acute glomerulonephritis nursing care plan

Glomerulonephritis is a prominent cause of renal impairment. Glomerulonephritis represents 10-15% of glomerular diseases. In most instances, the disease becomes progressive without timely intervention, eventually leading to morbidity. This makes chronic glomerulonephritis the third most common cause of end-stage renal disease in the United States, following diabetes mellitus and hypertension, accounting for 10% of clients on dialysis.

Acute glomerulonephritis (AGN) comprises a specific set of kidney diseases in which 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 of these syndromes. AGN progresses to chronic glomerulonephritis in about 30% of adults.

The causal factors that underlie AGN can be divided into infectious and noninfectious groups.

Infectious: The most common infectious cause of AGN has historically been infection by Streptococcus species. Two types have been described, involving different serotypes:

  • Serotype 12- Poststreptococcal nephritis due to an upper respiratory infection, occurring primarily in the winter months.
  • Serotype 49- Poststreptococcal nephritis due to a skin infection, usually observed in the summer and fall and more prevalent in southern regions of the United States.

Noninfectious: Noninfectious causes of AGN may be divided into primary kidney diseases, systemic diseases, and miscellaneous conditions or agents.

Multisystem systemic diseases

  • Vasculitis- This causes glomerulonephritis that combines the upper and lower granulomatous nephritides.
  • Collagen-vascular diseases- This causes glomerulonephritis through renal deposition of immune complexes.
  • Hypersensitivity vasculitis- This encompasses a heterogeneous group of disorders featuring small vessel and skin disease.
  • Cryoglobulinemia- This causes abnormal quantities of cryoglobulin in plasma that results in repeated episodes of widespread purpura and cutaneous ulcerations upon crystallization.
  • Polyarteritis nodosa- This causes nephritis from vasculitis involving the renal arteries.
  • Henoch-Schönlein purpura- This causes a generalized vasculitis resulting in glomerulonephritis.
  • Goodpasture syndrome- This causes circulating antibodies to type IV collagen and often results in rapidly progressive oliguric renal failure (weeks to months).

Primary renal diseases

  • Membranoproliferative glomerulonephritis (MPGN)- This is due to the expansion and proliferation of mesangial cells as a consequence of the deposition of complements.
  • Immunoglobulin A (IgA) nephropathy (Berger disease)- This causes glomerulonephritis as a result of diffuse mesangial deposition of IgA and IgG.
  • Idiopathic rapidly progressive glomerulonephritis- This form of glomerulonephritis is characterized by the presence of glomerular crescents. Three types have been distinguished: Type 1 is an anti-glomerular basement membrane disease, type II is mediated by immune complexes, and type III is identified by an antineutrophil cytoplasmic antibody.

Miscellaneous noninfectious causes

  • Guillain-Barre syndrome
  • Irradiation of Wilms tumor
  • Diphtheria-pertussis-tetanus (DPT) vaccine
  • Serum sickness
  • Epidermal growth factor receptor activation, and possibly its inhibition by cetuximab
  • COVID-19 vaccine

Acute Glomerulonephritis

Glomerular lesions in AGN are the result of glomerular deposition or in situ formation of immune complexes. On gross appearance, the kidneys may be enlarged up to 50%. Histopathologic changes include swelling of the glomerular tufts and infiltration with polymorphonucleocytes.

AGN involves both structural changes and functional changes. Structurally, cellular proliferation leads to an increase in the number of cells in the glomerular tuft because of the proliferation of endothelial, mesangial, and epithelial cells. The extra capillary proliferation of parietal epithelial cells leads to the formation of crescents, a feature characteristic of certain forms of rapidly progressive glomerulonephritis. Functional changes include proteinuria, hematuria, reduction in glomerular filtration rate (GFR), and active urine sediment with RBCs and RBC casts.

Nursing interventions for a client diagnosed with acute glomerulonephritis are mainly supportive because there is no specific therapy for renal disease. The following are nursing diagnoses associated with acute glomerulonephritis.

  • Excess Fluid Volume
  • Risk for Infection
  • Disturbed Thought Processes

Acute Glomerulonephritis (AGN) Nursing Care Plan 

Below are sample nursing care plans for the problems identified above.

Excess Fluid Volume

In acute glomerulonephritis (AGN), glomerular filtration is reduced by the glomerular capillary obstruction caused by the immunological injury. The reduced glomerular filtration results in a fall in the filtered load of sodium and water, leading to expanded extracellular volume. The hemodynamic characteristics of the disease are increased blood volume, hypertension, and normal or increased cardiac output. Blood volume expansion increases peripheral capillary filtration by increasing arterial and venous pressure. The primary event of edema formation in AGN is the increased blood volume, edema also results as decreased serum protein reduces the osmotic pressure in the circulating blood volume. This reduced colloid osmotic gradient results in the fluctuation of transcapillary fluid.

Nursing Diagnosis

  • Excess Fluid Volume

Related Factors

  • Compromised regulatory mechanisms
  • Immunological injury

Evidenced by

  • Oliguria
  • Changes in urine-specific gravity
  • Venous distention; BP and CVP changes
  • Peripheral or periorbital edema
  • Changes in mental status, confusion
  • Abnormal breath sounds
  • Ascites
  • Decreased hematocrit and hemoglobin

Desired Outcomes

After the implementation of nursing interventions, the client is expected to:

  • Display appropriate urinary output with normal specific gravity.
  • Demonstrate stable weight and vital signs within the normal range.
  • Be free of edema.

Nursing Interventions

Assessment Rationale
Measure intake and output accurately and document. A decreased urine output of less than 400 mL/24 hours may be the first indicator of impending renal failure, especially in a high-risk client. Accurate I&O is necessary for determining fluid replacement needs and reducing the risk of fluid overload.
Monitor the client’s vital signs and CVP. Tachycardia and hypertension can occur because of the failure of the kidneys to excrete urine and changes in the renin-angiotensin system, which helps regulate long-term blood pressure and blood volume. Invasive monitoring may be needed for assessing intravascular volume, especially in clients with poor cardiac function.
Weigh the client daily at the same time of the day, on the same scale, with the same equipment and mount of clothing. Daily body weight is one of the best monitors of fluid status. A weight gain of more than 0.5 kg/day suggests fluid retention.
Monitor urine-specific gravity. Urine-specific gravity measures the kidney’s ability to concentrate urine. The urine is usually dark, and the specific gravity is more than 1.020 with RBCs and RBC casts.
Assess skin, face, and dependent areas for edema. Evaluate the degree of edema on a scale of +1 to +4. Edema occurs primarily in dependent tissues of the body, such as hands, feet, and the lumbosacral area. The client may gain up to 4.5 kg (10 lbs) of fluid before pitting edema is detected. Periorbital edema may be a presenting sign of this fluid shift because these fragile tissues are easily distended by even minimal fluid accumulation.
Auscultate lung and heart sounds. Fluid overload may lead to pulmonary edema and heart failure, as evidenced by the development of adventitious breath sounds and extra heart sounds.
Assess the client’s level of consciousness and changes in mentation. Accumulation of toxins, acidosis, electrolyte imbalances, or developing hypoxia affects the mental status, resulting in confusion or restlessness.
Plan oral fluid replacement with the client, within multiple restrictions. Allow the client to have varied choices of beverages such as hot, cold, or frozen beverages. This may help avoid periods without fluids, minimizes the monotone of limited choices, and reduces the sense of deprivation and thirst.
Encourage protein-rich foods and rescue sodium intake. Although restricting salt may limit edema and limiting protein intake may reduce the amount of protein lost in the urine, most clients who are losing large quantities of protein actually need more protein to supplement this loss. Most clients may do well on a usual diet for their age. For progressive disease, dietary restrictions of 2g sodium, 2g potassium, and 40 to 60g protein a day helps reduce the build-up of wastes and prevent fluid overload states.
Arrange for rest periods and light activities. Bed rest is unnecessary, although it’s good to encourage the client to participate in light activities rather than active exercise. After one to two weeks, the client may attend school and engage in usual activities, although the competitive activity is limited until kidney function has returned to normal (about two months).
Monitor laboratory studies. A decreased hematocrit may suggest a dilutional type of anemia. Potassium levels may be raised in clients with severe renal impairment.BUN and creatinine levels are raised, demonstrating a degree of renal impairment. In addition, GFR may be low.
Monitor serial chest X-rays. Increased cardiac size, prominent pulmonary vascular markings, pleural effusion, and infiltrates indicate acute responses to fluid overload or chronic changes associated with renal failure and heart failure.
Educate the client about smoking cessation. Cessation of smoking is also paramount in decreasing the aggravation of renal disease.
Administer and restrict fluids, as indicated. Fluid management is usually calculated to replace output from all sources as well as estimate insensible losses due to metabolism and diaphoresis. The client with oliguria with fluid overload who is unresponsive to fluid restriction and diuretics may require dialysis.
Administer diuretics as prescribed. Loop diuretics may be required in clients who are edematous and hypertensive, in order to remove excess fluid and correct hypertension.
Administer antihypertensives as indicated. Antihypertensives may be given to treat hypertension by counteracting the effects of decreased renal blood flow and/or circulating volume overload.
Administer vasodilators as prescribed. Given in small doses, dopamine causes selective dilation of the renal vasculature, enhancing renal perfusion.
Prepare the client for dialysis as indicated. Dialysis may be done to reduce volume overload, correct electrolyte, and acid-base imbalances, and remove toxins. The type of dialysis depends on the degree of hemodynamic compromise and the client’s ability to withstand the procedure.

Risk for Infection

Normally, the kidney is the site of hormone production and secretion, acid-base homeostasis, fluid and electrolyte regulation, and waste-product elimination. In the presence of renal failure, these functions are not performed adequately, resulting in uremia marked by elevated concentrations of urea in the blood and associated with fluid, electrolyte, and hormone imbalances. Uremia has immunosuppressive effects that increase the client’s risk for infection, especially hospital-acquired infections.

Nursing Diagnosis

  • Risk for Infection

Risk Factors

  • Depression of immunological factors
  • Invasive procedures or devices
  • Changes in dietary intake
  • Malnutrition

Evidenced by

  • (Not applicable; the presence of signs and symptoms establishes an actual diagnosis)

Desired Outcomes

After the implementation of nursing interventions, the client is expected to:

  • Display no signs and symptoms of infection.

Nursing Interventions

Assessment Rationale
Assess skin integrity. Excoriations from skin scratching due to  rashes may become secondarily infected.
Monitor the client’s vital signs. Fever higher than 100.4℉ (38℃) with increased pulse and respirations is typical of an increased metabolic rate resulting from inflammatory process, although sepsis can occur without a febrile response.
Promote good hand hygiene by the client and staff. Proper hand hygiene reduces the risk of cross-contamination.
Avoid invasive procedures, instrumentation, and manipulation of indwelling catheters whenever possible. Use an aseptic technique. Limiting invasive procedures and the use of an aseptic technique limits the introduction of bacteria into the body. Early detection and treatment of developing infection may prevent sepsis.
Provide routine catheter care and promote meticulous perianal care. This reduces bacterial colonization and the risk of ascending urinary tract infection.
Encourage deep breathing, coughing, and frequent position changes. This prevents atelectasis and mobilizes secretions to reduce the risk of pulmonary infections, especially in the presence of pulmonary edema due to fluid overload.
Monitor laboratory strides, such as WBC count with differential. Although elevated WBCs may indicate generalized infection, leukocyte proliferation is indicated by the presence of neutrophils and monocytes within the glomerular capillary lumen and often accompanies cellular proliferation. Additionally, a shifting of the differential to the left is indicative of infection.
Obtain specimens for culture and sensitivity. Verification of infection and identification of specific organisms aids in the choice of the most effective treatment. Cultures of throat and skin lesions to rule out Streptococcus species may be obtained.
Administer antibiotics as indicated. Antibiotics are used to control local symptoms and to prevent the spread of infection to close contacts. Antimicrobial therapy does not appear to prevent the development of glomerulonephritis, except if given within the first 36 hours. Antibiotic treatment of close contacts of the index case may help prevent the development of post-streptococcal glomerulonephritis.

Disturbed Thought Processes

When the kidneys are not functioning properly, dysfunction can occur in acid-base homeostasis, fluid and electrolyte regulation, hormone production secretion, and waste elimination. Altogether, these abnormalities can result in metabolic disturbances. The build-up of uremic toxins in the blood may contribute to kidney failure as there are decreased hydrogen ions and impaired excretion of ammonium, and eventually, build-up of phosphate and additional organic acids. In turn, the resulting increased anion-gap metabolic acidosis may lead to lethargy and changes in mental status.

Nursing Diagnosis

  • Disturbed Thought Processes

Risk Factors

  • Hypoxia
  • Accumulation of toxins
  • Electrolyte imbalances

Evidenced by

  • Disorientation
  • Memory deficit, altered attention span
  • Impaired ability to make decisions or problem-solve
  • Lethargy, confusion
  • Irritability, withdrawal, depression
  • Changes in behavior

Desired Outcomes

After the implementation of nursing interventions, the client is expected to:

  • Regain and maintain an optimal level of mentation.
  • Identify ways to compensate for cognitive impairment and memory deficits.

Nursing Interventions

Assessment Rationale
Assess the client’s mental status and the extent of the impairment. Uremic syndrome’s effect can begin with minor confusion or irritability and progress to altered personality, and inability to assimilate information or participate in care. Awareness of changes provides an opportunity for evaluation and intervention.
Determine the client’s usual level of consciousness from family members. This will provide a comparison to evaluate the progression or resolution of impairment.
Provide a quiet, calm environment and reduction of external stimuli. Environmental stimuli should be reduced to minimize sensory overload and confusion while preventing sensory deprivation.
Provide information about the client’s status to the significant others or family members. Some improvement in mentation may be expected with the restoration of more normal levels of BUN, electrolytes, and serum pH.
Reorient the client to surroundings, person, time, etc by providing calendars, clocks, and outside windows. Reorienting the confused client helps provide clues to aid in the recognition of reality.
Present reality concisely and briefly, and do not challenge illogical thinking. Confrontation potentiates defensive reactions and may lead the client to mistrust and heightened denial of reality.
Establish a regular schedule for activities. This aids in maintaining reality orientation and may reduce fear and confusion.
Provide information and instructions in simple, short sentences. Ask direct yes or no questions. This method of communication may aid in reducing confusion and increase the possibility that communications will be understood and remembered.
Promote adequate rest and periods of undisturbed sleep. Sleep deprivation may further impair cognitive abilities.
Provide appropriate dietary requirements. A low-protein diet is not recommended in clients diagnosed with advanced uremia or malnutrition, as this type of diet can result in worsening malnutrition and has been associated with an increased risk of mortality with the initiation of dialysis. The current recommendations for a protein intake before dialysis are 0.8g to 1g of protein/kg of weight per day. The client should also reduce potassium, phosphate, and sodium intake to 2g to 3g, 2g, and 2g per day each, respectively.
Monitor laboratory studies, such as BUN, creatinine, serum electrolytes, and ABGs. Correction of imbalances can have profound effects on cognition. A 24-hour urine collection may provide insight into both GFR and creatinine clearance.
Prepare the client for imaging studies as appropriate. If the client presents with significant alterations in mental status, a brain computed tomography scan may be warranted.
Provide supplemental oxygen as indicated. Correction of hypoxia alone can improve cognition.
Avoid the use of barbiturates and opiates. Drugs normally detoxified in the kidneys will have increased half-life and cumulative effects, worsening confusion.
Prepare the client for dialysis. Marked deterioration of thought processes may indicate worsening of azotemia and general condition, requiring prompt intervention to regain homeostasis.


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