final ap case study

7/27/2019 FINAL AP Case Study

http://slidepdf.com/reader/full/final-ap-case-study 1/57

A CASE STUDY OF

COLLEGE OF NURSING

PATIENT WITH ACUTE

PYELONEPHRITIS

Submitted to:DENNISON JOSE C. PUNSALAN, RN, MN

SUBMITTED BY:

Camba, Ma. Liezel M.

Lumba, Chared Joy D.

Masbang, Maria Elaine D.

Pugeda, Bianca Camille P.BSN III-3 GROUP 12 SUBGROUP 1



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Table of ContentsI.INTRODUCTION .......................................................................................................................................... 4

A.Current trends about the disease condition ......................................................................................... 6

B.Reason for choosing such case for presentation ................................................................................... 7

C.Objectives .............................................................................................................................................. 8

II. NURSING PROCESS ................................................................................................................................... 7

A. Assessment ........................................................................................................................................... 7

1. PERSONAL DATA ................................................................................................................................... 7

a. Demographic data ............................................................................................................................. 7

b. Socio-economic and cultural factors ................................................................................................ 7

c. Environmental factors ....................................................................................................................... 82. PERSONAL HISTORY .............................................................................................................................. 8

a. Maternal – obstetric record .............................................................................................................. 8

b. Prenatal history ................................................................................................................................. 9

Growth and Development .................................................................................................................... 9

3. FAMILY HEALTH-ILLNESS HISTORY ...................................................................................................... 10

Genogram ........................................................................................................................................... 11

Explanation of Genogram ................................................................................................................... 12

4. HISTORY OF PAST ILLNESS ................................................................................................................... 12

5. HISTORY OF PRESENT ILLNESS ............................................................................................................ 12

6. PHYSICAL ASSESSMENT ....................................................................................................................... 13

Initial Assessment (LIFTED FROM THE CHART) .................................................................................. 13

First Nurse-Patient Interaction ........................................................................................................... 14

7. DIAGNOSTIC AND LABORATORY PROCEDURES .................................................................................. 17

III. ANATOMY AND PHYSIOLOGY ............................................................................................................... 24

SCHEMATIC DIAGRAM (CLIENT-CENTERED) .......................................................................................... 30

IV. THE PATIENT’S ILLNESS ......................................................................................................................... 31

Synthesis of the disease ......................................................................................................................... 31

1. Definition of the disease ................................................................................................................. 31

2. Predisposing/Precipitating Factors ................................................................................................. 33

3. Signs and Symptoms ....................................................................................................................... 34



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4. Health Promotion and Preventive Aspects of the Disease ............................................................. 35

V. THE PATIENT AND HIS CARE .................................................................................................................. 38

A. MEDICAL MANAGEMENT ................................................................................................................... 39

a. IVFs .................................................................................................................................................. 39

b. Drugs ............................................................................................................................................... 42

c. Diet .................................................................................................................................................. 48

d. Activity/Exercise.............................................................................................................................. 50

B. NURSING MANAGEMENT ................................................................................................................... 51

1. NURSING CARE PLAN .......................................................................................................................... 51

2. ACTUAL SOAPIEs ................................................................................................................................. 61

VI. CLIENT’S DAILY PRORGESS IN THE HOSPITAL ...................................................................................... 63

1. Client’s Daily Progress Chart ............................................................................................................... 63

VII. CONCLUSION AND RECOMMENDATIONS ........................................................................................... 68

VIII. LEARNING DERIVED ............................................................................................................................ 68

IX. BIBLIOGRAPHY ...................................................................................................................................... 71

Books .................................................................................................................................................... 71

Websites ............................................................................................................................................... 71



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I. INTRODUCTION

“A wise man should consider that health is the greatest of human blessings, and

learn how by his own thought to derive benefit from his illnesses.”

- Hippocrates

The quote stated above implies that man is in control of his health. Health is

indeed one of the greatest blessings that man could ever have. Being healthy is also

reflected in the way how man perceives his illness. It is either seeing the benefit or the

negative out of it. Man is in full control over what he would want to do with his body.

Illness is subjective to man. Therefore, it is up to him whether he would take it as a

challenge to conquer and step up in order to place himself in a better condition or get

conquered by the illness itself.

The urinary tract is the body’s drainage system for removing wastes and extra

water. The urinary tract includes two kidneys, two ureters, a bladder, and a urethra. The

kidneys are two bean-shaped organs, each about the size of a fist. They are located near

the middle of the back, just below the rib cage, one on each side of the spine. Every day,

the two kidneys process about 200 quarts of blood to produce about 1 to 2 quarts of

urine, composed of wastes and extra water. Children produce less urine than adults. The

amount produced depends on their age. The urine flows from the kidneys to the bladder

through tubes called the ureters. The bladder stores urine until releasing it through

urination. When the bladder empties, urine flows out of the body through a tube called

the urethra at the bottom of the bladder.

Pyelonephritis is caused by a bacterium or virus infecting the kidneys. Though

many bacteria and viruses can cause pyelonephritis, the bacterium Escherichia coli is

often the cause. Bacteria and viruses can move to the kidneys from the bladder or can

be carried through the bloodstream from other parts of the body. A UTI in the bladder

that does not move to the kidneys is called cystitis.



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One of the most common renal diseases, acute pyelonephritis is a sudden

inflammation caused by bacteria. It primarily affects the interstitial area and the renal

pelvis or, less often, the renal tubules.

Chronic pyelonephritis is persistent kidney inflammation that can scar the

kidneys and may lead to chronic renal failure. This disease is most common in patients

who are predisposed to recurrent acute pyelonephritis, such as those with urinary

obstructions or vesicoureteral reflux.

People most at risk for pyelonephritis are those who have a bladder infection

and those with a structural, or anatomic, problem in the urinary tract. Urine normally

flows only in one direction—from the kidneys to the bladder. However, the flow of urine

may be blocked in people with a structural defect of the urinary tract, a kidney stone, or

an enlarged prostate—the walnut-shaped gland in men that surrounds the urethra at

the neck of the bladder and supplies fluid that goes into semen. Urine can also back up,

or reflux, into one or both kidneys. This problem, which is called vesicoureteral reflux

(VUR), happens when the valve mechanism that normally prevents backward flow of

urine is not working properly. VUR is most commonly diagnosed during childhood.

Pregnant women and people with diabetes or a weakened immune system are also at

increased risk of pyelonephritis (National Kidney and Urologic Diseases Information

Clearinghouse-NKUDIC, 2012)

The estimated annual incidence of pyelonephritis was 27.6 cases per 10,000

persons. Only 7% of cases required hospitalization. Escherichia coli caused 85% of cases,

including 6 of 7 cases among inpatients for whom data were available. Of E. coli isolates,

85% were sensitive to trimethoprim-sulfamethoxazole, while 99% were susceptible to

ciprofloxacin.



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A. Current trends about the disease condition

Our local trend is a health program/service made by the Department of Health

which is about “Renal Disease Control Program (REDCOP)”

The REDCOP consists of the following components: RDR (Renal Disease Registry);

Study on GN and Kidney Stones; Follow-up of PNP cases; and Organ Donation.

This is a relatively new program with the objective of reducing the mortality and

morbidity rates caused by renal diseases. (http://www.doh.gov.ph/CHD-12-

new/degenerative.htm)

We have researched a foreign trend about “Kidney-damaging Protein Offers Clue

to New Treatment to Kidney Diseases”.

Scientists led by a University of Cincinnati (UC) kidney expert have found that a naturally

occurring protein that normally fights cancer cells can also cause severe kidney failure

when normal blood flow is disrupted. This finding, seen in mice in which the gene

controlling the protein is actually expressed or "turned on," could provide a target for

drugs that will reduce the risk of kidney damage in humans, the researchers believe.

Acute kidney failure is a life-threatening illness caused by sudden, severe loss of blood

flow to the kidneys (ischemia). Despite advances in supportive care, such as dialysis,severe kidney injury is a major cause of death.

The scientists, headed by Manoocher Soleimani, MD, director of nephrology and

hypertension at UC and the Cincinnati Veterans Affairs Medical Center, report their

findings, the issue of the Journal of Clinical Investigation.

The protein, thrombospondin (TSP-1), is known for its role in fighting cancer. It does this

by killing off cancer cells and preventing the tumor from building a greater blood supply.

Although TSP-1 causes irreversible, severe kidney damage when blood flow to mousekidneys is disrupted, the researchers say, this only occurs in animals whose TSP-1 gene is

turned on.



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The study showed that the protein damages kidney cells when blood flow is reduced for

30 minutes or more. When blood flow is restored to the kidneys, if TSP-1 protein is

present, normal kidney function doesn't return.

"This raises the important possibility that TSP-1 may serve as a target in preventing or

successfully treating acute kidney failure," said Dr. Soleimani. "Understanding the

mechanisms of kidney cell injury moves us that much closer to preventing this life-

altering damage from happening.

"If we can develop a drug that will inhibit or turn off the TSP-1 gene function, then

severe kidney damage could be prevented--even during a 30-minute disruption in blood

flow," he said.

"Since the incidence of death remains high in patients with damaged kidneys,

prevention or early treatment of acute kidney failure will increase survival."

The study showed that the damaging protein is released rapidly, in response to

diminished blood flow, in mice that have the active TSP-1 gene. TSP-1 also killed kidney

cells when exposed to them in a Petri dish.

"Most importantly," Dr. Soleimani said, "we found that genetically engineered mice,

which lack TSP-1 protein, were significantly protected from kidney damage. Mice

without TSP-1 preserved their kidney function relatively well, even after being subjectedto a 30-minute disruption of blood flow to the kidneys.

"Consequently, this study raises an important possibility that TSP-1 may serve as a

target for preventing or successfully treating acute kidney failure," Dr. Soleimani said.

(Source: http//:www.sciencedaily.com)

B. Reasons for choosing such case for presentation

This study was a part of the partial requirement in NCM 103 (R.L.E.) of

the Third year college students of the Angeles University Foundation. The group

decided to take up Acute Pyelonephritis as a subject in their case study in order for

them to learn further regarding this disease that affects the kidneys, since kidneys



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play a vital function in the over-all health of a person. This condition is usually

encountered in the medical field. In this case, it will be helpful not only for the

student nurses, but as well as for every medical professional to gain broader

knowledge and updates in the said condition.

C. Objectives

Nurse – Centered Objectives

After the completion of the study, the student nurse – researcher will be able to:

• Establish a therapeutic relationship with the patient and the significant others

• Gather the personal information of the client, from his / her past medical history

and from the family’s health history

• Perform a complete physical assessment (cephalocaudal) of the client

• Make a comprehensive understanding and analysis regarding the laboratory and

diagnostic findings, as a part of the nursing responsibilities of every nurse

• Identify the predisposing and precipitating factors of the client’s condition

• Determine the dependent and independent function as a nurse in rendering

health care services.

Patient – Centered Objectives

Upon completion of the study, the patient will be able to:

• Acquire and enhance knowledge about the disease, the factors that contribute

to the development of the client’s condition

• Build trust and gain respect among the nurses and able to deepen information

about his / her condition• Meet the needs of the client in the best way possible, either physically, mentally,

socially, spiritually and emotionally

• Develop independence in performing self – care before the discharge of the

client



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II. NURSING PROCESS

A. Assessment

1. PERSONAL HISTORY

a. Demographic data

“Kitkat” is a 22 years old female, affiliated in the Roman Catholic Church

(but a former Baptist) and a Filipino citizen. She was born on January 5, 1991 in

Mexico, Pampanga. She is an independent daughter and has her own family

already, living separately from her parents. Her family is currently residing at D-

10 B-92 L-22 Pandacaqui Resettlement, Mexico, Pampanga. She was admitted

last August 14, 2013 at 8:13pm with an acute pyelonephritis.

b. Socio-economic and cultural factors

The family falls under the nuclear type. Her own family with his husband

is composed of three members namely: Kitkat herself, husband Ferrero, and

their daughter Kisses, which is the first and only child. On the other hand,

Kitkat’s parents namely daddy Toblerone and mommy Cadbury lives separately.

Their family has a good relationship with each other. She is already independent

from her parents. She hasn’t finished fourth year in high school, but studied a

vocational course in electric (eg. Fixing cellphones, etc.)

Husband Ferrero works in a furniture shop and earns 10,000php a month.

While Kitkat is a plain housewife. Their family is categorized as not poor, and

according to Kitkat, the family’s income is enough to support and suffice the

needs of the family.

The patient came originally from Pampanga. She belongs to the Roman

Catholic religion and is going to church every Sunday together with her family.



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Their family uses herbal medications such as oregano. They also believe

in quack doctors (albularyos) but they still prefer medical treatment.

c. Environmental factors

Kitkat’s family is living in a house made up of concrete wood structure

which they own. Their ventilation is adequate because they have 6 windows and

2 doors as their source of ventilation. According to Kitkat, they maintain

cleanliness in their house. Their usual meal is a rice meal. Her family use mineral

water as their source of drinking. She eats 3 to 4 times a day.

2. FAMILY HEALTH-ILLNESS HISTORY



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EXPLANATION:

The genogram above shows that daddy Toblerone, father of Kitkat, is

already deceased. He died because of kidney problem, which is according to

mommy Cadbury that his kidney was “nalanta.” The mother of daddy Toblerone,

lola Mars, is hypertensive. On the other hand, mommy Cadbury, mother of

Kitkat, says that she also experiences dysuria, and also that of lola Crunch, the

mother of Cadbury. While lolo Snickers, father of Cadbury, had tuberculosis.

According to mommy Cadbury, problem in kidneys are their family line’s genetic

disease conditions. While daddy Toblerone was the first in his line to have a

kidney problem. The genogram presented up until the generation of Kitkat’s

grandmothers and grandfather both on the maternal and paternal side.

3. HISTORY OF PAST ILLNESS

The patient did not have any of the childhood illnesses such as

chickenpox, mumps, and measles. But already had fever, coughs, and colds. The

SO cannot remember about the immunizations of the patient, but verbalized

that it is incomplete. She has no allergies to certain drugs, food or any otherenvironmental agents. She had the same problem three years ago and was

hospitalized at Balitucan, Magalang. But she was also referred to JBL. She was

hospitalized at JBL for about six times because of the same problem too.

4. HISTORY OF PRESENT ILLNESS

On the 14

th

of August 2013, Kitkat experienced fever, nausea andvomiting, malaise, difficulty of breathing, cannot eat, flank and back pain, and

dysuria; then his husband, Ferrero, immediately brought her to JBL at 6 in the

evening. They didn’t do any home management. The patient then was diagnosed



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Review of systems:

General: No at loss

Skin: (-) rash

HEENT: (-) colds

Musculoskeletal: (-) weakness, (-) edema

Respiratory: (-) cough

Cardiovascular: (-) chest pain

GI: (-) LBM

First Nurse-Patient Interaction

Date of physical assessment: August 15, 2013

General Survey:

Received patient in a sitting position in the bed, conscious and coherent;

with ongoing IVF #2 PNSS 1L @ 600cc level regulated at 32gtts/min infusing

through the right metacarpal vein; with increased OFI but without output as of

9am, slightly febrile, good skin turgor, moist mucous membrane; VS as follows: T

of 39.7°C, PR of 96bpm, RR of 18bpm, BP of 100/60mmHg

Vital Signs: T: 39.7°C

PR: 96bpm

RR: 18bpm

BP: 100/60mmHg



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SKULL AND FACE

normocephalic shape skull with absence of nodules or masses upon palpation

symmetrical facial features and facial movements

was able to smile, frown, raise eyebrows, and puff her cheeks

HAIR AND SCALP

hair is long, black and straight upon inspection

evenly distributed with no lice and dandruff noted

SKIN AND NAILS

cold and clammy skin with absence of edema and nodules

fair skin complexion

good skin turgor

no presence of lesions

has short fingernails and toenails

without presence of pallor

EYES AND VISION

dark eyebrows are evenly distributed and symmetrically aligned with equal

movements

black pupil

eyelashes are also equally distributed and curled slightly outward and upward

eyelids close symmetrically with skin intact and no discharge or discoloration

bulbar conjunctiva is transparent and sclera appears white

without pale palpebral conjunctiva

lacrimal ducts have no edema or tearing upon palpation

cornea is transparent, shiny and smooth with visible details of iris



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pupils are equally round and reactive to light accommodation

left and right eye can see clearly in the periphery when looking straight ahead

and is able to read newsprint at a given distance

no discharges noted upon inspection

EARS AND HEARING

no tenderness behind the ears

auricles are same as the color of facial skin

aligned with outer canthus of eyes

not tender and recoil after being folded

left and right ear can hear clearly a normal voice tones

NOSE AND SINUSES

symmetrical and straight

no discharges or flaring

has uniform color and not tender

nasal septum is intact and in midline

air moves freely on both nares as client breathes

facial sinuses are not tender

no lesions

MOUTH AND OROPHARYNX

without dry and pale lips

without dental caries

tongue is at the center and pinkish in color with no lesions, no tenderness noted

and moves freely



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NECK

muscles equal in size

head centered

can move her head smoothly and with no discomfort

lymph nodes are not palpable

trachea is in the midline of the neck

thyroid gland is not visible upon inspection and ascends during swallowing upon

palpation

carotid artery and jugular veins are not distended or visible

THORAX AND LUNGS

chest symmetric volume

no tenderness noted

no masses noted

full and symmetric chest expansion

resonant sound upon percussion over the lungs

breathing is rhythmic, quiet and effortless

no adventitious breath sounds upon auscultation

spine is vertically aligned

HEART

presence of pulsation

normal heart rate

irregular in rhythm

peripheral pulses are symmetrical with that of the apical pulse

ABDOMEN



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uniform in color, flat, soft

non-tender and no masses

UPPER EXTREMITIES and LOWER EXTREMITIES

muscles are equal in size

no contractures

no tremors

no bone deformities

no tenderness palpated

can sense sharp and blunt objects was able to adduct her arm, supine and prone

her hands, shrug her shoulders against resistance, and flex and extend her arms



Page | 19

6. DIAGNOSTIC AND LABORATORY PROCEDURES

Diagnostics/

Laboratory

Procedures

Date

ordered;

Date

results

Indication(s)

OrPurpose

ResultsNormal

Values

Analysis

and

Interpreta

tionOf results

(client-

centered)

Creatinine DO&DR:

08/14/13

The kidneys

maintain the

blood creatinine

in a normal

range.

Creatinine has

been found tobe a fairly

reliable

indicator of

kidney function.

Elevated

creatinine level

signifies

impaired kidney

function or

kidney disease.

60.5 umol/l58-120

umol/l

The result

was

normal

which

means

that the

patient’skidneys

are

working

well

PotassiumDO&DR:

08/14/13

A potassiumtest checks how

much potassium

is in the blood.

Potassium is

both

an electrolyte a

nd a mineral. It

helps keep the

water (the

amount of fluidinside and

outside the

body's cells) and

electrolyte

balance of the

body. Potassium

is also

3.49 mmol/l3.50-5.50

mmol/l

Thepatient

has

hypokale

mia

indicating

electrolyte

imbalance

http://www.webmd.com/hw-popup/electrolytes-and-electrolyte-imbalances




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important in

how nerves and

muscles work.

SodiumDO&DR:

08/14/13

A test for

sodium in the

urine is a 24-

hour test or a

one-time (spot)

test that checks

how much

sodium is in the

urine. Sodium is

both

an electrolyte a

nd a mineral. It

helps keep thewater (the

amount of fluid

inside and

outside the

body's cells) and

electrolyte

balance of the

body. Sodium is

also important

in how nervesand muscles

work.

140.3 mmol/l135-145

mmol/l

The

patient

has

normal

sodium

level

Red blood

cells

DO&DR:

08/14/13

RBC count is

used to evaluate

any type of

decrease or

increase in the

number of red

blood cells as

measured per

liter of blood.

7.86 mmol/l 4-9 mmol/l

The

patient

has

normal

red blood

cells

HemoglobinDO&DR:

08/14/13

A hemoglobin

determination is

used to evaluate

the hemoglobin

content (and

thus the iron

115M:125-175g/L

F:115-155g/L

The

hemoglobi

n level of

the

patient is

normal.





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NeutrophilsDO&DR:

08/14/13

The neutrophil

white blood

cells are the first

ones on the

scene of an

injury and helpto tend the

initial wounds.

Like all white

blood cells

along with

fighting off

injuries, it is also

there duty to

attack bacteria

and otherintruders into

the body. While

they fight

disease

alongside other

white blood

cells, they do

not treat

infections like

antibiotics or

othermedications.

0.60 0.45-0.65

The

patient’s

neutrophil

s are

within

normalrange.

LymphocytesDO&DR:

08/14/13

Determine if

there is enough

cell that

produces

antibodies and

other chemicals

responsible for

destroying

microorganisms;contributes to

allergic

reactions, graft

rejection, tumor

control, and

regulation of

the immune

0.40 0.20-0.35

The

patient

has

elevated

lymphocyt

es which

compromi

ses her

immunityand

increases

susceptibil

ity to

further

infections.



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system

Platelet

count

DO&DR:

08/14/13

Platelets, which

are also called

thrombocytes,

are small disk-

shaped blood

cells produced

in the bone

marrow and

involved in the

process of blood

clotting.

104 150-400×109/L

The

patient

has

thromboc

ytopenia

which

predispos

es him to

risks for

bleeding.

UrinalysisDO&DR:

08/14/13

Urinalysis is part

of routinediagnostic and

screening

evaluations. It

can reveal a

significant

amount of

preliminary

information

about the

kidneys andother metabolic

processes.

Urinalysis

includes

remarks as to

the color,

appearance and

odor, pH, and

presence of

proteins,

glucose,ketones, and

blood and

leukocyte

esterase. In

addition, the

urine is

Color:Dark Yellow

Transparency:

Turbid

Albumin:

Negative

Reaction:

Positive

Specific Gravity:

1.030

Pus cells:

20-25/HPF

RBC:

18-20/HPF

Epithelial cells:Many

Bacteria:

Heavy

Yellow, Clear

Clear

Negative

Negative

1.010-1.025

0-5/HPF

0-3/HPF

Few

None

Color:

-Urineranges

from pale

yellow to

amber

because of

the

pigment

urochrom

e

(production of

bilirubin

metabolis

m)

Transpare

ncy

;-Patient

has turbid

urine that

maycontain

RBC’s or

WBC’s

bacteria,

fat, or

chyle, if



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elevated

levels

which

confirms

the

presenceof

microorga

nism in

the urine

Nursing Responsibilities:

Obtain blood sample from brachial artery

Mainstream clean catch urine



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An average adult produces about 1.5 liters (3 pt) of urine each day, and the body needs, at

a minimum, to excrete about 0.5 liter (1 pint) of urine daily to get rid of its waste products.

Excessive or inadequate production of urine may indicate illness and doctors often use

urinalysis (examination of a patient’s urine) as part of diagnosing disease. For instance, the

presence of glucose, or blood sugar, in the urine is a sign of diabetes mellitus; bacteria in the

urine signal an infection of the urinary system; and red blood cells in the urine may indicate

cancer of the urinary tract.

II STRUCTURE AND FUNCTION

The kidneys lie embedded in fat tissue on either side of the backbone at about waist level.

Each fist-sized kidney is reddish-brown, weighs 140 to 160 g (5 to 6 oz), and is similar in shape

to the kidney beans sold at the supermarket.

On the inner border of each kidney is a depression called the hilum, where the renalartery, the renal vein, and the ureter connect with the kidney (the adjective renal is from the

Latin term renalis, meaning of or near the kidneys). The renal artery delivers over 1700 liters

(450 gal) of blood to the kidneys each day, which these organs filter and return to the heart via



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the renal vein. Each kidney contains about 1 million microscopic coiled channels, called

nephrons, which perform this critical blood-filtering function and produce urine in the process.

The bulblike upper portion of the kidney’s nephrons filters water; urea, the nitrogen-

containing breakdown product of protein; salts; glucose; amino acids, the building blocks of

proteins; yellow bile compounds from the liver; and other trace substances from the blood. As

this material moves through a long, looped tubule, many of these filtered materials are

reabsorbed into the blood to be reused by the body to maintain normal body functions. Less

than 1 percent of the water and other materials remain behind to be excreted as waste

products in the urine.

These waste materials then pass from the nephrons into a funnel-shaped area called the

renal pelvis. From the renal pelvis, waste trickles out of the kidney into the ureter, which is

about 25 to 30 cm (10 to 12 in) long and about 0.5 cm (0.2 in) in diameter. The ureter empties

into a hollow, muscular sac called the urinary bladder. A valvelike flap of tissue at the point of

entry into the bladder prevents urine from flowing backward into the ureter. The urinary

bladder is able to expand and contract according to how much urine it contains. As it fills with

urine, the walls of the bladder stretch and become thinner, with the bladder itself lengthening

to 12.5 cm (5 in) or more and holding up to about 0.5 liter (1 pt) of urine. A ringlike sphincter

muscle surrounds the bladder’s outlet and prevents spontaneous emptying.

As the bladder becomes full, stretch-sensitive receptors in its walls are stimulated, and

the person becomes aware of the fullness. When the person is ready to urinate, or expel urine,

the sphincter relaxes and urine flows from the bladder to the outside through the urethra. In

females, the urethra is about 3.8 cm (1.5 in) long and is strictly a urinary passage. In males, the

urethra is about 20 cm (8 in) long; it passes through the penis and also serves to convey semen

during sexual intercourse.

In addition to their vital role in ridding the body of wastes through the production of

urine, kidneys play important regulatory roles. They maintain water balance, ensuring that the

amount of water in body tissues remains at a constant level. So, for example, if a person drinks



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a lot of water one day, but little water the next, the kidneys are able to adapt by regulating the

water balance in the tissues. The kidneys also control calcium levels in the blood to maintain

healthy bones. They aid in regulating the acid-base balance of the blood and body fluids so that

all body processes can proceed smoothly. By controlling salt levels, the kidneys help regulate

blood pressure. Finally, they stimulate the body to make red blood cells, the primary

component of healthy blood. Properly functioning kidneys are so vital to health that if they

cease to function, death follows within days.

All vertebrates dispose of excess water and other wastes by means of kidneys. The

kidneys of fish and amphibians are comparatively simple, while those of mammals are the most

complex. Fish and amphibians absorb a great deal of water and, as a result, must excrete large

quantities of urine. In contrast, the urinary systems of birds and reptiles are designed to

conserve water; these animals produce urine that is solid or semisolid.

8. THE PATIENT AND HIS ILLNESS

a. Schematic Diagram

PATHOPHYSIOLOGY OF THE DISEASE (BOOK BASED)

----PRECIPITATING FACTORS---- --PREDISPOSING FACTORS-- -Obstruction of urinary outflow -gender

-Vesicoureteral reflux -older age

-Neurogenic bladder -lifestyle

-Renal disease -environment

-Metabolic disturbances -pregnancy

-instrumentation

-chronic analgesic abuse



33 | P a g e

B. PLANNING (NURSING CARE PLAN)



Page | 34

Problem #1: Acute pain related to frequency of urination

Assessment Nursing diagnosis Scientific

explanation

Objective Interventions Rationale Expected outcome

S>Ø

O>patient

manifested:

>guarding behavior

>facial grimaces

The pt. May

manifest:

>suprapubic

tenderness

>low back pain or

flank pain

>fever

>chills

>fatigue

>anorexia

Acute pain related

to frequency of

urination

Atrophied

parenchyma

brought about by

narrowing of the

calyx neck and

scarring of

parenchyma causes

urine retention and

which further

causes unpleasant

sensation to the

patient thereby by

resulting to pain.

Short-term

goal: after 3 hours

of nursing

interventions,

patient will be able

to verbalize ways to

decrease pain.

Long term goal:

after 3 days of

nursing

interventions the


to report less pain

or increase pain

tolerance.

>Assess pain

characteristics:

location, quality,

severity, onset and

duration.

>Observe and

monitor signs and

symptoms of pain

such as BP, heart

rate, temperature,

color and moisture

of the skin.

>Anticipate need for

pain relief

>Eliminate

additional stressors

or sources of

discomfort

whenever possible.

>To identify extent

of pain.

>Some people deny

the experience of

pain when it is

present.

>Early intervention

may decrease the

total amount of

analgesia required.

>Pt. May experience

exaggeration in pain

or a decreased

ability to tolerate

painful stimuli if

environmental,

intrapersonal

factors are further

stressing them.

Short-term goal:

after 3 hours of

nursing

interventions,

patient shall have

verbalized ways to

decrease pain.

Long term goal:

after 3 days of

nursing

interventions the

patient shall have

reported less pain

or increase pain

tolerance.



35 | P a g e

>Provide rest

periods to facilitate

comfort, sleep and

relaxation.

>Use non-

pharmacologic pain-

relief methods:

distraction

techniques,

relaxation

techniques, music

therapy.

>Notify physician if

interventions are

unsuccessful or if

current complaint is

significant change

from past

experience.

>The pt’s

experiences of pain

may become

exaggerated as the

result of fatigue.

>Decreases one’s

awareness and

experience of pain.

Some methods are

breathing

modifications and

nerve stimulation.

>To prescribe

medication if

possible.



37 | P a g e

relatives not to

cover the

client with a

blanket, and

use less

restrictive

clothing’s Administer

Anti pyrectics

as prescribed

putting

ice packs

would be

helpful.

To

increase

heat lossthrough

conducti

on

To

support

circulatin

g volume

and

tissue

perfusion

.

Heat loss

by

convectio

n.

to avoid

further

increase



38 | P a g e

of clients

temperat

ure.

For

immediat

e

alteration of body

temperat

ure



39 | P a g e

Problem #3: Impaired urinary elimination related to disease conditions.

Assessment Nursing diagnosis Scientific

explanation

Objective Interventions Rationale Expected outcome

S>” Panay ang ihi

ko”

O> patientmanifested:

>Frequency of

urination

(5-6x/day)

>Body malaise

>A febrile

Patient may

manifest:

>dysuria

>Incontinence

Impaired urinary

elimination related

to disease

conditions.

The most common

mechanism by

which a UTI

develops is viaascending and

invading bacteria.

The organism

triggers an

inflammatory

response in the

lining of the urinary

tract.

Short term:

After 1-3 hours of

nursing

interventionspatient will be able

to verbalize

understanding on

the health

teachings given

Long term:

After 2 days of

nursing

intervention the


to demonstrate

behavior

techniques to

prevent urinary

tract infection

>Note the age and

sex of the client

(UTI’s are prevalent

among women andolder men)

>Determine client

previous pattern of

elimination and

compare with

current situations

>Determine client

usual daily fluid

intake

>Encourage client to

verbalize fear and

concern

>Instruct client to

increase fluid intake

>To gather

baseline data

>Contribute to

immobility

>To obtain

baseline data

>To provide

comfort

>To adjust care as

indicated

Short term: the

patient shall have

verbalized

understanding ofthe condition

Long term:

The patient shall

have demonstrated

behavior and

techniques to

prevent urinary

infection



42 | P a g e

Educate patients and their families about signs and symptoms of volume overload and

dehydration, and instruct patients to notify their nurse if they have trouble breathing or

notice any swelling. Instruct patients and families to keep the head of the bed elevated

(unless contraindicated)

b. Drugs

Name of Drugs

(Generic name,

Brand name)

Date

ordered;

Date

started;

Date

changed

Route of

Administration;

Dosage;

Frequency

General action Indications Client’s

response

to the

medication

Ceftriaxone

BRAND NAME

Rocephin

CLASSIFICATION

Antibiotic

Cephalosporin

(third

generation)

DO:

08/14/13

DS:

08/14/13

DC: -

IV 1gram +

30cc D5W x 30

min. infusion

every 12 hours

Ceftriaxone

binds to one or

more of the

penicillin-

binding proteins

(PBPs) which

inhibits the final

transpeptidation

step of

peptidoglycan

synthesis inbacterial cell

wall, thus

inhibiting

biosynthesis and

arresting cell

wall assembly

resulting in

bacterial cell

death.

· Lower

respiratory

infections

· UTI’s cause

byE. coli

· Gonnorhea

· Intra

abdominal

infections

· Skin and

skinstructures

infection

· Septicemia

· Bone and

joint

infections

· Meningitis

·

Perioperative

prophylaxis

The patient

did not

manifest

adverse

effects.

Nursing Interventions:

Assesspatient’s previous sensitivity reaction to penicillin or other cephalosphorins.

Assess patient for signs and symptoms of infection before and during the treatment

Obtain C&S before beginning drug therapy to identify if correct treatment has been initiated.



44 | P a g e

Do not breast feed while taking this drug.

Name of Drugs

(Generic name,

Brand name)

Date

ordered;

Datestarted;

Date

changed

Route of

Administration

; Dosage;

Frequency

General action Indications Client’s

response

to the

medicatio

n

Metoclopromid

e

BRAND NAME

Reglan

CLASSIFICATION

GI stimulant,

Antiemetic,

Dopaminergic

blocker

DO:

08/14/13

DS:

08/14/13

;

9 pm

DC:

08/14/13

1:20 am

IV 40mg now Metoclopramid

e enhances the

motility of the

upper GI tract

and increasesgastric

emptying

without

affecting

gastric, biliary

or pancreatic

secretions. It

increases

duodenalperistalsis which

decreases

intestinal transit

time, and

increases lower

oesophageal

sphincter tone.

-Prophylaxis

of

postoperativ

e nausea and

vomiting

when

nasogastric

suction is

undesirable

-Single-dose

parenteral

use:

Facilitation of

small-bowel

intubationwhen tube

does not pass

the pylorus

with

conventional

maneuvers

The

patient did

not

manifest

adverseeffects.

Nursing Interventions

Monitor BP carefully during IV administration.

Monitor for extrapyramidal reactions, and consult physician if they occur.



46 | P a g e

Nursing Interventions:

Do not exceed 4gm/24hr. in adults and 75mg/kg/day in children.

Do not take for >5days for pain in children, 10 days for pain in adults, or more than 3

days for fever in adults.

Extended-Release tablets are not to be chewed.

Monitor CBC, liver and renal functions.

Assess for fecal occult blood and nephritis.

Avoid using OTC drugs with Acetaminophen.

Take with food or milk to minimize GI upset.

Report N&V. cyanosis, shortness of breath and abdominal pain as these are signs of

toxicity.

Report paleness, weakness and heart beat skips

Report abdominal pain, jaundice, dark urine, itchiness or clay-colored stools.

Phenmacetin may cause urine to become dark brown or wine-colored.

Report pain that persists for more than 3-5 days

Avoid alcohol.

This drug is not for regular use with any form of liver disease.

c. Diet

Type of Diet Date General Indications Specific Client’s



47 | P a g e

ordered;

Date

started;

Datechanged

Description foods taken response

or reaction

to diet

NPO 4 hours DO:

08/14/13

DS:

08/14/13;

9 pm

DC:

08/14/13

1:20 am

To DAT

No food intake

for 4 hours.

- - The

patient

complied.

2. ACTUAL SOAPIEs

SOAPIE #1 (August 15, 2013)



48 | P a g e

S: “Nahihirapan akong umihi, tsaka masakit dito sa may puson ko tsaka tagiliran,” as verbalized

by the patient.

O: Received patient in a sitting position in the bed, conscious and coherent; with ongoing IVF #2

PNSS 1L @ 600cc level regulated at 32gtts/min infusing through the right metacarpal vein; with

increased OFI but without output as of 9am, slightly febrile, good skin turgor, moist mucous

membrane; VS as follows: T of 37.7°C, PR of 96bpm, RR of 18bpm, BP of 100/60mmHg

A: Impaired Urinary Elimination r/t altered renal function AEB imbalance intake and output 2°

Acute Pyelonephritis

P: After 4 hours of nursing interventions, the patient will be able to participate in measures to

correct abnormal elimination

I:

Established therapeutic relationship

Assessed patient’s general condition

Vital signs taken and recorded

Noted age and gender of patient

Investigated pain, noted location, duration and intensity

Noted frequency of urination

Asked client’s previous pattern of elimination

Encouraged patient to increase oral fluid intake

Discussed possible dietary restrictions such as caffeinated beverages

Assisted with developing toileting routines such as tined voiding

Provided tepid sponge bath

Reminded SO for patient’s ultrasound

E: Goal met AEB patient participated in measures to improve urinary function



Page | 49

V. EVALUATION

1. Client’s Daily Progress Chart

DAYS ADMISSION

(08/14/13)

(08/15/13)

Nursing Problems

1. Acute pain

2. Hyperthermia

3. Impaired urinary

elimination

4. Impaired physical

mobility

Vital signs:

Temperature

Pulse rate

Respiratory rate

Blood pressure

38.2

90 bpm

28 bpm

90/60mmHg

37.7

96

18

100/60mmHg

Diagnostic or Lab

Procedures

Hematology Test

Clinical chemistry

Urine Analysis

Hgb: 115

Hct: 0.34

WBC: 1.65Neutrophils: 0.60

Lymphocytes: 0.40

Platelets: 104

ANALYTE:

*Creatinine:60.5

ELECTROLYTES:

*Potassium: 3.49

*Sodium:140.3

*RBS:7.86

Color:

Dark Yellow

Transparency:

Turbid



50 | P a g e

Medical Mgmt.:

1. IVF

Albumin:

Negative

Reaction:

Positive

Specific Gravity:

1.030

Pus cells:

20-25/HPF

RRC:

18-20/HPF

Epithelial cells:Many

Bacteria:

Heavy

IVF #1 1L PNSS IVF #2 1L PNSS

Drugs

1. Ceftriaxone

2. Paracetamol

3. Omeprazole4. Metoclopromide

***

******

Diet NPO 4 hours DAT

Activity/Exercise - -

Surgical

Management

- -



51 | P a g e

III. SUMMARY OF FINDINGS

Pyelonephritis is caused by a bacterium or virus infecting the kidneys. One of the most

common renal diseases, acute pyelonephritis is a sudden inflammation caused by bacteria. It

primarily affects the interstitial area and the renal pelvis or, less often, the renal tubules.

Kitkat experienced fever, nausea and vomiting, malaise, difficulty of breathing, cannot

eat, flank and back pain, and dysuria. The patient then was diagnosed to have acute

pyelonephritis. The patient had cold clammy skin and irregular heart rhythm upon assessment.

The patient’s vital signs were within normal limits.

For the diagnostic tests, the result of the patient’s HCT level was 0.34% which is below

the normal range which indicates low RBC/hemoglobin to the plasma level. It indicates anemiaand oxygen insufficiency. The patient has elevated lymphocytes which is 0.40 that indicates that

her immunity compromises and increases susceptibility to further infections. The patient’s

platelet count is 104×109/L that suggests presence of thrombocytopenia which predisposes

him to risks for bleeding.

For the result of the urinalysis of the patient, the color of the urine ranges from pale

yellow to amber because of the pigment urochrome (production of bilirubin metabolism).

Patient has turbid urine that may contain RBC’s or WBC’s bacteria, fat, or chyle, if may reflect

renal infection. The patient has positive reaction indicating bacterial invasion. The patient’s

specific gravity is higher than normal range which indicates the concentrated urine. The patient

has elevated levels which confirm the presence of microorganism in the urine.

PNSS 1L was administered to the patient to replace fluid loss and electrolyte loss,

maintain patient’s hydration, nutritional status and fluid balance. It is used to supply the

necessary nutrient to the patient. Medications such as Ceftriaxone, Omeprazole,

Metoclopramide and Paracetamol were given to the patient. Ceftriaxone is an antibiotic that

inhibits biosynthesis and arrests cell wall assembly resulting in bacterial cell death, since

pyelonephritis is usually caused by bacteria affecting the kidneys. Omeprazole is a proton pump

inhibitor that suppresses gastric acid secretion. Metoclopramide is a GI stimulant, antiemetic,

and dopaminergic blocker that enhances the motility of the upper GI tract and increases gastric



52 | P a g e

emptying time. Paracetamol is an anti-pyretic that decreases fever by a hypothalamic effect

leading to sweating and vasodilation.

The patient manifested problems with acute pain and impaired urinary elimination.

Acute pain is due to the atrophied parenchyma brought about by narrowing of the calyx neck

and scarring of parenchyma causes urine retention and which further causes unpleasant

sensation to the patient thereby by resulting to pain. The patient then manifested guarding

behavior and facial grimaces. There was impaired urinary elimination because the most

common mechanism by which a UTI develops is via ascending and invading bacteria. The

organism triggers an inflammatory response in the lining of the urinary tract. The patient then

manifested frequency of urination (5-6x/day), dysuria, and body malaise.

The patient complied with the treatment regimen. For the IVF, the patient tolerated IV

infusion. There was no complaint of any pain or irritation. For the medications, there were no

adverse effects towards the patient.

IV. CONCLUSION

The Urinary System is a system of organs that produces and excretes urine from the

body. The major organs of the urinary system are the kidneys, a pair of bean-shaped organs

that continuously filter substances from the blood and produce urine. Each kidney contains

about 1 million microscopic coiled channels, called nephrons, which perform this critical blood-

filtering function and produce urine in the process.

In addition to their vital role in ridding the body of wastes through the production of

urine, kidneys play important regulatory roles. They maintain water balance, ensuring that the

amount of water in body tissues remains at a constant level.

The precipitating factors of the said condition are obstruction of urinary outflow,

vesicoureteral reflux, neurogenic bladder, renal disease, and metabolic disturbances. While for

the predisposing factors we have gender, old age, lifestyle, environment, pregnancy,

instrumentation and chronic analgesic abuse that could all lead to renal failure.



53 | P a g e

In the case of the patient, the genetic factor, gender as well as lifestyle contributed to its

progress. The bacterial invasion caused infection to the kidneys. The patient then manifested

Increased WBC, inflammation of renal tissue, pain, fever, chills, and bladder irritation.

V. RECOMMENDATIONS

This study is recommended to all student nurses in order to have a broader knowledge

regarding the condition Acute Pyelonephritis for them to become more efficient in

providing interventions that are necessary.

This study is recommended to all Health Care Professionals in order to gain more

knowledge and updates regarding the condition.

This is recommended to the Department of Health of the Philippines in order to address

concerns regarding the condition for them to take appropriate measures in preventing

the occurrence of the disease.

This is recommended to all concerned citizens in order to raise their awareness

regarding the information covering Acute Pyelonephritis.



Page | 54

VI. LEARNING DERIVED

At the end, the researcher realized that there is always something new to learn

that could help you be a better healthcare provider. It is indeed true that learning never stops.

And with the current trends that we have, it is part of the nurses’ responsibility to keep

themselves abreast with the new trends.

With the study made by the researcher, he had able to identify what acute

pyelonephritis is, its risk factors, signs and symptoms of the disease, diagnostic procedure that

can be done to diagnose the disease, its medical treatment, prevention and nursing care plan

specific for the disease. With the knowledge learned during the study, the researcher can be

able to promote wellness by health teachings to patients and to persons unfamiliar with the

disease and prevention of the disease.

During the course of the study, the importance of proper bacterial

contamination control and hand washing was found out for the prevention in the spread of

bacterial contamination especially in the hospital.

The researcher found out that proper knowledge of the staff regarding the

disease condition of a patient with acute pyelonephritis is vital for the betterment of his service

as one of the providers of care on a hospital.

- Camba, Ma. Liezel M.

Our case, acute pyelonephritis, had made a big challenge to our group. For it was

our first time in the medicine ward and our first time to encounter it. Though we poured all our

efforts in making these case a successful one, there were still errors which we cannot avoid. I

had already a mindset, since the first time I made a case study, that all data that will be

collected must be true and reliable. Because making a case study must come from facts all

throughout. They must come from a good source such as the chart and the SO of the patient.



55 | P a g e

Until now I have only realized that sometimes, these data aren’t enough so it’s better to

analyze deeply the acquired data. We must ask some professional advice, such as from our

clinical instructor or the physician, if there are data that seems to be confusing. It is also helpful

if the acquired data are studied very carefully such as the drugs that are given to a patient.

Handling the patient manifested dysuria and pain made me appreciate more and

comprehend better about the case. I was able to help my patient by performing proper

interventions, most especially wound care. And it is quite an overwhelming feeling knowing

that somehow, I made my patient’s condition better.

-Lumba, Chared Joy D.

“Health is like money, we never have a true idea of its value until we lose it.”

~Josh Billings

The quote stated above made an analogy between health and money. It is true

that we have to value health like how we do value money. It is for the reason that once

health is lost, like money, it’s hard to get it back, or if you do get it back, oftentimes, you

can’t make it twice as good as before. While we are still in the healthy state of our lives, let

us spend as much energy as we could in order to maintain it. It is really hard when you

regret at the end of not doing your part in making yourself healthy, especially when you

know you had the chance to work it out.

As a student nurse, this was the first time that I got exposed in the Medicine

ward, only for a short span of time though. But still, I was able to witness the struggles of

each patient in the ward, striving to get better each day. I have encountered different grave

disease conditions that I once only knew and heard about in our lecture class.

Through this case study that we have made, I have gained more knowledge regarding a

disease that involves one of the major organs of the body which are the kidneys. They truly

serve a serious purpose. As a student nurse, I was able to be educated about this matter. As

a future registered nurse, hopefully, I will be making use of all the things I have learned



about the said condition, since it is usually encountered in the field. I have gained not only

knowledge but as well as confidence in carrying out with this condition because of the

things I have learned from it. Little by little, I am being more equipped with the actual

experience of encountering a patient with such condition and making a study out of it.

-Masbang, Maria Elaine D.

This case gave us a peek of the wide range of debilitating diseases that could

harm vital organs. It is expected that we, student nurses, could deliver to the needs of our

patients accordingly but through this case study presentation, the specific care we must provide

to the patient was in detail with rationale. Dealing with patients with pain is an extreme test if

character but on the other side,to know that she was able to share her pain with you is

somehow relieving. It is a fulfilling task and a privilege as well.

-Pugeda, Bianca Camille P.

final ap case study

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