Acute glomerulonephritis (AGN) is an inflammatory disease of the specialized tuft of capillaries within the kidney called the glomerulus. In its several forms, Acute glomerulonephritis was the leading cause of chronic renal failure in the United States until the mid-1980s, but because of more aggressive treatment approaches, it is now third, after diabetes mellitus and hypertension. Acute Glomerulonephritis continues to be a fairly common disorder worldwide, however. The inflammatory changes occur because of deposits of antigen-antibody complexes lodged within the glomerular membrane. Antigen-antibody complexes are formed within the circulation in response to an antigen or foreign protein. The antigen may be of external origin, such as a portion of the streptococcus bacterial cell wall, or of internal origin, such as the changes that occur in systemic diseases like systemic lupus erythematosus (SLE).
If the source of the causative antigen is temporary, such as a transient infection, the inflammatory changes subside and renal function usually returns to normal; if the source of antigen is long-term or permanent, the Acute glomerulonephritis may become chronic. During the acute phase of the disease process, major complications include hypertension, hypertensive encephalopathy, acute renal failure, cardiac failure, and seizures. Chronic glomerular nephritis leads to contracted, granular kidneys and end-stage renal disease. Rapidly progressive Acute glomerulonephritis (RPGN; also known as crescentic nephritis), an acute and severe form of kidney inflammation, can cause loss of kidney function within days. Inflammation at the sites of renal filtration (the glomerular basement membrane) causes leakage of blood proteins into the urinary space. The condition is caused by inflammation of cells in the urinary space that form crescents, hence the name crescentic nephritis.
Etiologic factors are unclear, but most experts identify an immunologic origin for the disease. Acute glomerulonephritis may occur as an isolated (primary) disorder, as a disorder associated with an infectious disease, or as a secondary disorder. Primary Acute glomerulonephritis occurs in mesangiocapillary Acute glomerulonephritis and in IgA nephropathy. Infection-associated Acute glomerulonephritis follows an infection such as group A betahemolytic streptococcus (GABHS) infection. Nonstreptococcal postinfectious Acute glomerulonephritis may occur after an attack of infective endocarditis, sepsis, pneumococcal pneumonia, viral hepatitis, mumps, or measles. RPGN is associated with vasculitie, SLE, Goodpasture’s syndrome, and IgA nephropathy.
Nursing care plan assessment and physical examination
Question the patient or parents about an untreated respiratory tract infection that has occurred in the last 1 to 3 weeks. Ask the patient about the medical history to identify any multisystem diseases. Because patients often describe a history of weight gain and edema of the hands and face, ask the patient if his or her rings are tighter than usual. Some patients may also describe decreased urine volume, changes in urine color (dark, smoky), increased fatigue and activity intolerance, muscle and joint achiness, shortness of breath, and orthopnea. Elderly patients’ symptoms may be more vague and nonspecific, such as achiness and nausea.
Note any signs of fluid retention, such as edema in the face and hands. As you speak to the patient, you may notice dyspnea and labored breathing. Inspect the neck veins to determine if engorgement is present. The patient’s urine output is usually decreased and is often dark or even coffee colored. When you auscultate the patient’s heart and lungs, you may hear basilar crackles and an S3 heart sound. Most patients have an elevated arterial pressure. Weigh the patient each day, and monitor abdominal girth. Provide ongoing monitoring for visual changes, vomiting, adventitious breath sounds, abdominal distension, and seizure activity. These signs and symptoms indicate the potential onset of the complications and need to be reported to the physician.
Patients and families may be anxious about changes in the patient’s appearance, an uncertain prognosis, and the possibility of lifestyle changes. Older children and adults may be concerned about their appearance. Assess the patient’s and family’s coping mechanisms, support systems, and stress levels.
Nursing care plan primary nursing diagnosis: Fluid volume excess related to glomerular inflammation and decreased renal filtration.
Nursing care plan intervention and treatment plan
Most patients with Acute glomerulonephritis recover spontaneously. During the acute phase, when urine is grossly hematuric and blood pressure is elevated, the patient is placed on bedrest and symptoms are managed pharmacologically. A dietary consultation is necessary to implement dietary restrictions that can manage increased blood pressure, decreased urine output, and the presence of nitrogenous products in the urine. Usually, sodium and fluid restriction is instituted to manage hypertension and edema. Depending on the course of their disease, some patients also need potassium and protein restrictions. If the patient is on fluid restriction, work with the patient and family to devise a schedule of fluid intake that maximizes patient preference and comfort.
Focus on decreasing discomfort, reducing complications, and providing patient education. Work with the patient to develop a schedule for daily hygiene that limits fatigue and overexertion. Cluster care to provide for rest periods, and assist the patient with relaxation techniques. Assist children with the usual bedtime rituals. Increase activity gradually as symptoms subside.
While the patient is on bedrest, perform active or passive range-of-motion exercises each shift, and assist the patient to a new position every 2 hours. Monitor the patient’s skin for breakdown. If the patient is recovering from an infection, prevent secondary infection. Take time to answer the patient’s and parents’ questions fully. If you note that the family is coping ineffectively with the illness or prognosis, make a referral to a clinical nurse specialist.
Nursing care plan discharge and home health care guidelines
Inform patients and families about the disease process, prognosis, and treatment plan. Discuss with them the possibility that abnormal urinary findings may persist for years after Acute glomerulonephritis has been diagnosed. Demonstrate all home care techniques, such as medication administration. Discuss the dosage, action, route, and side effects of all medications. If the patient is placed on
antibiotics, encourage her or him to complete the entire prescription. Teach the patient and family to seek professional assistance for all infectious processes (particularly respiratory infections with sore throat and fever); monitor body weight and blood pressure at home or through a clinic; avoid contact with individuals with infectious processes. Discuss the need for ongoing laboratory monitoring of electrolytes and renal function tests during the months of convalescence, as recommended by the physician. Explain that after acute poststreptococcal Acute glomerulonephritis, any gross hematuria that occurs when the patient has a viral infection needs to be reported to the physician.