CENTRAL LUZON DOCTORS’ HOSPITAL - EDUCATIONAL INSTITUTION, INC

Romulo Highway, San Pablo, Tarlac City

Tel No. (045) 982-5019/982-5052/982-0264 Fax No. (045) 982-0780/982-

2757 

DEPARTMENT OF NURSING

In partial fulfillment of the requirements for NCM_109 RLE, 

Care of Mother and Child at Risk or with Problems (Acute and Chronic)

Submitted by: GROUP 3

Espinosa, Jan Cyril
Ferrer, Orlyn Joy
Gallebo, Cyrille
Garcia, Jimlord
Garcia, Le-An Walter
Gutierrez, Yoof Clarideth
Javier, Joy Ann
Laxamana, Yvonne
Manabat, Rica
Maniti, Khate
Manuel, Lewy Shea
Mariano, Paulyn Rae

Submitted to:
Catherine K. Flores, RN, MSN
Darell G. Absalud, RN, MSN

May 2022
 I. Introduction

          A child should be enjoying his/her life. Playing with cousins, friends, and neighbors. But

not all children are given a chance to enjoy their childhood. Some children develop diseases and

illnesses at an early stage of their life. Which can be a threat to their life. It is sad to know that

there are children who undergo this situation, but this happens in reality.

          According to Brown (2021), acute glomerulonephritis is defined as inflammation and

subsequent damage of the glomeruli leading to hematuria, proteinuria, and azotemia; it may be

caused by primary renal disease or systemic conditions. The glomerular filtration rate is

decreased, leading to activation of the renin-aldosterone system and subsequent salt and water

retention, resulting in edema and hypertension.

        

Parmar (2020) stated that acute glomerulonephritis (GN) comprises 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. Acute nephritic syndrome is the most serious and potentially devastating form of

the various renal syndromes. 

         This happens when the kidney doesn’t work normally because of inflammation. The kidney

cannot filtrate the fluid accordingly which can cause edema. As nurses, we have the

responsibility to help to diagnose acute glomerulonephritis because if this is left undiagnosed it

can be permanent kidney disease. As nurses, we should do all the needed tests. And holistically

assess the client.

        
Acute glomerulonephritis can be seen in people who sign and symptoms of pink or cola-colored

urine from red blood cells in your urine (hematuria), foamy or bubbly urine due to excess protein

in the urine (proteinuria), high blood pressure (hypertension), fluid retention (edema) with

swelling evident in your face, hands, feet, and abdomen, urinating less than usual, nausea and

vomiting, muscle cramps, and fatigue.

         In this study, the client is John Johnsons, 8 years old male. The client is currently living in

Tarlac City, Tarlac. Upon check, the mother of the client stated that she is concerned about her

child because she noticed that her child has coke-colored urine, complained of back pain and the

child's face is swelling.

         This paper contains the objectives, the health history of the client, current health status,

head-to-toe physical assessment data to be used in formulating a nursing care plan, laboratory

findings, drug study, recommendations, and the evaluation of the objectives.

           At the end of the study, it is expected that this will give the client the knowledge that is

imparted to us. May this serve as a start for the improvement of aiming for proper service and

care to the patient who has acute glomerulonephritis.

 II. Objectives

 This chapter presents the general and specific objectives of the study. Setting objectives

provides direction for planning an individualistic nursing intervention. It facilitates motivation

for the client and the nurse by providing a sense of achievement (Kozier, Erb et. al., 2004).

General

At the end of the study, the student nurse will be able to perform the nursing process

(assessment, diagnosis, planning, intervention, and evaluation) that will give the client the

chance to improve his health status and be free from pain caused by acute glomerulonephritis.

Specific

At the end of the study the student nurse will be able:

1. To holistically assess the client.

2. To review body systems.

3. To give emphasis to the most affected body parts of the client.

4. To know the mental state of the client.

5. To formulate a nursing care plan that best suits the client.

6. To analyze drugs or medications taken by the client.

7. To provide health teachings necessary for client with acute glomerulonephritis; and

8. To evaluate nursing interventions.

 III. Nursing Process

Data Base

0. Nursing Health History A

1. Demographic Data

Name: John Johnsons

Age:  8 years old

Sex: Male

Social affiliation: Single

Religion: Roman Catholic

2. Chief Complaint/s

The client reports brownish urine and face edema also complains of back pain in the flank

area and dull generalized headache.

3. History of Present Illness:

The client has been experiencing fever and sore throat in the last two weeks. The patient's

guardian said he was relieved by taking paracetamol and after two days face started to swell, and

urine was brownish. No family history of renal failure nor renal transplant.
4. Past Medical History

i. Pediatric and Adult Illness

The patient has no reported past medical history of illnesses.

ii. Immunizations/Tests

The patient is fully immunized with all the basic vaccines.

iii. Hospitalizations

The patient’s guardian reported that his child hasn't been hospitalized.

iv. Injuries: None

v. Transfusions: None

vii. Medications

The client had taken paracetamol when experiencing fever and sore throat in the last two weeks.
6.Genogram
7. Review of System

GENERAL DESCRIPTION

  John Johnsons is an 8-year-old residing from Matatalaib, Tarlac, weighing 46 kg and

standing 152 cm, and has been reported to have brownish urine and facial edema. Complains of

back pain in the flank area and dull generalized headache that has not been relieved by

medications.

1. SKIN

There is no presence of skin rashes, lesions and has no reported itching.

A. SKIN

Itching X

Bruising X

Rash X

Bleeding X

Lesion X

Color Change X

2. EYES

Mild Periorbital edema is noted in patient’s both eyes, because loose tissues can more

easily accommodate fluid.

B. EYES
Pain X

Itching X

Vision loss X

Diplopia X

Blurring X

Excessive tearing X

Glasses/Contact lenses X

3. EARS

Both ears of the client are clear, no presence of discharges and no complaint of hearing

loss.

C. EARS

Aching X

Discharge X

Tinnitus X

Hearing loss X

4. NOSE

Patient’s nose is normal, no reported discharge and epistaxis. No obstruction is noted.

D. NOSE

Obstruction X
Epistaxis X

Discharge X

5. THROAT AND MOUTH

There is reported soreness in the patient's throat and has no signs of bleeding gums in

inspection.

E. THROAT AND MOUTH

Soreness /

Bleeding Gums X

Toothache X

Tooth decay X

6. NECK

There is no presence of enlarged lymph nodes noted, no reported swelling, dysphagia and

hoarseness.

F. NECK X

Swelling X

Dysphagia X

Hoarseness X

7. CHEST
 The chest is clear, no abnormal breath sounds are heard upon auscultation. No reported

chest pain respiration, no presence of cough, no lumps and bleeding noted.

G. CHEST

Coughing X

Wheezing X

Rest Exertion X

Bleeding X

Pain on respiration X

Breast lumps X

Breast pain X

Nipple Discharge X

Hemoptysis X

Dyspnea X

8. GIT
 Due to too much protein escaping into the urine leaves a lack of protein in blood results

in poor appetite.

H. GASTROINTESTINAL TRACT

Food tolerance X

Heartburn X

Nausea X

Jaundice X

Vomiting X

Pain X

Bloating X

Excessive gas X

Constipation X

Change bowel movements X

Melena X

9. GU

Due to subsequent damage of the glomeruli, red blood cells and proteins leak through the

glomerular filter and expelled in the urine causing it to have a brownish color, experience

flank pain, and decrease in urine output.

I. GENITOURINARY TRACT
 Dysuria X

Nocturia X

Retention X

Polyuria X

Dribbling X

Hematuria /

Flank pain /

Oliguria /

11. EXTREMITIES

No report of any joint pains, edema, and stiffness and no show of varicose veins on extremities.

J. EXTREMITIES

Joint pains X

Varicose veins X

Claudication X

Edema X

Stiffness X

Deformities X
12. NEURO

John is experiencing a dull generalized headache. Mental Health Status: Fear and Anxiety: due

to edema on his face John fears that other kids will ridicule him and anxious when he will

recover as he wants to go back to school.

K. NEURO

Headaches /

Dizziness X

Memory loss X

Fainting X

Numbness X

Tingling X

Paralysis X

Paresis X

Seizures X

M. MENTAL STATUS

Anxiety /

Depression X

Insomnia X

Sexual Problems X
 Fears /

b. Nursing Health History B

1. General Description of Client

An 8-year-old male patient named John Johnsons, currently residing in
Matatalaib, Tarlac. He is 152cm tall and weighing 46kg. John has a brown skin
color. He looks like a brave child because he is not afraid of nurses or doctors.
2. Health-Perception-Health Management Pattern
According to his mother, two weeks ago, John was in a state of good health, but
only two days later, he developed a fever and sore throat. He recovered because
 his mother gave him paracetamol. His mother stated that he had never been
hospitalized until she noticed that his face was swollen, and his urine was cola
colored. He also complains of pain in the flank area and a dull generalized
headache that has not been relieved by medications. John had no history of any
accidents. His mother stated that he takes tiki-tiki as his vitamins.
3. Nutritional-Metabolic Pattern
His mother reported that he drinks a lot of water, but he has a poor appetite. The
client had no history of any weight loss or weight gain. He has no food allergies,
and no difficulty with swallowing.
4. Elimination Pattern
According to his mother, John voids once or twice a day, and his urine is cola-
colored but has no foul smell. He had no previous history of hematuria and no
history of passage of stones through the urethra. His mother also verbalized that
his bowel movements are regular.
5. Activity-Exercise Pattern
According to the client, he plays often, and he loves to ride his bicycle.
6. Sleep-Rest Pattern
His mother stated that he sleeps and wakes up early, but he doesn’t take a nap in
the afternoon. She also stated that John never used any sleeping aids or
medications to promote sleep.
7. Cognitive-Perceptual Pattern
The patient's mother claims that her son has a good memory. He has excellent
sensory and auditory adequacy.
8. Self-Perception-Self-Concept Pattern
The patient's confidence was reduced due to swelling of his face, according to the
mother, who also stated that her son skipped two days of classes due to swelling
of his face.
9. Role-Relationship Pattern
The patient gets along well with his family, particularly his mother. He is always
honest about his worries and feelings.
10. Sexuality-Reproductive Pattern
There is no abnormality with the patient's reproductive organ, and there is no sign
or history of infection.
11. Coping-Stress Tolerance Pattern
According to the mother, her son is constantly cheerful, and when he is sad, he
used to eat his favorite foods and watching cartoons as a coping strategy.
12. Value-Belief Pattern
Mother and her family choose to believe in superstitions and traditional Filipino
healers such as manghihilot and tawas, but they always go to the hospital when
they are sick.
 PHYSICAL ASSESSMENT

1. SKIN

AREA/FEATURE TECHNIQUE SKILLS NORMAL KEY ANALYSIS AND

TO ASSESS FINDINGS FINDINGS INTERPRETATION

Color Inspection Inspect variations in Color varies from The client’s skin is Due to low supply of
skin color under light to ruddy pink pale. hemoglobin.
natural sunlight to or dark brown,
ensure accurate depending on the
findings. race. Color is
uniform except for
sun-exposed areas
or normally
pigmented areas
(nail beds, palms,
lips) in dark-
skinned people.

Lesions Inspection Note for color, size, Freckles, skin tags The client’s skin is Normal
and anatomic in the elderly, and free from moles,
location and some types of lumps, and freckles,
distribution. birthmarks and and no palpable
Palpation moles are normal. lesions and lumps
Palpate lesions with
finger pads for
mobility and contour
(flat, raised, or
depressed) and
 consistency (soft or
durable)

Moisture Inspection and Note amount and Moisture varies The client’s skin Normal
Palpation distribution with activity, body texture is smooth.
and environmental
temperature, and
humidity in skin
folds and the
axillae.

Temperature Palpation Palpate with the The temperature The client’s Normal
dorsum of hand should be uniform Temperature is
noting for uniformity and within the uniform and within
of warmth. normal range. the normal range

Texture (quality, Palpation Palpate with finger The texture is not The client’s skin Normal
thickness, pads in different uniform like the texture is not
suppleness) areas palms and soles uniform some areas
are thicker than are thicker (sole
any area. Wrinkled palm) and some
and leathery skin areas are more
in the elderly thinner
results from
normal aging. The
process decreases
collagen,
subcutaneous fats,
and sweat glands.

Mobility and Palpation Assess mobility and The absence of The client’s Normal
turgor (elasticity) turgor to measure the indention is Mobility and turgor
elasticity of the skin dependent areas of skin is in good
to determine the and the resilience condition and free
degree of hydration. of the skin springs from edema.
back to its
Palpate-dependent previous state after
areas like the sacrum, being pinched.
feet, and ankles for
mobility by applying
pressure with the
thumb for 5 seconds.
Rate the degree of
edema (accumulation
of fluid in
intercellular spaces)
by assessing the
depth of indentation.

Edema may be
described on a scale
as follows:

1. 0 = no pitting

2. 1+ = trace/mild
(2mm) pitting

3. 2+ = moderate
(4mm) pitting

4. 3+ = deep/severe
(6mm)

5. 4+ = very
deep/severe (greater
 than 8mm)

Pinch a fold of skin

on the sternal area
using a forefinger and
note for the spread
with which it returns
to place (turgor).

2. HAIR

AREA/ TECHNIQUE SKILLS NORMAL KEY ANALYSIS AND

FEATURE TO FINDINGS FINDINGS INTERPRETATION
ASSESS

Color and Inspect Assess for color and Color varies from The client’s hair, Normal
Distribution distribution of scalp black to pale blonde eyebrow, and
hair, eyebrows, based on the amount eyelashes are
eyelashes, and body of melanin present. Evenly
surface. distributed.

black hair color

Texture and Palpation Assess for the Thin, straight, The client's hair Normal
oiliness skin’s texture and coarse, thick, or texture is smooth
oiliness with the use curly. Hair is shiny and shiny. Thin
of palm. and resilient and straight hair

infestation Inspection Assess for any Free from any The client’s scalp Normal
presence of infestation. is free from any
 infestation by infestation
examining the hair
and scalp.

3. SCALP

AREA/ TECHNIQUE SKILLS NORMAL KEY ANALYSIS AND

FEATURE TO FINDINGS FINDINGS INTERPRETATION
ASSESS

Scaliness and Inspection Part the hair The scalp should The client's Scalp Normal
scars repeatedly all over the be shiny and appears shiny and
scalp and inspect for smooth without smooth
scaliness and scars. lesions, lumps, or
masses. No signs of
lesions, lumps,
and masses are
present

Tenderness, Palpation Place finger pads on Absence of There are no signs Normal
lesions, lumps, the scalp at the front redness or of redness is
masses and palpate down the scaliness. present on the
midline and each side scalp
for tenderness,
lesions, lumps, or
masses.
 4. NAILS

AREA/ TECHNIQUE SKILLS NORMAL KEY ANALYSIS AND

FEATURE TO FINDINGS FINDINGS INTERPRETATION
ASSESS

Color, shape, and Inspection Inspect for color and Nailbeds is highly The client’s Normal
texture Palpation shape vascular with a Nailbed looks
Palpate nailbed for pink color in normal with a
firmness and texture light-skinned pinkish color. No
clients and signs of
longitudinal pigmentation.
streaks of brown
or black No signs of
pigmentation in clubbing are
dark-skinned present
clients. The angle
between
fingernail and Nail Bed is firm
base is about 160
degrees.
Nailbed is firm

Capillary refill Palpation Press two or more nails When pressure is Capillary refill is Normal
between thumb and released from the less than 2
index finger and note nail, it promptly seconds
the degree of blanching returns to its
and return to normal. normal color.
color.

Lesions Inspection Inspect the tissue The tissue The client’s tissue Normal
surrounding nails for surrounding the surrounding nails
lesions. nail is intact. is intact and has no
lesions.
 5. SKULL

AREA/FEATURE TECHNIQUE SKILLS NORMAL KEY ANALYSIS AND

TO ASSESS FINDINGS FINDINGS INTERPRETATION

Shape and Inspection Inspect skull for shape, Rounded, The client’s Normal
symmetry symmetry, size in symmetrical, skull shape is
proportion to body and normocephalic, round,
position. and upright. normocephalic,
and upright.

Contour, Masses, Palpation Palpate with finger pads Smooth, non- Smooth, non- Normal
Depressions and beginning in the frontal tender, free of tender, free of
Tenderness area and continuing masses or masses or
over parietal, temporal, depressions. depressions.
and occipital areas for
contour, masses,
depressions, and
tenderness.

6. FACE

AREA/FEATURE TECHNIQUE SKILLS NORMAL KEY ANALYSIS AND

TO ASSESS FINDINGS FINDINGS INTERPRETATION
Facial features Inspection Inspect facial features May be oval, The client’s Normal
for expression, shape, round, or square. face is an Oval
and symmetry of Symmetrical shape with
eyebrows, placement of features and symmetric
nose, eyes, and ears. movement. facial
expressions and
movements.

Edema and masses Inspection Inspect for any presence No edema and The client’s Normal
of edema and masses masses face is free
from edema and
masses

7. EYES

AREA/ TECHNIQUE SKILLS NORMAL KEY ANALYSIS AND

FEATURE TO FINDINGS FINDINGS INTERPRETATION
ASSESS

Visual Acuity Inspection Test visual acuity. Normal vision The client has Normal
1. Position Snellen chart based on the normal vision.
 20 ft. in front of the Snellen chart is 20/20 Snellen
client.
20
/20 at 20 feet the chart
2. Remove corrective normal eye can
lenses, if appropriate. read the chart).
3. Instruct the client to
cover one eye and read
lines starting with the
top of the chart from left
to right.
4. Note the line where
the client reads more
than half of the letters.
5. Record results as a
fraction sc (without
correction), 20/ distance
number, and the number
of the letters missed.
6. Repeat the same steps
for the other eye.
7. If appropriate, repeat
steps with the patient
wearing the corrective
device.

Edema and Inspection ***The 6 Fields of Gaze The upper eyelids The client’s normal
masses 1. Conjugate left lateral cover only the Eye movement
gaze uppermost part of appears
the iris and are symmetrical
2. Left down and lateral
free from
gaze
nystagmus
3. Right down and (involuntary
lateral gaze rhythmic
 4. Conjugate right lateral oscillation of the
gaze eyes). A few
5. Right up and lateral beats of
gaze nystagmus with
extreme lateral
6. Left up and lateral
gaze can be
5. Observe parallel eye normal.
movement.
6. Pause during upward
and lateral gaze fields to
detect involuntary
rhythmic oscillation of
eyes.
7. Note the position of
the upper eyelid about
the iris and eyelid bag as
the client’s eye moves
from up and down.
8. Move the object
forward to about 5
inches in front of the
client’s nose at the
midline and observe for
convergence, and record
the result.

External Inspection Observe the upper The upper eyelid The client’s Normal
anatomical eyelid. should overlap eyes are free
structures the iris. from
inflammation,
Check eyes and eyelids
crusting,
for inflammation, Eyes and eyelids
edema, or
crusting, edema, masses. should be free
masses.
 from
Inspect lacrimal glands inflammation,
and sacs for swelling. crusting, edema,
or masses.

Palpation Check for blocking of The lacrimal Mild periorbital Mild periorbital
the nasolacrimal duct by gland should not edema is noted edema is a result of a
pressing against the be palpable. defect in renal
inner orbital rim of the excretion of salt and
lacrimal sac. Tears flow freely water.
from the lacrimal
Inspect duct by palpating gland over the
on the lacrimal sac and cornea and
observing for conjunctiva to the
regurgitation of fluid. lacrimal duct.

Inspection Inspect bulbar and The Bulbar is The client’s Normal

palpebral conjunctiva transparent with Bulbar of the
and sclera. small blood eye looks
a. Instruct the client to vessels. normal and
look upward while The palpebral moist with a
depressing the lower lid conjunctiva pinkish
with a thumb. covering the appearance of
b. Inspect for color, inside of the eyelids. Small
redness, swelling, upper and lower blood vessels
exudates, or foreign eyelids is pink are present
bodies. and moist. Cornea appears
The sclera is moist, clear,
c. Inspect cornea, lenses,
white with some and shiny.
pupil, iris, and anterior
superficial blood Pupils are black
chamber:
vessels round and equal
1. Stand in front of the in diameter.
client. depending on the
 2. Shine penlight directly race.
on the cornea.
3. Move light laterally Corneas are
and view cornea from moist, shiny, and
that angle; note color, clear.
discharge, and lesions. Lenses are
4. Look at the pupil and transparent.
note size and shape. Pupils are black,
5. Shine penlight directly round, and of
on pupils to assess lens equal diameter,
and color. ranging from 2-
6. Look at the iris for 6mm.
size, and the ability of The entire iris
pupils to react to light. should illuminate
7. Shine a light obliquely when shining
through the anterior light laterally too
chamber from the lateral nasally.
side toward the nasal
side.

Inspection Test for pupillary Pupils should Pupils constrict Normal

response to light and constrict quickly quickly to
reaction to in direct response light, equal and
accommodation in dimly to light and the accommodate.
lit rooms. opposite pupil
1. Instruct the client to should also
look straight ahead. constrict.
2. Bring penlight from Pupils should be
the side of the client’s equal in size.
face to directly in front Papillary
of the pupil. accommodation
 3. Note quickness or causes
response to light. constriction in
4. Shine light into the response to
same eye observing for objects that are
response or pupil for near.
equality of size and Pupillary
repeat steps to the other dilatation occurs
eye. when pupils
5. Instruct the client to accommodate
gaze at your finger held objects at a
4-6 inches from her nose distance, with
then to glance at a symmetrical
distant object while you convergence of
note pupillary reflex. eyes.
6. Move your finger
toward the bridge of the
client's nose noting the
response of both pupils.
7. Record results in
PERRLA (pupils equal,
round, reactive to light
accommodation).

8. EARS

AREA/FEATURE TECHNIQUE SKILLS- NORMAL KEY ANALYSIS AND

TO ASSESS FINDINGS FINDINGS INTERPRETATION

External ear Inspection Examine external ear, Symmetrical, The client’s ear Normal
called the auricle or with upper color is normal.
 pinna for placement, attachment at eye The client’s
symmetry, color, corner level, and Ears are
discharge and is fleshed symmetric
swelling. colored.

Palpation Palpate the auricle Firm, smooth, The client’s Normal

between the thumb free from lesions Ears are
and index finger noting and pain. smooth. No
lesions or tenderness signs of lesions
by moving auricle up are present. No
and down, same pain upon
withthe mastoid tip. palpation
Press inward on tragus
noting any tenderness.

Auditory acuity Inspection The Whispered Voice The client should The Client can Normal
Test 1. Instruct the be able to repeat easily repeat
client to occlude one whispered words. the whispered
ear with words on both
finger and repeat the ears.
words when heard.
2. Stand 1-2 feet away
from the client, out of
view to avoid client
from lip reading, and
softly whisper numbers
on side of the ears.
Increase voice volume
until client identifies
uttered number.
3. Repeat procedure on
other ear.
4. Record results.
 9. NOSE AND SINUSES

AREA/FEATURE TECHNIQUE SKILLS NORMAL KEY ANALYSIS AND

TO ASSESS FINDINGS FINDINGS INTERPRETATION

Nose Inspection Inspect the nose for Located The client’s Normal
symmetry, deformity, symmetrically, nose is in
flaring, or midline of the symmetrically
inflammation and face, and is midline of the
discharge from the without swelling, face, and free
nares. bleeding, lesions, from swelling,
or masses. bleeding,
Test patency of each lesions, or
nostril: Each nostril is masses.
patent. Each nostril is
a. Instruct client to patent.
close the mouth and
apply pressure on one
nare and breathe

b. Repeat tests on
opposite nares.

Nasal cavities Inspection Inspect the nasal cavity The mucosa is The client’s Normal
with a penlight: pink or dull Mucosa
without swelling appears pink,
a. Tilt the client’s head or polyps. and no signs of
in an extended swelling are
position. The septum is present.
midline and The septum is
b. Place a non- intact. in the midline
 dominant hand on the A small amount and intact.
client's head using your of clear watery
thumb and lift the tip discharge is
of the nose. normal.

c. With the lit penlight,

assess each nostril; and
note for the color of
anterior nares, nasal
septum for deviation,
perforation, or
bleeding, and inspect
for swelling and
discharge.

Nasal sinuses Palpation Apply gentle upward None-tender air- None-tender Normal
pressure on frontal and filled cavities. and filled with
maxillary areas air cavities
avoiding pressure on Resonant sound produce
the eyes. upon percussion.
Resonant sound
Percuss area and note
upon
the sound.
Percussion.
10. MOUTH

AREA/FEATURE TECHNIQUE SKILLS NORMAL KEY ANALYSIS AND

TO ASSESS FINDINGS FINDINGS INTERPRETATION

Breath Inspection Stand 12-18 inches in front Breath should The client’s Normal
Lips of client and smell the smell fresh. lips and
breath. Lips and mucosa color is
Observe lips for color, mucosa should pink, firm,
moisture, swelling, lesions be pink, firm, moist, and free
a. Instruct client to open and moist from
mouth and use tongue without inflammation
depressor to retract buccal inflammation or and lesions
mucosa and note color, lesions.
hydration, inflammation,
or lesions.
b. Invert lower lip with
thumbs on inner oral
mucosa and muscle tone.
Repeat the procedure with
thumb and index finger for
the upper lip.
Gums Inspection Inspect gums for gingivitis Gums are pink, The client’s Normal
Palpation and note color, edema, smooth, and Gums appear
retraction, bleeding and moist. pink, smooth,
lesions. and with a firm
Gums are firm. texture.
Palpate gums with tongue
blade for texture

Teeth Inspection Ask client to clench teeth Teeth are The client’s Normal
to assess position and properly Teeth are
alignment with the use of aligned, properly
a tongue depressor, expose smooth, white aligned, with
molars and and shiny. white-
note for tartar, cavities, yellowish color
extraction and color. and shiny
appearance.

Tongue Inspection Instruct client to protrude When The client’s Normal

Palpation tongue: protruded, the Tongue lays
1. Inspect dorsum of tongue lays midline, pink,
tongue and note for midline, moist, and
color, hydration, texture, medium red or smooth.
symmetry. pink in color, The dorsal
2. With penlight, inspect moist and surface is
sides and ventral surface smooth along slightly rough,
and note for size, lateral margins, with no lesions.
texture, nodules, or with free The ventral
ulcerations. mobility. surface is
3. Still with penlight, The dorsal smooth, moist
 inspect floor of mouth, surface is and has no
salivary glands, and duct slightly rough lesions.
openings.Grasp tongue (taste buds) and
with a gauze and gently free from
pull it to one side and lesions.
palpate full length of The ventral
tongue. surface is
highly vascular,
smooth, moist,
and free of
lesions.

Palate Inspection Inspect the soft and hard Palates are

palate with a penlight: concave and
a. Instruct client to extend pink.
head backward and hold Hard palate has
mouth open. ridges. Soft
b. Inspect the hard palate Palate is
(roof of mouth) and soft smooth.
palate for color, shape,
lesions.

Pharynx Inspection Inspect pharynx using With phonation, Pharynx is Normal

tongue depressor and the soft palate pink, vascular,
penlight: and uvula rise
a. Explain procedure to symmetrically. no lesions.
client. The pharynx is
b. Instruct client to tilt head pink, vascular, Client produce
back and open mouth. lesion free. gagging
c. With non-dominant Tonsil size is reaction
hand, place tongue evaluated using
depressor on middle the grading
third of tongue. With the scale.
 dominant hand, shine
light into back of throat.
d. Instruct client to say
“ah” and note position,
size, appearance of
tonsils and uvula.
e. Inform client of eliciting
gag reflex by touching
the posterior 1/3 of
tongue with tongue
blade if palate and uvula
fail to rise symmetrically
with phonation.

11. NECK

AREA/FEATURE NORMAL KEY ANALYSIS AND

TO ASSESS TECHNIQUE SKILLS FINDINGS FINDINGS INTERPRETATION

Symmetry and Inspection Instruct client to: Muscles are The Client’s Normal
Musculature symmetrical muscle is
a. Flex chin to chest with the head symmetrical and
and to teach side and in a central the head is in the
shoulder to test position. central position
anterior
sternocleidomastoid Movement
muscle. through a full
range of
b. Hyperextend the motion without
neck backward to test complaint of
posterior trapezia. discomfort or
 limitation.

Thyroid Palpation With the client seated, The thyroid The client’s Normal
an assessment may be cannot be Thyroid is
Auscultation done with the visualized. also smooth and
posterior and anterior no signs of
approaches: tenderness and
enlargement are
It may or may
present
not be felt.

A. POSTERIOR
APPROACH
If felt, it should
1. Stand behind the be smooth,
soft, non-
client and place
tender, and not
thumbs on the nape of enlarged.
the neck and bring
fingers interiorly
around the neck with
their tips resting over
tracheal rings.

2. Ask the client to tilt

the chin forward to
relax neck muscles
and swallow.

3. Palpate the isthmus

rise under fingers and
feel each lateral lobe
before and while the
client swallows.

4. Ask the client to

flex forward and to
left, and displace
thyroid cartilage to
right with tips of left
fingers. Note any
bulging of the gland.

5. Press fingers of the

left hand against the
left side of the thyroid
cartilage to stabilize it
while palpating with
the fingers of the right
hand while the client
swallows.

6. Note consistency,
nodularity, or
tenderness as the
gland moves upward.

7. Repeat steps to the

opposite side.
B. ANTERIOR
APPROACH

1. Stand in front of the

client.

2. Instruct client to tilt

chin forward and
place a right thumb on
thyroid cartilage and
displace cartilage to
the right.

3. Grasp elevated
displaced right lobe
with thumb and
fingers of the left hand
and palpate for
consistency,
nodularity, or
tenderness as client
swallows.

4. Repeat steps to the

opposite side.

If the gland appears

enlarged, place the
 bell of the stethoscope
over the gland and
listen for vascular
sounds such as soft,
rushing sound, or bruit

Trachea Inspection Note for position. Midline Trachea is in Normal

position midline
Palpation Place thumbs and
index finger on sides above the No feeling of
suprasternal tenderness
of trachea and apply
notch.
gentle pressure and and no lumps
palpate.

Lymph nodes Palpation Palpate lymph nodes Lymph nodes Lymph nodes Normal
and instruct client to should not be are not palpable.
relax and flex neck palpable.
slightly forward.
Small,
1. Stand in front of movable
seated client.
nodes are
2. Methodically insignificant.
palpate both sides of
face and neck
simultaneously with
gentle pressure,
move pads and tip of
middle three fingers
in small circular
motion. Follow a
 systematic sequence
in palpating the
lymph nodes.

3. Note size, shape,

mobility,
consistency and
tenderness.

12. THORAX & LUNGS

AREA/FEATURE NORMAL KEY ANALYSIS AND

TO ASSESS TECHNIQUE SKILLS FINDINGS FINDINGS INTERPRETATION

Shape, symmetry, Inspection Place the client in a Respirations are Respiration is Normal
and diameter sitting position with quiet, effortless, regular.
arms folded across and regular, with
12-20 breaths per Thorax rises and
the chest, back falls in unison.
minute.
exposed.
1. Assess shape and Thorax rises and
symmetry by taking falls in unison
note of the rate and with the
rhythm of respiratory cycle.
respiration, Ribs slope across
movement of the and down,
chest wall with deep without
inspiration, and full movement or
expiration. bulging in the
intercostal
 2. Estimate spaces.
anteroposterior
diameter in
proportion to lateral
diameter.

Lesions Palpation 1. Palpate for lesions The thumb Thumbs rise

or areas of pain. should separate symmetrically The presence of mild
an equal distance during thoracic costovertebral angle
2. Palpate thoracic of 3-5cm and in expansion and tenderness may
the same return to the indicate kidney
expansion at 10th rib
direction during midline on infection.
by placing thumb
thoracic expiration
close to client’s expansion and
spine and spreading meet in the There is a
hands over the midline on presence of mild
thorax. Note expiration. costovertebral
divergence of angle (CVA)
thumbs; feel for tenderness.
range and symmetry The posterior
of movement during thorax is free Fremitus can be
deep inhalation and from tenderness, felt
full exhalation. lesions and symmetrically
pulsations.
3. Place the ulnar
aspect of the open
hand at the right Fremitus is equal
apex of the lung and on both sides of
place hand at each thorax, strongest
posterior thorax at the level o9f
tracheal
 location. Then bifurcation.
instruct the client to
say “99” and palpate
for tactile fremitus
(vibrations caused by
vibrations). Note
areas of increased
and decreased
fremitus.

4. Move hands from

side to side, from
light to left with the
client repeating the
words with the same
intensity every time
hands are placed on
the back.

Sound Percussion 1. Start at lung Air-filled lungs Resonant sound Normal

apices by moving create a resonant was percussion.
hands from side to sound.
side across the top of
each shoulder. Note
sound produced from
each percussion
strike and compare
with contralateral Identify
contralateral
 sound. sound; bones
create flat sound.
2. Continue Thorax is more
downward and post resonant in
lateral every other children and thin
adults.
intercostal space.
Note intensity, pitch,
duration, and quality
of percussion.

Breath sounds Auscultation 1. Place the Posterior sound: The client’s Normal
diaphragm of the vesicular and Vesicular and
stethoscope on the bronchovesicular. bronchovesicular
right lung apex. sounds are heard
Instruct the client to
inhale and exhale
deeply and slowly Lateral sound:
when the stethoscope vesicular
is felt on the back.
Repeat on the left
lung apex.
A large chest will
2. More downward produce
every other decreased breath
intercostal space and sound.
auscultate, placing
the stethoscope in
the same position on
both sides.

3. Auscultate lateral
aspect by placing
 stethoscope directly
below right axilla
instructing the client
to breathe only
through the mouth
and to inhale and
exhale deeply and
slowly. Proceed
downward on every
other intercostal
space on the same
side.

4. Repeat the last

step on the left side.

B. ANTERIOR THORAX

AREA/FEATURE NORMAL KEY ANALYSIS AND

TO ASSESS TECHNIQUE SKILLS FINDINGS FINDINGS INTERPRETATION

Symmetry, rhythm Inspection Place the client in a Thorax rises and Thorax has a Normal
and slope sitting position or falls in unison normal symmetry
supine position. with respiratory and slope.
cycle, ribs at 45-
Inspect client’s chest
degree angle with Thorax rises and
the sternum. falls in unison
 for: Inspiratory breath with respiratory
sounds are not cycle, ribs at a 45-
1. Symmetry and audible at a degree angle with
depth of movement. distance of more sternum
than 2to 3 cm
2. Slope of ribs and from the mouth.
musculoskeletal
deformities.

Tenderness, 1. Place fingertips Same normal No lesions and Normal

pulsation, masses, on the right apex findings with tenderness were
and crepitance Palpation above the clavicle. posterior palpated.
palpation.
Proceed downward
Thumb has
to each rib and separated in an
intercostal space and equal distance of
note for tenderness, 3- 5cm in the
pulsation, masses, same direction
Respiratory during thoracic
excursion and crepitance.
Repeat on the left expansion and has
met in the midline
side.
during expiration.
2. Assess respiratory
excursion by placing
thumbs along each
coastal margin with
hands on the lateral
rib cage. Instruct
Tactile Fremitus client to inhale
deeply; note for the
 divergence of
thumbs on
expansion; feel
range and symmetry
of respiratory
movement.

3. Palpate for tactile

fremitus. Gently
displace female
breasts as necessary.

Symmetry and Percussion Percuss anterior Resonant sound Resonant sound Normal
sound surface by: over lung tissue heard
(hyperresonance
1. Percuss 2-3 in children and
strikes along the thin adults)
right lung apex and Cardiac, liver,
repeat on the left and gastric
lung apex. Proceed silhouettes emit
downward, dull sounds.
percussing in every
Ribs emit a flat
ICS going from right
sound.
to left in the same

Assess each thorax

area:

1. Resonant lungs
 filled.

2. Cardiac dullness:
3rd-5th ICS left of the
sternum.

3. Liver dullness:
place finger parallel
to the upper border
of expected liver
dullness in the right
Auscultation midclavicular line; Anterior sounds:
percuss downward. bronchial,
bronchovesicular,
4. Gastric air bubble: vesicular.
repeat procedure
A large chest will
done on liver
produce
dullness on the left decreased breath
side. sounds.

Auscultate anterior
surface by
instructing the client
to breathe through
the mouth and
compares
symmetrical areas of
lungs from above
 downward:

1. Listen to breath
sounds and note
intensity and
identify variations
from normal.

2. Identify any
added sounds by
location on the chest
wall and time in the
respiratory cycle.

3. If breath sounds
are diminished, ask
the client to breathe
hard and fast with
mouth open.

13. CARDIOVASCULAR

AREA/FEATURE NORMAL KEY ANALYSIS AND

TO ASSESS TECHNIQUE SKILLS FINDINGS FINDINGS INTERPRETATION
Arterial Pulses Palpation 1. Compress the Normal Heart The client’s
radial artery with rate heart rate is
your index finger and normal
middle finger.

Heart Inspection Precordial Movement The client’s The client’s Normal

Heart rate can Heart rate can be
1. Position the patient be heard and heard and
supine with the head palpated for palpated for
slightly elevated every part of every part of
inspection and inspection and
2. Always examine palpation palpation.
from the patient’s
right side. Heartbeat is
Heart beat is palpable and no
3. Palpate for point of palpable and tenderness
maximal impulse. no tenderness
Palpation (normally located at
4th or fifth ics, lmcl)

4. Listen with the

diaphragm at the
right 2nd ICS

Auscultation 5. Listen to the 2nd

ICS near the sternum.

6. 3rd, 4th, 5th ICS near

sternum
 7. Listen for apex

Tissue perfusion Palpation Perform the Allen Palms should The client’s Normal
Test to determine the turn pink Palms turn back
patency of radial and promptly. to normal color
when pressure is
ulnar arteries.
released
Instruct client to rest
hands on lap.

1. Compress both the

radial and ulnar
arteries.

2. Firmly compress
arteries and instruct
clients to open their
hands.

3. Note the color of

palms.

4. Release one artery

and note the color of
the palm.

5. Repeat steps on
other arteries on the
same hand.
 14. ABDOMEN

AREA/FEATURE NORMAL KEY ANALYSIS AND

TO ASSESS TECHNIQUE SKILLS FINDINGS FINDINGS INTERPRETATION

Generalized appearance Inspection Placing the client in a Contour is flat The client's The abdomen's
of abdomen supine position with or rounded and abdomen is tenderness is due to
knees flexed over a bilaterally diffusely tender, inflammation of the
pillow, hands at the symmetrical. without guarding kidney.
side or over the chest, and rebound.
undrape patients from The umbilicus
the xiphoid process to is depressed
symphysis pubis to and beneath the
expose the abdomen. abdominal
surface.
1. Inspect abdomen
from rib margin to Visible
pubic bone and note peristalsis
for contour and slowly
symmetry. transverses the
abdomen in
2. Inspect umbilicus slanting
for contour, location, downward
signs of movements as
inflammation, or observed in
hernia. thin clients.
Pulsations of
3. Observe for the abdominal
smooth, even aorta are
respiratory visible in the
movements. epigastric area
in thin clients.
4. Observe for surface
motions (visible
 peristalsis)

Bowel sounds Auscultation Auscultate the bowel High pitched The client’s Normal
sounds on the sounds are abdomen
abdominal quadrants heard every 5 produces a
to 15 seconds Height of
using the diaphragm
as intermittent gurgling sound,
of the stethoscope. gurgling which can be
1. Begin by placing sounds in all 4 heard in every
the diaphragm on the quadrants as a quadrant.
RLQ. Listen for a full result of fluid
minute to the and air
frequency and movement in
GIT.
character of bowel
movements. Bowel sounds
2. Repeat the same should always
step proceeding in be heard at the
sequence to RUQ, ileocecal valve.
LUQ, and LLQ.
3. Listen at least for 5
minutes before
concluding the
absence of bowel
sounds.

Abdominal quadrants Percussion Begin percussion in Tympany is Tympany is Normal

RLQ, move upward heard because heard Dullness is
to RUQ, cross over to of air in the heard over the
stomach and organs
LUQ, and down to
intestines.
LLQ. Note when
 tympani changes to Dullness is
dullness. heard over
organs.

15. NEUROLOGIC SYSTEM

ASSESSMENT OF COMMON DEEP TENDON REFLEX

TYPE ASSESSMENT NORMAL REFLEX KEY ANALYSIS AND

FINDINGS INTERPRETATION

Biceps 1. Flex client’s arm There should be flexion There is flexion of arm at Normal
between 45-degree of the arm at the elbow. elbow
angle and 90
degrees.
2. Place thumb firmly
on biceps tendon just
above
the crease of
antecubital
fossa.
3. Tap thumb with
reflex hammer.

Triceps 1. Flex client’s arm at Extension of elbow There is an extension of Normal

45 degrees and 90- the elbow
degree
 angle.
2. Tap triceps tendon
just above the elbow.

Brachioradialis 1. Flex client’s arm at Flexion of forearm There is an extension of Normal

45- degree angle and the forearm
place on
lap with the arm
semipronated.
2. Tap brachioradialis
tendon on thumb side
of the wrist.

Patellar 1. Ask the client to sit Extension of leg below There is extension of leg Normal
in a chair or on edge the knee. below the knee
of bed with
legs hanging freely or
in
supine position with
knee
flexed.
2. Tap patellar tendon
just
below the patella.

Achilles 1. Ask client to sit Plantar flexion of foot. There is plantar flexion of Normal
with feet dangling foot
and partially
dorsiflexed or in a
supine
position with legs
flexed at
knee and thigh
 externally
rotated.
2. Tap the Achilles
tendon just above the
heel.

Plantar (Babinski) 1. Position client’s Bending of the toes Bending of the toes Normal
ankle firmly against downward. downward.
the bed.
2. Slowly stroke
client’s sole with the
handle of the
reflex hammer.

16. BREAST

AREA/FEATURE NORMAL KEY ANALYSIS AND

TO ASSESS TECHNIQUE SKILLS FINDINGS FINDINGS INTERPRETATION

External Anatomical Inspection Inspect for size and The breast can be The client’s Normal
Structure symmetry of the a variety of sizes breast appears
breast. and are symmetrical.
somewhat round
and pendulous.
One breast may
normally be
larger than the
other.

Inspection Inspect color and Color varies There are no Normal

texture. depending on the signs of
 client’s skin tone. discoloration
The texture is in the client’s
smooth, with no breast. Smooth
edema. texture and no
edema is
Linear stretch present.
marks may be
seen during and
after pregnancy
or with
significant
weight gain or
loss.

Inspection Inspect the areolas Areolas vary The client's Normal

and nipples. from dark pink to Areolas are
dark brown, enlarged.
depending on the
client’s skin The client’s
tones. They are Nipples are
round and may equal
vary in size. bilaterally and
They are round it is in the
and may vary in same location.
size. Small Also, the
Montgomery nipples are
tubercles are inverted.
present.

Nipples are
nearly equal
bilaterally in size
 and are in the
same location on
each breast.
Nipples are
usually everted,
but they may be
inverted or flat.

Palpation Palpate for masses. No masses There are no Normal

should be masses,
palpated. nodules, or
However, a firm lumps palpated
inframammary in clients.
transverse ridge
may normally be
palpated at the
lower base of the
breasts.

Palpation Palpate the nipples. The nipple may There is no Normal

Compress the nipple become erect, colostrum
gently with your and the areola when being
thumb and index may pucker in palpated.
finger. Note any response to
discharge. stimulation. A There are no
milky discharge signs of
is usually normal abnormal
only during discharges.
pregnancy and
lactation.
However, some
women may
normally have a
 clear discharge.

Laboratory Findings

Diagnostic/laboratory Date Indication/ Nursing responsibilities prior to, during, and

procedures ordered/date Purposes after the procedure
done

Complete Blood Count 5/25/22 To identify and prevent - Explain that discomfort may be felt when
complications skin is puncture
- Help the patient to relax
- Apply manual pressure on puncture site

Urinalysis 5/25/22 To identify gestational - Explain the clean catch method

complications - Ensure that specimen is transported
correctly
Renal Function Test 5/25/22 To measure how efficiently your - Tell the patient to do the 24-hour urine
kidneys are working sample

CBC (Complete Blood Count)

TESTS RESULT REFERENCE RANGE ANALYSIS AND
INTERPRETATION
WBC 13,600 4,500 – 11,000 cells/mcL Elevated
HGB 8.2 g/dL 11.5 - 13.5 g/dL Decreased
Platelets 278,000/mL 150,000 – 450,000 /mL Normal
 URINALYSIS
CHEMICAL REFERENCE MICROSCOPIC REFERENCE RANGE
RANGE
Color Red Yellow RBC 30 – 49/Hpf 2 – 4/Hpf
Protein 0.1 g/dL 0-14 mg/dL WBC 5-9/Hpf 2 – 5/Hpf
Leukocytes Few Negative Epithelial Cell Negative Negative
Esterase Casts 3 – 4/Hpf 0 – 2/Hpf
Crystals Negative Negative

RFT (RENAL FUNCTION TEST)

TESTS RESULT REFERENCE RANGE ANALYSIS AND
INTERPRETATION
Serum Creatinine 0.47 mg/dL 0.29 – 0.48 mg/dL Normal
Serum Albumin 2.7 gm/dL 3.4 – 4.7 gm/dL Decreased
Sodium 134 mmol/L 134 – 150 mmol/L Normal
Potassium 4.4 mmol/L 3.5 – 5 mmol/L Normal
Calcium 7.2 mg/dL 8.6 – 10.3 mg/dL Decreased
Phosphorous 7.8 mg/dL 2.8 – 4.5 mg/dL Elevated
Total Protein 6.5 g/dL 6.0 – 8.3 mg/dL Normal
E. Anatomy and Physiology Review

Acute Glomerulonephritis is the inflammation of the glomeruli after a streptococcal infection.

It is primarily observed in the early school-age child and is characterized by an acute episode of
hematuria and proteinuria.

URINARY SYSTEM

The role of the urinary system is to remove waste substances from the body by continually
filtering and cleaning the blood, producing a waste fluid called urine. In addition, this system
helps control the levels of salts and fluids in the body. This plays a huge role in the said disease
and its clinical manifestations.

KIDNEYS - These are paired organs that lie on either side of the spine. They filter the blood and
produce urine. The kidneys also secrete erythropoietin in response to cellular hypoxia. Scarring
on kidney tissues occurs in AGN, which leads to the decrease in ability of the kidney to filter the
blood and produce urine.

GLOMERULI - Glomeruli (singular: glomerulus) are extremely small blood vessels that play a
part in filtering the blood to form urine. Each glomerulus with its renal tubule comprises a unit
known as a nephron, and a kidney has more than a million nephrons. In AGN, a sudden onset of
inflammation of the glomeruli happens due to infections originating from different parts of the
body. The immune response causes inflammation of the glomeruli.

URETERS - Ureters are muscular tubules that carry urine from the kidneys to the bladder.

BLADDER - This is a hollow organ with muscular walls that can expand to store various
amounts of urine.

URETHRA - A tube that carries urine from the bladder to the outside. Males have longer
urethras than females.
BLOOD

Blood is a living liquid made up of cells and fluid. It is pumped around the blood vessels by
the heart. Its main role is to deliver oxygen and nutrients to the tissues of the body and carry
waste products away.

RED BLOOD CELLS - The main function of red blood cells is to carry oxygen from the lungs
to the body tissues. And to carry carbon dioxide as a waste product away from the tissues and
back to the lungs. Hemoglobin is an important protein in red blood cells that carries oxygen from
the lungs to all parts of our body. A patient with AGN has a chance of developing Anemia, or the
low concentration of red blood cells due to the lack of erythropoietin produced in the Kidneys.

PLATELETS - Blood cells are called platelets or thrombocytes. They develop in the sponge-
like tissue of your bones, known as bone marrow. Platelets are vital in the coagulation of blood.
When one of your blood vessels is damaged, you will often bleed.

PLASMA - Plasma serves as a transport medium for delivering nutrients to the cells of the
various organs of the body and for transporting waste products derived from cellular metabolism
to the kidneys, liver, and lungs for excretion. It is also a transport system for blood cells, and it
plays a critical role in maintaining normal blood pressure. Damage to the glomeruli from
inflammation or scarring can lead to increased blood pressure.

WHITE BLOOD CELLS - White blood cells (WBCs) are a part of the immune system. They
help fight infection and defend the body against other foreign materials. Some are involved in
recognizing intruders. Some kill harmful bacteria. Others make antibodies to protect your body
against exposure to bacteria and viruses. Patients with AGN are normally seen with high levels
of WBC due to prior streptococcal infection.
G. Pathophysiology

Glomerulus injury can occur by infections, toxins, drugs, diseases, or vascular disorders. It is
mainly. After the disturbance and inflammation of the glomerular membrane, the permeability of
the membrane increases which would raise the chances of losing substances through the urine.
NURSING CARE PLAN (Prioritization of problems)

1) Excess fluid volume as evidenced by facial edema

2) Activity Intolerance related to Anemia as evidenced by fatigue
3) Impaired renal perfusion related to glomerular malfunction as evidenced by hematuria

NURSING CARE PLAN #1

CUES NURSING PROBLEM NURSING RATIONALE EXPECTED

DIAGNOSIS STATEMENT INTERVENTION OUTCOME
(GOAL)

Subjective: Excess fluid After 1-2 days of - Obtain complete - To have baseline After 1-2 days of
volume as nursing physical data on the progress nursing intervention,
“My son’s face evidenced by intervention, the assessment of fluid elimination the goal was met as
seems swollen,” as facial edema patient will be able evidenced by the
through physical
verbalized by the to: patient:
appearance.
patient’s mother.
- Stabilize fluid
volume as - Monitor daily - To have a - Stabilized fluid
Objective: measurable account
evidenced by weight. volume as evidenced
balanced input and on the fluid by balanced input
- Edema on face
output, and free elimination. and output (urine
signs of edema output greater than
- (+) proteinuria
- To know the or equal to 30
progressing mL/hr), and free
-Urine output of less
- Monitor fluid condition via signs of edema
than 30 mL/hr. intake and output
glomerular
every 4 hours.
V/S: filtration.
BP - 138/90mmhg - To know the
PR - 100bpm - Monitor extent of protein
RR - 20cpm laboratory values loss which led to
T - 37 C especially for the
edema.
protein level in the
urine.

- Maintain dietary
restrictions during
the acute phase.

- a. To help prevent
a. Sodium fluid retention via
absorption.

- b. It helps prevent
b. Protein fast elevation of
BUN level.

- Helps prevent
further fluid
- Maintain fluid accumulation while
restriction there is decreased
glomerular
filtration.

- Administer - Fights infection

antibiotics and progression of
(Erythromycin) as
ordered. scarring.

- To reduce fluid
- Administer excess, through
diuretics. urinating.
NURSING CARE PLAN #2

CUES NURSING PROBLEM NURSING RATIONALE EXPECTED

DIAGNOSIS STATEMENT INTERVENTION OUTCOME
(GOAL)

Subjective: “My After 2-3 days of Independent: After 2-3 days of

son has been having Activity proper nursing -Assess the ability -Provides data about proper nursing
headaches that limit Intolerance related intervention, the to move and energy reserves intervention, the
his daily activities,” to anemia as patient will progress engage in play during the acute goal was met as seen
as verbalized by the evidenced by to having an activities, and the stage of the disease with the patient's
patient’s mother. fatigue increased activity level of weakness and recognition of progression to an
tolerance as and fatigue. bed rest status. increased activity
evidenced by tolerance as
Objectives: increased Hgb level -Encourage bed -Conserves energy evidenced by
-Decreased Hgb of 10 g/dL (100 rest and disturb and limits the increased Hgb level
level of 8.2 g/dL (82 g/L). only if needed. production of waste of 10 g/dL (100
g/L) materials (e.g: g/L).
creatinine) which
BP - 138/90mmhg increases the work
of the kidneys.
PR - 100bpm
-Provides adequate
RR - 20cpm -Provide rest rest and reduces
periods stimuli and fatigue.
T - 37 C after any activity in
a quiet
environment and
schedule care.
-Provides diversion,
-Provide for quiet stimulation and
play (watercolor, requires minimal
drawing), reading, energy
TV, as symptoms expenditures.
subside.
-Promotes
-Emphasize the understanding of the
purpose and need to conserve
relevance of energy and rest to
activity restriction. help in recovery.

-Avoids fatigue and

conserves energy
-Inform parents during recovery.
and child about the
importance of rest
after ambulation or
any activity.
-Promotes increased
-Provide low flow oxygen levels.
oxygenation.
-Helps in managing
-Educate patient stress which further
about relaxation improves the quality
techniques. of rest.

-To boost
hemoglobin levels.
-Give health
teachings to the
parents and child
regarding foods
that are high in
Iron and can help
in Iron absorption.
Dependent:
-Refer to a -This will help in
nutritionist for managing Iron
thorough diet supplementation in
plans. the body, and other
restrictions for
Renal health (such
as salt intake).

-Provides
Collaborative: parameters
-Refer to a Medical regarding the
Technologist for patient's
Complete Blood hemoglobin levels.
Count (CBC).
NURSING CARE PLAN #3

CUES NURSING PROBLEM NURSING RATIONALE EXPECTED

DIAGNOSIS STATEMENT INTERVENTION OUTCOME

Subjective: Impaired Renal Short-term: Independent: Short-term:

“I notice his Perfusion related to - After 3hrs of - Establish rapport with - This is to After 3hrs of nursing
unusual urination glomerular nursing the patient and encourage patient intervention, the
pattern ranging intervention, caregiver. and caregiver goal was met as
malfunction as
from once to the patient will be cooperation. evidenced by:
twice a day” as evidenced by able to:
verbalized by the oliguria and - Maintain a record of - This gives a - demonstrated
patient’s mother. hematuria. - demonstrate the patient's vital signs. baseline of participation in
The patient also participation in Every four hours, check information that can his/her
stated that he his/her the patient's vitals. The be utilized as a Recommend
noticed a dark Recommend patient's blood pressure benchmark as the treatment program.
color of his treatment should be closely condition
urine, like a program. monitored. progresses. - Obtained normal
coke. Increased blood blood pressure.
- Obtain normal pressure might
Objective: blood pressure. aggravate renal Long-term:
V/S disease even more. After 3-4 days of
BP - 138/90mmhg Long-term: Damage to the nursing intervention,
PR - 100bpm After 3-4 days of glomeruli prevents the goal was met as
RR - 20cpm nursing salt and fluid from evidenced by:
T - 37 C intervention, being evacuated,
the patient will be raising heart rate - demonstrated
able to: and blood pressure. changes in lifestyle
and behavior to
Fatigue - demonstrate - Determine the factors - To figure out what prevent the
changes in that influence an causes and occurrence of
Decrease urine lifestyle and individual's contributes to the complications.
output - 2x a day behavior to circumstances as well condition.
 prevent the as situations that have - the patient being
Below 30cc of occurrence of the potential to affect able to void with a
urine output complications the complete physical normal color of
system. urine.
(Oliguria) - void with a
normal color of - Take note of the - In order to rule out - excreted urine
Edema urine. characteristics of the hematuria, frequently.
urine and measure the proteinuria, and
Hematuria
- excrete urine specific gravity of the kidney disease.
frequently patient’s urine.

- Compare my current - It’s possible that

status to the patient's the discomfort is
regular voiding pattern. coming from the
Note the presence, afflicted organ.
intensity, and duration
of the pain.
- to see if there is an
- Check the urine improvement of
output every 1-2hrs urine excretion.

- Determine the - Rennin production

patient's normal blood and blood pressure
pressure range by can both be affected
monitoring their blood by GFR.
pressure.
- To determine the
- Any indicators of severity of kidney
dependent generalized dysfunction
edema should be
looked out for.
- To alleviate his
- Encourage individuals fear about his health
to share their thoughts and correct his
on the prognosis or the illusions about it.
discussion's long-term
consequences.

- Encourage the patient - To improve one’s

to maintain a positive sense of well-being.
outlook and, if
necessary, employ
relaxation techniques
such as guided imagery.

Dependent:
- Provide medicine as
indicated. As directed
by the physician, - In order to
administer recuperate quicker.
antihypertensives The patient's
(Nifedipine) and medical condition is
diuretics (Furosemide). treated using it.
Blood pressure is
controlled with the
use of
antihypertensive
medications
(Nifedipine).
Edema and plasma
volume can be
reduced using
diuretics
(Furosemide).

Collaborative:
- Collaborate with other
health care practitioners - Urinalysis is to test
like medtech for the urine of the
urinalysis and patient. In this lab test
we can see if the
nutritionist for a good
patient has hematuria
proper diet. or other problems.
Nutritionists provide
well balanced food
for the patient.
DRUG STUDY
BRAND DOSAGE/
NURSING
NAME/ CLASSIFICA STOCK INDICATI CONTRA SIDE ADVERSE
ACTION RESPONSIBILI
GENERI TION DOSE/ ON INDICATION EFFECTS REACTION
TIES
C FORM
Generic calcium- 30 mg Thought to Vasosp Contraindi Bloating or CNS: If patient is
Name: channel OD PO inhibit astic cated in swelling of dizziness, kept on
blockers Capsul calcium ion angina patients’ the face, light- nitrate
nifedipine influx (Prinz hypersensit headedness, therapy while
es: 5 arms,
across metal or ive drug, in giddiness, nifedipine
Brand mg, 10 cardiac and variant those hands, headache, dosage is
Name: mg, 20 smooth angina), taking lower legs, weakness, being
mg muscle classic strong or feet nervousness, adjusted,
Procardia cells, chronic CYP450 mood urge
decreasing stable inducers cough changes, continued
contractility angina (rifampin), shakiness, compliance.
and oxygen pectoris and in sleep Patient may
difficult or
demand. . patients disturbances take SL
Drug may with labored , fever. nitroglycerin,
also dilate cardiogeni breathing as needed, for
coronary c shocks or CV: acute chest
arteries and ST- dizziness or flushing, pain.
arterioles. segment lightheaded heat
elevation ness sensation, Tell patient
MI. peripheral that chest
edema, pain may
Increased fast, palpations, worsen
angina and irregular, transient briefly as
MI have pounding, hypotension. therapy starts
occurred at or racing or dosage
start of heartbeat or EENT: increases.
therapy or pulse nasal
with congestion, Instruct
dosage feeling of sore throat, patient to
titration of warmth blurred swallow
dihydropyr vision. extended-
idine release
headache
calcium GI: nausea, tablets
channel heartburn, without
blockers. muscle diarrhea, breaking,
Reflex cramps constipation, crushing, or
tachycardi cramps, chewing
a may rapid flatulence. them.
occur, weight gain
resulting in Musculoske Advise
angina or letal: patient to
MI in shakiness in muscle avoid taking
patients the legs, cramps, drug with
with arms, tremor, grapefruit
obstructive hands, or inflammatio juice.
coronary feet n, joint
disease, shortness of stiffness. Tell patient
especially not to abrupt
breath
in the Respiratory unless
absence of : dyspnea, directed by
concurrent tightness in cough, prescriber.
beta the chest wheezing, Abrupt
blockade. chest withdrawal
tingling of congestion, may cause
Avoid use the hands or shortness of rebound
in patients breath. angina in
feet
with HF; patients with
drug may Skin: CAD.
worsen trembling dermatitis,
symptoms. or shaking pruritus, Advise
of the hands urticaria, patient that
Use with or feet sweating. Adalat CC
extreme Others: tablets
caution in difficulties contain
unusual
patients weight gain in balance, lactose and
with serve or loss chills, shouldn’t be
aortic sexual used by
stenosis. difficulties. patients with
weakness
Drug may galactose
reduce intolerance,
coronary wheezing Lapp lactase
perfusion, deficiency, or
resulting in glucose-
ischemia. galactose
malabsorptio
n.

Reassure
patient taking
the extended-
release tablet
that the wax
mold may be
passed in the
stools.
Assure
patient that
drug has
already been
completely
absorbed.

Tell patient
to protect
capsules from
direct light
and moisture
and to store
at room
temperature.
 DOSAGE/
BRAND NURSING
CLASSIFICA STOCK INDICATI CONTRA SIDE ADVERSE
NAME/ ACTION RESPONSIBILIT
TION DOSE/ ON INDICATION EFFECTS REACTION
GENERIC IES
FORM
Generic diuretics 1mg/kg/ Inhibits Acute Contraindicat nausea or CNS: vertigo, Advise patient
Name: ('water day, given sodium pulmonary ed in patients vomiting headache, to take drug in
pills'). every 12 and edema hypersensitiv dizziness, morning to
furosemide chloride e to drug and paresthesia, prevent need to
hours (SD: diarrhea
reabsorpti in those with restlessness, urinate at night.
Brand 20MG/ml on at the anuria. fever. If a second dose
Name: of 2ml proximal constipati is needed, tell
amp) and distal Use on CV: patient to take it
Lasix tubules cautiously in orthostatic in early
Injection: stomach
10 mg/mL and the patients with cramping hypotension, afternoon, 6 to 8
Oral ascending hepatic thrombophlebi hours after
loop of cirrhosis and tis with IV morning dose.
Solution: feeling
Henle. in those administration
10mg/mL, allergic to like you . Inform patient
40MG/mL sulfonamides or the of possible need
Tablets: . room is EENT: for potassium or
20 mg, 40 spinning blurred or magnesium
mg, 80 (vertigo) yellowed supplements.
mg, 500 vision,
transient Instruct patient
mg dizziness
deafness, to stand slowly
tinnitus. to prevent
headache dizziness and to
GI: limit alcohol
blurred abdominal intake and
vision discomfort strenuous
and pain, exercise in hot
diarrhea, weather to avoid
itching or
anorexia, worsening
rash nausea, dizziness upon
vomiting, standing
increased constipation. quickly.
urination Pancreatitis.
Advise patient
GU: to report all
azotemia, adverse
nocturia, reactions and to
polyuria, immediately
frequent report ringing in
urination, ears, serve
oliguria. abdominal pain,
or sore throat
and fever; these
symptoms may
indicate toxicity.
 DOSAGE/
BRAND SIDE NURSING
CLASSIFIC STOCK CONTRA ADVERSE
NAME/ ACTION INDICATION EFFECT RESPONSIBILI
ATION DOSE/ INDICATION REACTION
GENERIC S TIES
FORM
Generic macrolide Injection: Inhibits Uncomplicat Contraindica Feeling CNS: fever Tell patient to
Name: antibiotics 500 mg bacterial ed urethral, ted in sick take drug as
protein endocervical patients (nausea) CV: vein prescribed,
erythromycin synthesis , or rectal hypersensiti irritation or even after
by binding infection ve to drug or thrombophlebiti feeling better.
Brand Name: to the 50S caused by other Being s after IV
subunit of chlamydia macrolides. sick injection, Instruct patient
Erythrocin the trachomatis, (vomitin ventricular to take oral
ribosome. when g) arrhythmias. from of drug
Bacteriost tetracyclines Diarrhea with full glass
atic or are GI: of water 2
bactericida contraindicat pseudomembra hours before or
Stomach
l, ed. nous colitis, 2 hours after
depending cramps abdominal pain, meals for best
on and cramping, absorption.
concentrati Loss of diarrhea,
on appetite nausea, The drug may
vomiting. be taken with
Bloating food if GI upset
Hepatic: occurs. Tell the
and
indigesti hepatic patient not to
on dysfunction. take the drug
with fruit juice
Skin: eczema, or to swallow
rash, urticaria. the chewable
tablets whole.
Others:
anaphylaxis, Instruct patient
overgrowth of to report all
non-susceptible adverse
bacteria or reactions,
fungi. especially
diarrhea,
nausea,
abdominal
pain, vomiting,
and fever.

Instruct parents
or caregivers to
report vomiting
or irritability
immediately.
Stages of Child Development and Milestones from 7-12 Years

Jean Piaget: The Age Period of 7-12 Years Make up the Concrete Operational Stage.
According to Swiss psychologist Jean Piaget, during this period, children develop the ability to
think logically and have more "adult like" thought patterns that, among other things, include the
ability to:

● Look at things in-depth: Realize that things are not always as they seem and that outward
appearances are only one aspect to be considered.

● View matters from several angles: Approach objects or situations with the question "what
if?" and can envision different scenarios that may play out based on specific actions.

Erik Erikson: The Age Period of 7-12 Years Make up the Industry versus Inferiority Stage

According to Erik Erikson, during this time, a child's most significant relationships are those
with his friends and peers. Although parents are obviously still very important, they don't have
the same influence and authority as in younger years.

Because of this shift, a child's self-esteem and confidence tend to be more susceptible to how he
believes those outside his family see him.

According to Erikson, this period is characterized by a focus of 'being able'. This ability to
accomplish what you set out to do (to realize your own potential), is what he calls industry.
Supporting this focus on industry is vital for the existential building of self-esteem.

Freud proposed that personality development in childhood takes place during five psychosexual
stages, which are the oral, anal, phallic, latency, and genital stages. During each stage sexual
energy (libido) is expressed in different ways and through different parts of the body.
These are called psychosexual stages because each stage represents the fixation of libido
(roughly translated as sexual drives or instincts) on a different area of the body. As a person
grows physically certain areas of their body become important as sources of potential frustration
(erogenous zones), pleasure or both.
Latency Stage (6 years to puberty)
The latency stage is the fourth stage of psychosexual development, spanning the period of six
years to puberty. During this stage the libido is dormant and no further psychosexual
development takes place (latent means hidden).
Freud thought that most sexual impulses are repressed during the latent stage, and sexual energy
can be sublimated towards schoolwork, hobbies, and friendships.

Much of the child's energy is channeled into developing new skills and acquiring new
knowledge, and play becomes largely confined to other children of the same gender.

Age 8 can be a magical year. It's the year that little kid really becomes a big kid. Middle
childhood is a time of physical, mental, and emotional growth. It's possible you'll notice that
your child no longer asks for your help with their homework, and they may be wanting to spend
more time with their friends.

Eight-year-olds are becoming more independent and more mature. You may be pleased to see
that they begin to show genuine empathy for others and start to put others first in situations that
they haven't before, such as happily letting a younger sibling go first in a family game. This age
is not without its challenges, but overall, it tends to be a peaceful and enjoyable year between
children and their parents.

Physical Development At the age of 8-10 years old, children experience changes such as
these:
● Increase in body strength and hand dexterity through physical activities
● Improved coordination and reaction time
● Increase in large-muscle coordination, leading to success in organized sports and games
● Increase in small-muscle coordination, allowing them to learn complex craft skills
● Refinement of finger control
● Increased stamina (They can run and swim farther.)
● Approaching or reaching puberty for girls, which can make them look grown-up
● Enjoyment of rough-and-tumble games with peers
● Sexual development, which is more rapid in girls than boys
● Refinement of group game skills and team sports skills such as throwing, catching and
kicking
● Development of manual skills and interest in things such as cooking and carpentry
● Slow and steady growth (Arms are lengthening; hands are growing. Girls are growing
faster.)
Discharge Plan

Medications For a patient with acute Nifedipine is to treat high

glomerulonephritis, it is advised to blood pressure.
continue with the nifedipine,
furosemide and erythromycin.

Exercise The client should be encouraged to

have a leisurely exercise atleast 1
hour a day.

Diet Eat a diet that is low in protein, salt,

and potassium

Drink less fluids

Hygiene Encourage and assist the patient in Oral hygiene helps

maintaining appropriate and good alleviate the condition and
oral hygiene facilitates comfort

Teaching (health) Monitor daily weight and daily

input and output

Monitor blood pressure

Out-Patient Referral Seek medical attention immediately For the patient to

if the patient is swelling of your immediately follow-up her
ankles or face, blood in your urine health concern.
and high blood pressure.
Medical and Nursing Management

 The patient has been hospitalized because of reports such as brownish urine and back
pain in the flank area and dull generalized headache. Medications such as nifedipine,
furosemide, and erythromycin is administered by the physician to bring back the normal
color of urine, and to ease the back pain and headache of the patient.
 The patient is advised to eat selected foods such as leafy vegetables, fruits, and brown
rice because headache and back pain can be treated with this type of diet. The patient was
also advised to drink 8 glasses a day to avoid dehydration that may cause brownish urine
 Modification of the amount and size of meals consumed throughout the day may help
relieve symptoms of headache and back pain. The meals should contain more
carbohydrates than fat and acid. Protein-rich meals also decrease symptoms. Lighter
snacks, including nuts, dairy products, and beans, are often endorsed. Drinks that contain
electrolytes and other supplements are advised. If certain foods or food preparations
trigger furthermore headache and back pain, they should be avoided
 The patient is advised to get more rest, particularly sleeping with good posture is advised
to avoid back pain. The urine color should be also supervised and documented once a
day.
EVALUATION

RECOMMENDATION

The findings of this study have resulted in several policy recommendations. To begin, improving

normal develop diseases and illnesses at an early stage of their life, health outcomes require

experience of comfort. On this goal to Improve the Student Nurse will be able to perform the nursing

process, it is important to Identify which action may be needed.

Most children do not experience any complications, this happens when the kidney doesn’t work

normally because of inflammation. The kidney cannot filtrate the fluid accordingly which can cause

edema.

For further studies, the nursing students should review the signs and symptoms to report early if it is an

attack and necessary treatment to prevent significant complications and give the client knowledge to

improve of proper service and care to the client who has Acute glomerulonephritis.
REFERENCES:

https://www.mayoclinic.org/drugs-supplements/nifedipine-oral-route/side-effects/drg-20071680

https://www.medicalnewstoday.com/articles/furosemide-oral-tablet

https://www.nhs.uk/medicines/erythromycin/side-effects-of-erythromycin/

Nursing 2021 Drug Handbook

https://chicagoabatherapy.com/articles/7-relaxationself-calming-strategies-used-in-pediatric-aba-
therapy/#:~:text=Have%20the%20child%20sit%20down%20and%20sit%20face,in%20and
%20let%20out%20all%20of%20the%20air.

https://www.bing.com/ck/a?!
&&p=63fe1c3693f80d170d39695cf301648cf62b485d1444ddd1ce40b489d77cc56cJmltdHM9M
TY1NDEzODk1OCZpZ3VpZD1lNWI3ZDc5Yi01YzhiLTQwZmYtYmQxMy0wMGM5NDNm
ZmM4MTgmaW5zaWQ9NTI3NQ&ptn=3&fclid=75af7bca-e220-11ec-92af-
65f64eaac0a5&u=a1aHR0cHM6Ly9teS5jbGV2ZWxhbmRjbGluaWMub3JnL2hlYWx0aC9kaX
NlYXNlcy8zOTI5LWFuZW1pYQ&ntb=1

https://rnspeak.com/acute-glomerulonephritis-agn-nursing-intervention/

https://medicine.uiowa.edu/iowaprotocols/pediatric-vital-signs-normal-ranges

https://nursestudy.net/glomerulonephritis-nursing-diagnosis/