OUR LADY OF FATIMA UNIVERSITY

COLLEGE OF NURSING

REGALADO, FAIRVIEW, QUEZON CITY

CASE PRESENTATION

ACUTE GLOMERULONEPHRITIS

PRESENTED BY:

BSN 4A1-A

Group 1

Almerino, Ma. Alfie Rose J.

Apostol, Gloria G.

Bacnis, Arjay Aezon

Banza, Heidee Marie B.

Fajardo, Veronica Kaychelle T.

Galeno, Josefina

Moreno, Beryl Jean Z.

Ostia, Quenz Chavyrrie

Pasos, Dianne O.

Ramos, Messalea B.

Romero, Robert Bryan O.

PRESENTED TO:

Ms. Teresita Joyce O. Ayala, R.N, RM, MAN

January 26, 2011

Ospital ng Lungsod ng Sapang Palay

(OLSP)

TABLE OF CONTENTS

I. INTRODUCTION

II. OBJECTIVE

III. PATIENT’S PROFILE

IV. PHYSICAL ASSESSMENT

V. THEORETICAL FRAMEWORK

VI. LABORATORY/ DIAGNOSTIC FINDINGS

VII. ANATOMY AND PHYSIOLOGY

VIII. PATHOPHYSIOLOGY

IX. COURSE IN THE WARD

X. NURSING CARE PLAN

XI. DRUG STUDY

XII. DISCHARGE PLANNING

INTRODUCTION

Acute glomerulonephritis is an active inflammation in the glomeruli, it 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,

or capillary endothelium. In acute glomerulonephritis, the kidneys are normal in size or

enlarged and edematous, and the surface of the kidney may show punctate

hemorrhages.

Symptoms of acute glomerulonephritis include the following: Hematuria is a universal

finding, even if it is microscopic. Gross hematuria is reported in 30% of pediatric

patients. Edema (peripheral or periorbital) is reported in approximately 85% of pediatric

patients; edema may be mild (involving only the face) to severe, bordering on a

nephrotic appearance. Headache may occur secondary to hypertension; confusion

secondary to malignant hypertension may be seen in as many as 5% of

patients. Shortness of breath or dyspnea on exertion secondary to heart failure or

pulmonary edema; usually uncommon, particularly in children. Possible flank pain

secondary to stretching of the renal capsule. Hypertension is seen in as many as 80%

of affected patients. Hematuria, either macroscopic (gross) or microscopic, may be

noted. Skin rashes (ie, malar rash frequently seen with lupus nephritis) may be

observed. Abnormal neurologic examination or altered level of consciousness occurring

because of malignant hypertension or hypertensive encephalopathy. Arthritis may be

noted.

A doctor can diagnose AGN by performing Urinalysis, CBC, Electrolytes, including BUN

and creatinine (to estimate the glomerular filtration rate [GFR). Procedure like renal

biopsy is required for definitive diagnosis. Primary diseases that solely affect the

kidneys and cause AGN, are Immunoglobulin A nephropathy (IgA nephropathy,

Berger’s disease), membranoproliferative nephritis (type of kidney inflammation), post

infectious GN (GN that results after an infection).

Glomerulonephritis may be a temporary and reversible condition, or it may get worse.

Progressive glomerulonephritis may lead to chronic kidney failure and end-stage kidney

disease.

The goal of treatment is to stop the ongoing inflammation and lessen the degree of

scarring that ensues. Depending on the diagnosis, there are different treatment

strategies. Often the treatment warrants a regimen of immunosuppressive drugs to limit

the immune system’s activity. This decreases the degree of inflammation and

subsequent irreversible scarring.

Most epidemic cases follow a course ending in complete patient recovery as many as

100%. Most cases occur in patients aged 2-12 years. Only 10% of cases occur

in patients older than 40 years Less than 5% of cases occur in patients younger than 2

years old. Male to female ratio is 2:1. In children, most common is post infectious AGN,

the majority of which is post streptococcal AGN.

The DOH had recorded a total of 19,475 cases last year.

As a group, we decided to study this kind of disease for us to know more about the

complications. As a nursing students, we must not only focus to one corner or merely by

just taking care of our patients but to know their underlying condition as well for the

better and good nursing intervention done to promote maximum living ability.

Furthermore, we have chosen this case study in order to identify and determine the

general health problems and needs of the patient with an admitting diagnosis of acute

glomerulonephritis. This study also intends to help patient as well as its significant

others to promote health and medical understanding of such condition through the

application of the nursing theories and nursing skills.

OBJECTIVES

General Objective:

The group aims to have a better understanding about Acute Glomerulonephritis (AGN)

for us to be an effective nurse in this course condition.

Specific Objectives:

At the end of the case study, the students must able to:

Define and recognize AGN and to describe its pathophysiology, clinical

manifestation and medical management.

Incorporate nursing process and promote appropriate nursing interventions.

Know and promote preventive measures such as healthy lifestyle and

management.

PATIENT’S PROFILE

Biographic Data

Name : Patient RL

Age : 13 years old

Gender : Male

Address : Bulacan

Birthday : September 10 1997

Religion : Roman Catholic

Civil Status : Single

Nationality : Filipino

Source of information : RL and his Auntie

Room : 21

Bed no. : 7

Date of Admission: January 14, 2011

Time of Admission: 11:39 am

Chief Complaint : Pain (Radial area)

ADMITING DIAGNOSIS: AGN

PHYSICAL ASSESSMENT

DATE PERFORMED JANUARY 24 AND 25, 2010

PART OF THE BODY

MEASUREMENT NORMS ACTUAL FINDINGS

ANALYSIS

Initial Vital Signs

Temperature

Cardiac Rate

Respiratory Rate

Blood Pressure

General appearance

Body built

Over – all hygiene and

grooming

36.5 – 37.0°C

55 – 85 bpm

12 – 18 cpm

110 – 135 / 65 – 85 mmhg

Height: 5’3”Weight: 107 – 130

lbsBMI: 19 – 23

(G&A notes 2005)

Clean and neat

37.5°C

25 cpm

120 / 90 mmhg

4’2”68 lbs

BMI:

Clean and neat (morning care

done)

Febrile(abnormal)

Abnormal due to fear

Normal

AbnormalAbnormal

Clean and neat

Mental Status

Attitude

Effect/ mood appropriateness

of response

Cooperative

Appropriate in situation

Cooperative

Sometimes inappropriate

Normal

Abnormal due to he wants to

go home

Quantity, quality & organization of

speech

Relevance and organization of

thoughts

Understandable, moderate, exhibit

thought association

Logical sequence, make sense of

reality

UnderstandableModerate, exhibit

thought association

Logical sequence, make sense of

reality

Normal

Normal

SKIN Color appropriate to genetic

background

Color appropriate to genetic background

Edematous skin Abnormal due to lack of protein

thiamine & excess sodium

HAIR Evenness of growth

Texture and thickness

Evenly distributed hair

Fine thick hair

Short hair blackish w/ gold hair w/c is evenly distributed

Fine thick hair

Normal

Normal

HEAD Size, shape and symmetry

Symmetry of facial movement

Facial features

Rounded(normocephalic)

Symmetry of facial movement

Symmetry or asymmetrical facial

features

Normocephalic

Symmetry of facial movement

Symmetry of facial features

Normal

Normal

Normal

EYES Color, texture and presence of

lesion of palpebral

conjunctiva

Clarity and

Shiny, smooth and pink conjunctiva with ( - ) lesion

Transparent, shiny

Smooth and pink or red conjunctiva

with ( - ) lesion

Shiny, smooth and

Normal

Normal

EARS

NOSE

texture of cornea

Presence of edema in the

eyelids

Auricles; color, symmetry of size

and position

Auricles; texture elasticity; areas of tenderness

Hearing acuity response to

normal

External nose: shape, size, color

flaring or discharge from

nares

Patency of both nasal cavities

& smooth details of iris is available

No edema and hallowness

Color uniform to face; symmetry

position

Mobile, firm and not tender; pinna

recoils after it is folded

Normal voiceTune audible

Symmetry and straight, no

discharge or flaring, uniform color

without contraptions

Air moves freely as the client breathes through the nares

details of iris is available

Presence of edema

Color uniform to face; symmetry

position

Firm and not tender; pinna

recoils after it is folded

Normal voiceTune audible

Symmetric and straight, uniform

color, no discharge and without contraptions

Both nares is patent

Abnormal due to edema

Normal

Normal

Normal

Normal

Normal

MOUTH

LIPS

TEETH

Symmetry of contour and

texture of oral mucous

membrane

Color, and condition and presence of

dentures

Uniform pink color, soft, moist, smooth

texture; symmetry of contour, ability to

purse lips

Smooth, white shiny tooth enamel; smooth intact

dentures

Pink in color and slightly dry

Smooth, white shiny tooth

enamel; smooth intact dentures

Abnormal, may suggest dehydration

because strict fluid intake

Normal

ANTERIOR

THORAX

POSTERIOR

THORAX

Breathing patterns

Anterior thorax auscultation

Quiet, rhythmic, and effortless

respirations

Broncho vesicular and vesicular breath

sounds

Vesicular and broncho vesicular

breathSounds

Quiet, rhythmic and effortless respirations

Broncho vesicular and vesicular breath sounds

Vesicular and broncho vesicular

breath sounds

Normal

Normal

Normal

UPPER EXTREMITIES

Shoulder

Elbow

Performs internal and external rotation

of the arms

Perform flexion and extension, pronation

and supination of forearm

Can perform internal & external

rotation of the arms

( but pain during ROM)

Can perform flexion &

extension, pronation & supination of

forearm

Abnormal due presence of

edema

Abnormal due to presence of

edema

ABDOMEN

Hands and fingers

Wrist

Contour and symmetry

Performs flexion, extension, abduction

and adduction

Perform flexion and extension, radial and ulnar flexion

Flat, rounded or scaphoid, no

abnormal enlargement, no bulges or ridges

( but pain during ROM)

Can perform flexion, extension,

abduction & adduction

( but pain during ROM)

Can perform flexion &

extension, radial & ulnar flexion

( but pain during ROM)

Flat, rounded, no abnormal

enlargement, no bulges or ridges

Abnormal due to presence of

edema

Abnormal due to presence of

edema

Normal

LOWER EXTREMITIES

Knees (Right knee)

(Left knee)

No presence of inflammation, lesion. Can flex and rotate

No presence of inflammation, lesion. Can flex and rotate.

No presence of inflammation

lesion. Can flex & rotate

No presence of inflammation

lesion. Can flex and rotate

Normal

Normal

DEVELOPMENTAL TASK

According to Erik Erikson who adapted Freud’s theory, people continue to develop

throughout life. He describe eight stages of development, each stages must be

accomplished in order to reach the level of achievement. The resolution of the task can

be complete, partial successful or unsuccessful, success to complete any development,

the healthier the personality is failure to complete can be viewed as a series by crises,

damages the ego. Both positive and negative aspects of the critical life periods.

Patient X is under adolescent in the stage of development task, he is 13 y/o (12-20 y/o)

an identity vs. role of confusion, a coherent sense of self plans to actualize once

abilities, feelings of confusion, in decisiveness and possible anti-social behavior.

According to patient X, he is living with his aunt for almost four years now. The reason is

his parents are separated since he was born. He shows positive reaction regarding on

his health condition by being cooperative to health care providers. Negative aspects of

his life, helps him to feel brave enough to become independent

Based on Gordon functional patterns, which provide a framework to signify the

sequences of recurring behavior. Patient X, during our interaction describes normal

sleeping rest pattern, exercise by walking when he go to school and do some household

chores assigned to him. Cognitive and self perception including relationships shows

lack of development, a little bit stress seen but still tolerable, acts of being tough

despites of living with his family was noticeable on his values belief pattern.

LABORATORY / DIAGNOSTIC FINDINGS

URINALYSIS

DATE EXAMINATION NORMS RESULT INTERPRETATION

ANALYSIS

1/15/11

Color

Transparency

Reaction

Specific gravity

Protein

Sugar

RBC

Pus cells

Epithelial cells

Mucus threads

Amorphous

urates

Straw/amber

Clear

Acidic

1.005–1.030

Negative

Negative

< 2 / hpf

few

few

few

Yellow

Hazy

Acidic

1.03

+++

Negative

100 > /hpf

10-12/hpf

+

++

+++

Not normal

Not normal

Normal

Normal

Not normal

Normal

increased

increased

Normal

Normal

positive

Concentrated

Measures urine density, or the ability of the

kidney to concentrate or dilute the urine over that

of plasma.

Increase in concentration due to

kidney problem

Due to decreased

glomerular filtration/

indications kidney problem

indicates inflammation in the urinary tract

indicates kidney/urinary tract infection

due to kidney disease, the urine is concentrated

that made amorphous urates form

Coarse granular

cast

negative

None

1-2/hpf positive indicates urinary tract infection

BLOOD CHEMISTRY

DATE EXAM NORMS RESULT INTERPRETATION

ANALYSIS

1/15/11

BUN

Creatinine

2.5-6.4 mmol/L

35.4-123.8

mmo/L

9.9 mmol/L

83.3 mmol/L

increased

Normal

due

to decreased

glomerular filtration rate due to kidney problem

HEMATOLOGY

DATE EXAMINATION NORMS RESULT INTERPRETATION

ANALYSIS

1/14/11

Hgb

Hct

WBC count

140-170 g/L

0.4-0.5

5-10x109

82 g/L

0.26

24.5x109

decreased

increased

increased

Due to malnutrition

Indicates anemia

Indicates inflammation in the urinary tract

Indicates  infection

Differential

Count

Segmenters

Lymphocytes

Eosinophils

0.55-0.65

0.25-0.35

0.00-0.05

0.9

0.06

0.04

decreased

decreased

Normal

indicates Infection

Patient

Is susceptible in infection

1/20/11

Hgb

Hct

WBC count

Differential

count

Segmenters

Lymphocytes

140-170 g/L

0.4-0.5

5-10x109

0.55-0.65

0.25-0.35

76 g/L

0.24

10.6x109

224x103

0.81

0.19

decreased

Not normal

Slightly increased

Not normal

Not normal

Due to malnutrition

due to presence of

infection

infection

Deficiency in

immune

response

indicates infection

KUB SONOGRAM

Right kidney                         8.08 x 4.8 x 4.3 cm

Left kidney                            8.8 x 5.8 x 5.4 cm

Size                                        normal

Findings                                slightly echogenic kidneys

Ureters                                   non-dilated

Urinary bladder findings normally filled, smooth wall

Impression                            diffuse parenchymal changes of kidneys

 

           

ANATOMY AND PHYSIOLOGY OF URINARY SYSTEM

Functions:

Help maintain the homeostasis by controlling the composition, volume and

pressure of the blood.

Excrete the waste products of the body.

Regulation of the blood pH.

Contributions to metabolism.

Composition of the Urinary System

Kidney

1. The two reddish kidney beans are said to be retroperitoneal organs.

2. The right kidney is slightly lower than the left kidney.

3. The three layers surround each kidney: Renal Capsule (deep layer), Adipose

capsule or the Perirenal fat (intermediate layer), Renal Fascia (superficial layer).

4. Renal Hilus > it is where the blood and lymphatic vessels and nerves enters and

exit the kidney. It is also through which the ureter leaves the kidney.

5. Renal Sinus > it is a cavity within the kidney and also entrance of the renal hilus.

6. Within the kidney are three distinct regions: Renal Cortex (a superficial reddish

area), Renal Medulla (a deep reddish brown

region) and Renal Pelvis (formed by the 2

calyces)

7. within the renal medulla lies the Renal

Pyramids

8. Major Calyx > is formed by the union of 2 or

more calces.

9. Minor Calyx > receives the urine from several renal papilla.

Nephron

I. (from Greek νεφρός - nephros, meaning "kidney")

II. It is the basic structural and functional unit of the kidney.

III. Parts:

* Glomerulus > is a capillary tuft that receives its blood supply from an afferent

arteriole of the renal circulation.

> it is like a ball of yarn

>The glomerular blood pressure provides the driving force for water and solutes

to be filtered out of the blood and into the space made by Bowman's capsule.

* Renal Tubule > is the portion of the nephron containing the tubular fluid filtered

through the glomerulus.

>The components of the renal tubule are:

Proximal convoluted tubule

Loop of Henle

o Descending limb of loop of Henle

o Ascending limb of loop of Henle

Distal convoluted tubule

Mechanism of Urine Formation:

1. Glomerular Filtration

2. Tubular Re-absorption

3. Tubular Secretion

Ureter

There are two uterine tubes that carry urine from the kidneys to the bladder.

Each ureter is about ten to twelve inches long. Urine flows down partly by gravity,

but mainly by waves of contractions which pass several times per minute through

the muscle layers of the urethral walls.

Each ureter enters the bladder through a tunnel in the bladder wall, which is

angled to prevent the urine from running back into the ureter when the bladder

contracts.

Urinary Bladder

is the organ that collects urine excreted by the kidneys before disposal by

urination

A hollow muscular, and distensible (or elastic) organ, the bladder sits on the

pelvic floor. Urine enters the bladder via the ureters and exits via the urethra.

It stores for about 1000mL of urine.

Urethra

It is a tube that connects the urinary bladder to the genitals for removal out

of the body.

In males, the urethra travels through the penis, and carries semen as well

as urine. In females, the urethra is shorter and emerges above the vaginal

opening.

The external urethral sphincter is a striated muscle that allows voluntary

control over urination.

In the human female, the urethra is about 1.5–2 inches (4–5 cm) long and

exits the body between the clitoris and the vagina, extending from the

internal to the external urethral orifice.

In the human male, the urethra is about 8 inches (20 cm) long and opens

at the end of the penis.

NEPHRON

PATHOPHYSIOLOGY OF ACUTE GLOMERULONEPHRITIS

Post Streptococcal Infection

(Group-A, Beta-Hemolytic)

Antigen-Antibody Complex form

It deposits in the Glomeruli

Inflammatory Response

(Inflammation of Glomerulus)

Production of Endothelial Cells

-Increase permeability of -Blocking of the Capillaries Hematuria

Basement membrane of Glomeruli &

-Vasospasm of Afferent Proteinuria

Edema Arterioles

Oliguria Glomerular Filtration Rate

decreases

Retention of Water and Sodium

Hypervolemia

Hypertention

COURSE IN THE WARD

January 14, 2011

A 13 year old male patient was admitted in the ER, accompanied by his mother, with a

chief complaint of shortness of breath and dizziness. Patient is weak looking upon

admission and has had seizure. He was seen and examined by Dr. Enriquez, with

orders of low salt, low fat diet; fluid intake limitation to 645 mL for 24 hours; CBC,

blood typing, BUN, creatinine, C3, ESR, ASO, chest x-ray (posterior, antero-lateral),

KUB UTZ; I/O monitoring. Patient was hooked with D5W 1L inserted as venoclysis at

KVO regulation. Medications ordered were amlodipine 5 mg PO OD; furosemide 30 mg

TIV q 120; diazepam 5 mg TIV for seizure; penicillin G 750 mg TIV q 60; phenobarbital

300 mg TIV q 80 as loading dose then shift to 50 mg TIV q 80. Dr. Enriquez also

ordered for O2 inhalation via nasal cannula at 5 L/min. Patient was febrile (38.2 0C) at

1:45 pm and was given paracetamol 300 mg TIV at 2 pm. CBC was done and relayed to

the physician. Consent for admission was secured and signed.

In the afternoon, Dra. Dungca seen and examined the patient and ordered for

ceftriaxone 1.5 g TIV q 120; captopril 25 mg tab ½ tab BID (12 hours apart); for

urinalysis; BP strict monitoring q 20; UO monitoring; discontinue penicillin G; heplock

insertion. Patient was febrile (38.7 0C), paracetamol given TIV.

January 15, 2011

The doctor seen and examined the patient and was ordered with the same diet – low

salt, low fat, soft diet and fluid intake limitation. The patient had blurring of vision,

headache, weak in appearance, conscious and coherent, febrile (38.4 0C). The patient

was instructed to do TSB and was given paracetamol. At 2:30 pm, the doctor changed

the patient’s fluid intake limitation to 1L for 24 hours. The result of BUN, creatinine, and

urinalysis was relayed to Dr. Enriquez, while urinalysis was referred to Dr. Lim.

In the afternoon, the patient complained of headache and dizziness, was febrile and

given paracetamol. The patient was positive for tea colored urine.

January 16, 2011

Patient appears weak with blurring of vision. He was transferred to Room 21. Upon

endorsement for the shift (7-3pm), the patient was still weak in appearance and

complains pain at the IV site. He was given O2 inhalation 5 L/min via nasal cannula.

BP was 90/60 at 12 pm, a febrile, without dizziness and without blurring of vision. Due

medications were given and needs were attended.

January 17, 2011

The patient was negative for dizziness, blurring of vision, difficulty of breathing the

whole day, still with O2 inhalation 5 L/min via nasal cannula. During the 7am-3pm shift,

O2 inhalation was temporarily stopped and IVF was removed due to phlebitis at IV site,

and again reinserted on the other arm. Medications were given and needs were

attended.

January 18, 2011

The patient was seen and examined by Dr. Flores and gave new order for furosemide to

start at 20 mg tablet BID for 3 days. Reminded the patient’s watcher to facilitate KUB

UTZ, C3, ASO, ESR; ordered for BP monitoring q 20 and I/O monitoring. Heplock was

removed, during the shift of 11pm-7am, because of phlebitis at insertion site, and was

again reinserted aseptically during the 7-3pm shift. The patient was again slightly

febrile and was instructed to do TSB.

January 19, 2011

The patient was again febrile and instructed watcher to do TSB. Patient experienced

pain at IV insertion site. IVF terminated and reinserted at 1:10 pm. He was febrile, with

readings of 38 0C and 38.4 0C, and was given paracetamol TIV with BP readings of

120/80 mmHg on 7-3pm shift and 120/90 mmHg on the next shift.

January 20, 2011

The doctor ordered for Sumapen 500 mg q 60 for 5 days; D5 0.3 NaCl regulated at 20-25

gtts/min; to secure 2 units of packed RBC of blood type B; paracetamol 1 ampule q 60

prn for temperature > 38 0C. The result for CBC with pH was referred to Dra. del

Rosario. The patient was given paracetamol TIV for fever and was instructed to do TSB.

Heplock was removed during 7-3pm shift. Hematology result was referred to Dr.

Maghoo. The patient had fever again, instructed the watcher to facilitate availability of

IVF and abhocath for BT. Reason for having blood transfusion was discussed and

request for BT of 2 units of PRBC was given to the watcher. D5 0.3 NaCl 500 cc IVF

inserted and regulated at 25-26 gtts/min. Another paracetamol 300 mg 1 ampule was

given prn TIV.

January 21, 2011

The patient was febrile and given paracetamol 300 mg 1 ampule TIV. Seen and

examined by Dr. Lim, and reminded the watcher to have C3, ASO, ESR performed.

Another physician ordered for chest x-ray; continue ceftriaxone 1.5 gm q 120 TIV; start

ciprofloxacin 250 mg tab, 1 tablet BID; V/S monitoring q 40. The patient was reminded

on oral restriction and for PPD. IV medications not met, only oral medications were

given (amlodipine, furosemide, Sumapen). Needs were attended.

January 22, 2011

Advised patient to limit OFI. The patient was seen and examined by Dr. Lim and

ordered for chest x-ray. IVF was dislodged during 7-3 pm shift, hooked with D5 0.3 NaCl

1L, but then again it was terminated d/t phlebitis at IV insertion site. The patient had tea

colored urine. Medications were given. Furosemide 20 mg tab BID for 5 days was

completed. Needs were attended.

January 23, 2011

The patient was hooked with D5 0.3 NaCl 1L regulated at 25 gtts/min. Seen and

examined by physician. Medications were given and needs were attended.

January 24, 2011

The patient has a standing order for C3, ASO, ESR, PPD, and chest x-ray. The

physician ordered for OFI limitation. Medications were given and needs were attended.

BP AND UO MONITORING

DATE SHIFT TIME TEMPERATURE (0C) BP (mmHg) UO (cc)

1-14-11 7-3

3-11

12126810

37.638.837.838.738.6

150/90140/80140/80130/90130/80130/90

350

1-15-11 11-7 246

37.737.537.7

130/90130/90

130/100350

7-3 810122

37.237.837.138.2

130/70130/80130/80120/80

510

3-11 4:30610

38.138.538.9

120/80110/80110/70

160

1-16-11 11-7 26

37.136.9

110/70120/80

550

7-3 10122

36.436.437

110/7090/6090/60

600

3-11 610

36.236.4

100/70110/80

700

1-17-11 11-7 26

36.636

110/70110/70

1500

7-3 102

36.336.1

110/70120/80

3-11 610

3837.5

120/80110/80

1-18-11 11-7 26

36.937.1

120/80110/80

500

7-3 810122

37.537.137.538.4

110/80110/80110/80110/70

200

3-11 468

37.837.437.4

110/70100/70100/60

350

1-19-11 11-7 1026

37.538.535.9

110/80110/80100/80

300

DATE SHIFT TIME TEMPERATURE (0 C) BP (mmHg) UO (cc)

1-19-11 7-3 810122

36.336.236.838

110/80110/80110/80120/80

300

1-20-11 11-7 1226

39.336.3

120/80120/80110/60

400

7-3 810122

37.437

37.837

100/80100/80110/80110/80

300

3-11 46810

38.138

37.937.5

110/80120/80120/80110/80

1-21-11 11-7 1226

37.137.237.1

120/80110/80110/80

300

7-3 810122

38.336.536.436.4

110/70110/70110/70110/70

200

1-22-11 7-3 810122

36.536.436.937

120/80120/80120/70120/70

250

1-23-11 11-7 246

36.836.736.7

130/90120/80120/80

300

7-3 810122

36.136.636.937.4

110/80110/80110/70110/70

3-11 46810

37.137.737.337.4

120/80110/80110/80120/80

1-24-11 11-7 12246

37.137.336.936.8

120/70110/70110/70110/70

200

7-3 810122

36.936.936.936.8

110/80110/80110/80110/80

150

IV FLUID

DATE SHIFT KIND OFSOLUTION

VOL gtts/min

TIME STARTED

TIMEENDED

REMARKS

1-14-11 7-3 D5 W 1 L KVO 11:00

1-14-11 3-11 shifted to heplock

1-20-11 7-3 heplockterminated

1-20-11 3-11 D5 0.3 NaCl 500cc 25-26 8:00 1:30

1-21-11 7-3 D5 0.3 NaCl 1L 25-26 7:00 5:30 followup

1-23-11 3-11 D5 0.3 NaCl 1L 25 9:50 8:20 Followup

MEDICATION LIST

DRUG / DOSAGE

DATE AND TIME GIVEN14 jan 15 jan 16 jan 17 jan 18 jan 19 jan 20 jan 21 jan

amlodipine 5 mg PO OD

11:30 pm

am am 6 am 6 am 6 am 6 am 6 am

furosemide30 mg TIV q 120

11:30 pm

12 am12 pm

12 am12 pm2 pm8 pm

8 am6 pm

6 am

DC

diazepam5 mg IV for seizure

12:15 pm3 pm

paracetamol300 mg TIV q 40

2 pm10 pm

2am6 am 6 pm

2 pm6 pm

2 am2 pm10 pm

2 am

penicillin G750 mg IV q 60

(-) ANST

DC

phenobarbital50 mg IV q 80

9 pm 6 am2 pm4:35

12 am8 am6 pm

2 am10 am10 pm

6 am6 pm

2 am10 am

2 am10 am

6 am2 pm10 pm

ceftriaxone1.5 gm q 120

10 pm 10 am10 pm

10 am10 pm

10 am 12 am12 pm

2 am2 pm

6 am 6 am6 pm

captopril25 mg tab ½ tabBID

9 pm 9 am9 pm

9 am10 pm

10 am10 pm

10 am 10 am 10 am

DRUG /

DOSAGE

DATE AND TIME GIVEN18 jan 19 jan 20 jan 21 jan 22 jan 23 jan 24 jan

furosemide20 mg tab ½ tab BID for 3 days

6 am6 pm

6 am8 pm

6 am6 pm

6 am10 pm

6 am12 pm Completed

Sumapen500 mg/cap q 60

12 pm6 pm

12 am6 am12 pm

12 am6 am12 pm6 pm

12 am6 am12 pm6 pm

2 am8 am2 pm

paracetamol300 mg 1 ampQ 60 prn T > 380 C

8 pm 8 am8 pm

ciprofloxacin250 mg tab BID

6 am6 pm

6 am6 pm

6 am

BLOOD TRANSFUSION BP MONITORING

TIME BP (mmHg) REMARKS

10:5011:0511:2011:5012:202:203:30

120/70120/90

150/100150100130/90

130/100130/100

prior to BT15 min15 min30 min30 min2 hourspost BT

expiration date: 24 hours after packing

date/time packed: 21 jan 2011 / 9:40 pm

DISCHARGE PLANNING

Medication are explained to the patient and family members the importance of taking

medicines.

Discuss to the patient and family the dosage, frequency and adverse effects of  the

drugs.

Encourage/instruct to keep the edematous extremities to elevate as often.

Provide warm environment.

Tell the patient that she should have self-monitoring by checking his vital signs and

weighing regularly.

Temperature

Respiratory Rate

Pulse Rate

Blood Pressure

Limit of water intake, monitor intake and output.

Hygiene should be proper for comfort.

Proper hand washing.

Improve Nutritional Status.

Out -patient schedule for follow check-up must be followed.

Instruct the patient to seek regular check-up.

Diet should be low fat and low sodium foods that will help not worsen his condition.

Eat five or more servings of vegetables and fruit daily.

Intake of fluids 8-10 glasses a day to avoid constipation.

Spiritual health affects the wellness of an individual greatly.