing.

To evaluate degree of compromise

Assist client in proper deep breathing exercise

To promote good lung expansion

Position the client in semi-fowlers position by


elevating the head of the bed

Auscultate

chest.

Encourage adequate rest periods between


activities

To evaluate the changes in gas exchange which


affects the level of consciousness and skin tone.

To prevent compression of the diaphragm by


allowing the organs in the peritoneal cavity to
lowerdown.

To evaluate presence/character of breath sounds


and secretions.

To avoid overexertion

To promote proper breathing/ to prevent obstruction


of circulation

Instruct significant others not to let the child wear


tight clothing.

To prevent cause of abdominal distention.

To limit impact on client's breathing.

Instruct

SO not to let the client overeat and eat


gas-forming foods.
Educate

SO about environmental factors that may


trigger disease of the patient
Anxiety may be causing acute or chronic
hyperventilation.

Note

emotional responses(e.g., gasping, crying,


reports of tingling fingers)

INTERVENTION
COLLABORATIVE
Administer diuretic (furosemide)
IV/stock 40mg/2mL/0.3cc every
12 hours, as ordered.
Administer

RATIONALE

To increase water excretion

oxygen at lowest
concentration indicated and
prescribed repiratory medications.

For

Monitor pulse oximetry, as


indicated.

management of underlying
pulmonary condition, respiratory
distress.

To verify maintenance/
improvement in O2 saturation

EVALUATION
After 4 days of rendering effective
nursing care, the client with altered
breathing pattern was able to restore
normal breathing by evidence of
absence of nasal flaring, no restlessness,
no pale skin with respiratory rate of 40
cpm, with the temperature of 37 C, and
heart rate of 90 bpm, with the BP of
100/70 mmHg. Chest x-ray shows
negativity of fluid retention in the lungs.

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