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Bulacan State UniversityCity of Malolos, Bulacan
College of Nursing
In Partial fulfilmentof the
Requirementsin
Related Learning Experience
Submitted by:BSN 3-A Group 1
Alonzo, Jessa Marie J.Angeles, Kim Alrhyn L.
Balbin, Carmina J.Camangon, Pamela RoseCruz, Joseph Isaiah D.C.
Cuaderno, Angela C.Dellosa, Rowena A.
Galvez, Mark Nickole M.Magalona, Norie Rose S.
Mercado, Ronald Carlo L.Pineda, Yasmin M.
Ramos, Mark Kevin C.Torres, Ralph Ronald D.
October 1, 2010
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“A CASE STUDY OF A PATIENT DIAGNOSED WITHACUTE PYELONEPHRITIS”
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TABLE OF CONTENTS
I. Introduction II. Nursing HEALTH HISTORY
A. DEMOGRAPHIC DATA B. Reasons for Visit / Chief Complaint C. History of Present Illness D. History of past illnessE. Genogram F. Functional Health Pattern
1. Health Perception / Health Management Pattern 2. Nutritional Metabolic Pattern 3. Elimination Pattern 4. Activity / Exercise Pattern 5. Sleep Rest Pattern 6. Cognitive Perceptual Pattern 7. Self-Perception / Self-Concept Pattern 8. Role Relationship Pattern 9. Sexuality Reproductive Pattern
10. Coping Stress Tolerance 11. Values Belief Pattern
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III. Growth and DevelopmentIV. Anatomy and Physiology V. Physical assessment
VI. Pathophysiology VII. Review of systems
VIII. diagnostic procedures and laboratory testsIX. Medical management
1. IVF, BT, NEBULIZATION, NGT, TPN, OXYGENATION THERAPY, ETC2. Drugs 3. Diet 4. Activity / Exercise
X. Nursing Care Plan XI. Discharge Planning
XII. Conclusion XIII. Bibliography
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I. INTRODUCTION
This is a case of patient RDL, 67 years old, with a chief complaint of “masakit ang tagiliran ko” who sought consultation at the Emilio G. Perez Memorial District Hospital last September 14, 2010 and he was admitted with an initial diagnosis of Acute Pyelonephritis.
Pyelonephritis is a kidney infection usually caused by bacteria that have traveled to the kidney from an infection in the bladder. It is most often occurs as a result of urinary tract infection, particularly in the presence of occasional or persistent backflow of urine from the bladder into the ureters or kidney pelvis (vesicoureteric reflux).
There are two types of Pyelonephritis: Acute uncomplicated pyelonephritis and Chronic pyelonephritis. They differ primarily in their clinical picture and long-term effects. Acute uncomplicated pyelonephritis is a sudden development of kidney inflammation while chronic pyelonephritis is a long-standing infection that does not clear.
Acute pyelonephritis is a potentially organ- and/or life-threatening infection that characteristically causes some scarring of the kidney with each infection and may lead to significant damage to the kidney (any given episode), kidney failure, abscess formation (eg, nephric, perinephric), sepsis, or sepsis syndrome/shock/multiorgan system failure. Wide variation exists in the clinical presentation, severity, options, and disposition of acute pyelonephritis.
Diagnosing and managing acute pyelonephritis is not always straightforward. In the age range of 5-65 years, it typically presents in the context of a symptomatic (eg, dysuria, frequency, urgency, gross hematuria, suprapubic pain) urinary tract infection (UTI) with classic upper urinary tract symptoms (eg, flank pain, back pain) with or without systemic symptoms (eg, fever, chills, abdominal pain, nausea, vomiting) and signs (eg, fever, costovertebral angle tenderness) with or without leukocytosis. However, it can present with nonspecific symptoms.
Local and Foreign Statistics
Pyelonephritis is very common, with 12-13 cases annually per 10,000 population in women and 3-4 cases per 10,000 in men. Women are most likely to be affected, maybe due to short urethra. Infants and the elderly are also at increased risk, reflecting anatomical abnormalities and hormonal status. Uncircumcised boys have greater than circumcised boys. Higher incidence related to poor hygiene may be observed in some socio-economic group. In race, White Americans have higher incidence other than Africans, other Americans and Asians.
In south east asia, Philippines has the second most number of children having UTI( pyelonephritis and cystitis) after Indonesia. In Cordillera region, Philippines, got a statistic between 2000-2005 with almost 100, 000 respondent about the most leading cause of diseases/illness. UTI ( pyelonephritis and cystitis )
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is in the Top 10 leading cause of morbidity with the approximately number of 3980 people in that average of year. According to WHO, UTI is not generally a part of leading cause of morbidity in the world.
Local and Foreign Trends
Local
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)
Foreign
“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. 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 mouse kidneys is disrupted, the researchers say, this only occurs in animals whose TSP-1 gene is turned on. 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. If we a drug can be develop 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. 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.
A genetically engineered mice was found which lack TSP-1 protein were significantly protected from kidney damage. Mice without TSP-1 preserved their kidney function relatively well, even after being subjected to 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)
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OBJECTIVES:
General Objective
This case presentation aims to identify and determine the general health problems and needs of the patient with an admitting diagnosis of Acute Pyelonephritis.
Nurse – Centered Objectives
After the completion of the study, the nurse – researcher will be able to:
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 Perform self – care before the discharge of the client
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Significance of the Study
This case study facilitates understanding to the condition of acute pyelonephritis. Furthermore the study could be important to the following:
To the patient, this study provides awareness to her condition and may create cooperation that will lead to fast recovery and maintain a holistic sense of wellness even while in the hospital
To the nursing students, this would study help us to know the primary needs and have skills to properly assess patient with acute pyelonephritis , also this may can generate appropriate nursing caring plan, pathophysiology to address this care or mange effectively to the future clients.
To the Clinical Instructors, this study may enhance and broaden their knowledge, skills and attitude on patient with acute pyelonephritis also can formulate efficient strategies and approaches to the student for adding knowledge with the condition acute pyelonephritis.
To the health care providers, this study may help by giving them additional knowledge, and skill to handle this situation. Then also give them knowledge to handle student when they get a hospital exposure,
For the future researcher and case presenters, this study and ideas presented may be used as reference data in conducting new or same case study/ presentations. This study also serves as a cross reference as they give them a background or overview to the disease process acute pyelonephritis.
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Reason for choosing such case study
We chose Acute Pyelonephritis as our case because we want to broaden and enhance our knowledge about this illness. Since we’re taking up Medical-
Surgical Nursing, we’re very much interested to advance our learning concerning the problems in the urinary system as well as the proper assessment and
intervention for this certain disease.
Our purpose for this study is to provide a wide variety of services on an inpatient and outpatient basis by providing nursing health care. Providing care to the
client will vary depending on the employment setting, the nurse’s credentials and needs of the client are our goals. Collaboration is our key to finish these study and
continuity of case to the client to move through the health care system. We need to ensure that our clients have essential information and skills to manage self care
before being discharge from the hospital.
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II. NURSING HEALTH HISTORY
A. DEMOGRAPHIC DATA
Name: Patient RDL Age: 67 y/oSex: MaleCivil Status: MarriedPosition in the Family: FatherAddress: Masantol, PampangaReligion: Roman Catholic Birth Date: July 24, 1943Birth Place: Masantol, Pampanga Nationality: FilipinoEducational Attainment: High School Under graduateOccupation: CarpenterHealth care financing & usual source of medication care: Phil Health Date of Admission: September 14, 2010 Time: 11:00 amDate of Discharge: September 18, 2010 Time: 4:00 pmInitial Diagnosis: Acute PyelonephritisFinal Diagnosis: Acute Pyelonephritis
B. CHIEF COMPLAINT
“Masakit ang tagiliran ko”, as verbalized by the client.
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C. HISTORY OF PRESENT ILLNESS
On September 13, 2010 while he was watching television he suddenly experienced left lower flank pain of 7/10 scale with guarding behavior, facial grimace, irritability and positioning to avoid pain. He used topical ointment (Katinko) to ease the pain but he claimed that it had no effect. His children told him to go to the hospital for a check-up. He sought care on September 14, 2010 and was admitted at the Emilio G. Perez Memorial District Hospital at 11:00 am. Upon admission the client has a fever with 37.8° temperature and complains of nausea and vomiting upon admission. After the examination, the physician diagnosed that the client has an Acute Pyelonephritis.
D. HISTORY OF PAST ILLNESS
Client RDL was never been hospitalized before the present hospitalization. He remembered childhood diseases such as measles and mumps. He stated that, when he had measles, he boiled lagundi leaves and used it in taking a bath. He can’t recall if he had a complete vaccination due to aging. He verbalized no allergies on both food and medicines. According to him, he had an accident while at work. He fell from the boat and he thought that’s the reason why he experienced left lower flank pain intermittently. After the accident, he only rested at home. He was just using katinko to ease the pain.
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F. FUNCTIONAL HEALTH PATTERNS
1. Health Perception/Health Management pattern
Prior During
The client doesn’t have any cough or colds in the past. Whenever he experienced the pain, he only used “katinko” to relieve the pain. He thought that proper nutrition is the most important thing that will keep him healthy. He also stated that he doesn’t smoke nor drink alcoholic beverages. In addition, he was never consulting to a quack doctor because he believed that the real doctors are more knowledgeable.
The client feels that he was weak and not capable of doing certain things like he can do before. While on the hospital, he thinks that health is his primary concern. He eats fruits and vegetables as written in the nutritional metabolic pattern.
2. Nutritional Metabolic Pattern
72-HOUR DIET RECALLPrior to hospitalization
Date: September 11, 2010 (Saturday)Breakfast Snack Lunch Snack Dinner 1 cup of rice2 medium size hotdog2 glasses of water (480 mL)
1pc hamburger2glasses of Coca- Cola (480 mL)
1 cup of rice,1 small piece of chicken breast,1 bowl of chopseuy,3 glasses of water (720 mL)
1 pack of cheese bread1 glass of sprite (240 mL)
1cup of rice1pc. medium size fried galunggong2 glasses of water (480 mL)
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Date: September 12, 2010 (Sunday)Breakfast Snack Lunch Snack Dinner 1 pc scrambled egg,1 cup of plain rice2 glasses of water (480 mL)
1 bowl of champorado1 glass of water (240 mL)
1 cup of plain rice, 1 bowl of dinuguan, 3 glasses of water (720 mL)
1 pack of hopia2glasses of pineapple juice (480 mL)
1cup of rice1bowl of pakbet2 glasses of water (480 mL)
Date: September 13, 2010 (Monday)Breakfast Snack Lunch Snack Dinner 5pcs. of pandesal2 glasses of water (480 mL)
1pc of egg sandwich2 glasses of orange juice (480 mL)
1cup of rice1bowl of mongo 2 glasses of water (480 mL)
1pack of cheese bread2 glasses of orange juice (480 mL)
1cup of rice1pc. medium size fried tilapia2 glasses of water (480 mL)
During hospitalization
Date: September 14, 2010 (Tuesday)Breakfast Snack Lunch Snack Dinner 2 pcs. of pandesal1 cup of energen
Cookies (eggnog 10pcs.)1 glass of water (240 mL)
Cookies (eggnog 20pcs.)1 bottle of water (500 ml)
1pc. small size of sugar apple1pc. medium size of banana2pcs. small size of lansones5pcs. small size of grapes2pcs. small size of rambutan½ bottle of water (250ml)
1 bowl of lugaw10pcs. of cookies (eggnog)1 bottle of water (500 ml)
Date: September 15, 2010 (Wednesday)Breakfast Snack Lunch Snack Dinner 1 saucer of pakbet½ cup of rice1 bottle of water (500 ml)
1pc. of ensaymada1 bottle of water (500 ml)
1bowl of lugaw½ bottle of water (250ml)
10pcs. of cookies (eggnog)1 bottle of water (500 ml)
½ cup of rice Small piece of chicken breast1 bottle of water (500 ml)
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Date: September 16, 2010 (Thursday)Breakfast Snack Lunch Snack Dinner 1 bowl of lugaw1 bottle of water (500 ml)
2 slice of bread1 bottle of water (250 mL)
1 bowl of sopas1 bottle of water (500 mL)
2 packs of sky flakes1 bottle of water (500 mL)
1 pack of pan de coco1 bottle of water (500 mL)
Prior DuringClient RDL usually eats 5 times a day. His typical food intakes prior to hospitalization are bread, rice, egg, hotdog, veggies and fishes. He stated that, he loves to eat fishes and vegetables. He has a good appetite and no eating discomfort. His usual fluid intake is about 8 - 10 glasses a day, aside from water the client also drinks at least 4 glasses of juice and 3 glasses of soft drinks.
He usually eats 5 times a day. His usual intake fluid is about 8-10 glasses a day. He was ordered to have a low-salt and low- cholesterol diet. His usual intakes are cookies, fruits, vegetables and water.
3. Elimination Pattern
Prior to hospitalizationOutput September 11 September 12 September 13
Frequency:UrineStool
4 times a day2 times a day
4 times a day2 times a day
4 times a day2 times a day
Amount 550 ml every urination 550 ml every urination 550 ml every urinationCharacteristics:UrineStool
Aromatic smell, yellowish in color
Formed, brownish in color, foul odor
Aromatic smell, yellowish in color
Formed, brownish in color, foul odor
Aromatic smell, yellowish in color
Formed, brownish in color, foul odor
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During Hospitalization
Output September 14 September 15 September 16Frequency:UrineStool
4 times a dayonce a day
4 times a dayonce a day
4 times a dayonce a day
Amount 550 ml every urination 550 ml every urination 550 ml every urinationCharacteristics:UrineStool
Aromatic smell, yellowish in color
Slightly formed, brownish in color, foul odor
Aromatic smell, yellowish in color
Slightly formed, brownish in color, foul odor
Aromatic smell, yellowish in color
Slightly formed, brownish in color, foul odor
Prior DuringOur client defecates twice a day and urinates 4 times a day with a yellowish in color without any discomfort. He perspires easily.
He defecates once during hospitalization and urinates four times a day without any discomfort.
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4. Activity/Exercise PatternPrior During
The client takes a bath once a day. He seldom takes a bath after his work. Aside from his work, walking is only the form of exercise he does. He could perform all activity with full self care.
_0_ Feeding _0_ Grooming
_0_ Bathing _0_ General mobility
_0_ Toileting _0_ Cooking
_0_ Bed mobility _0_ Home maintenance
_0_ Dressing _0_ Shopping
Level 0- Full self-care
Level I- Requires use of equipment/device
Level II- Requires assistance or supervision from another person
Level III- Requires assistance or supervision from another person or device
Level IV- Is dependent and does not participate
He could perform activity with full self care such as bed mobility, dressing, and grooming except for general mobility that requires assistance or supervision from another person. During hospitalization, ambulation and range of motion was the only exercise limited for him.
_0_ Feeding _0_ Grooming
_0_ Toileting _II_ General mobility
_0_ Bed mobility
_0_ Dressing
Level 0- Full self-care
Level I- Requires use of equipment/device
Level II- Requires assistance or supervision from another person
Level III- Requires assistance or supervision from another person or device
Level IV- Is dependent and does not participate
\
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5. Sleep/Rest Pattern
7 days Sleep Pattern
September 10,2010
September 11,2010
September 12,2010
September 13,2010
September 14,2010
September 15,2010
September 16,2010
Time of sleep 9pm 9pm 8pm 8pm 8pm 8pm 8pm
Time awakened
6am 5am 5am 5am 5am 5am 5am
NAP 1-2 pm 1-2 pm 1-2 pm 1-2pm 7-8 am 11:30-1:00 pm 12-2 pm
Prior During
Client RDL sleeps 8-9 hours a day. He has no sleeping difficulty but he urinates every early in the morning. His usual activity for relaxation is watching television and he also listens to the radio.He usually takes a nap every Sunday from 1pm-2pm because that’s the only day he had no work.
The client stated that he sleeps 8-9 hours. He usually urinates early in the morning. He also awakes 12 in the morning because of vital signs taking. He also stated that, he listens to the radio and used his cellular phone as an entertainment.
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6. Cognitive - Perceptual Pattern
Prior DuringThe client has a problem on his vision, he is farsighted. He uses eyeglasses but he can’t recall the grade. He doesn’t have any problems with his other senses. He doesn’t have any difficulty in learning and analyzing things.
The client has a problem on his vision, he is farsighted. He uses eyeglasses but he can’t recall the grade. He doesn’t have any problems with his other senses. He doesn’t have any difficulty in learning and analyzing things.
7. Self-Perception/Self-Concept Pattern
Prior DuringOur client thinks that he was very lucky because he attained that age of 67. He stated that, he is very contented and blessed with his life now because he sees his family happy and healthy. He said that he has a good communication to his community and friends. Every time he feels angry, he entertained himself by playing some games.
He perceived himself by saying “matanda na at kulubot na” but he was not mad by being old. He stated that, although he is old, he can still do all things that others can. He can still communicate well. He can answers each questions with high self-esteem. Pain still continues to bother him from time to time.
8. Role - Relationship Pattern
Prior DuringClient RDL described himself as a loving father. He always feels good whenever he accomplishes every duties and responsibilities at home such as raising his grand children and sometimes polishing their backyard. They live in one compound. As he verbalized, family problems are part of living. First and foremost is the financial matter. He has many friends within the community, making him feel very happy. He’s doing his very best to raise their family well and comfortable specially their grand children.
Client RDL are not capable of doing things such as carpentry. He was not able to go to work due to pain in his back but he still hoping that he will become more healthy after all this hospitalization.He stated that, he’s a member of Phil Health so they could easily pay the hospital bill and he still shows his concerns and love for his family. Moreover, he is the one who makes decision in their home known as patriarchal.
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9. Sexuality - Reproductive Pattern Prior During
They had sexual intercourse twice a month and he masturbates twice a week. They don’t use any contraceptives or protective measures because they intend to have children. As they grow old, they lessen their sexual intercourse.
No further problems on sexuality.
10. Coping Stress Tolerance
Prior DuringClient RDL seeks advice with his wife every time he feels frustrated. He deals his problems calmly but whenever he feels a little bit stress, he stated that rest is all he’s doing in that matter. Moreover, he also prays to God to seek for help. He also believes that in every problem there is a way.
As of hospitalization, the only cause of his stress was his present illness. He learns to manage and cope on his present condition by obeying and understanding the instructions given by his doctor. First and foremost, rest is all he need.
11. Values Belief Pattern
Prior During He is a Roman Catholic in religion. For him, religion is very important although he is not active but he’s still faithful that God will provide everything.He also added that prayers are still part of the norms that they do.
He is a Roman Catholic in religion. For him, religion is very important although he is not active but he’s still faithful that God will provide everything.He also added that prayers are still part of the norms that they do.
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III. GROWTH AND DEVELOPMENT
THEORY ERIKSON’S PSYCHOSOCIAL DEVELOPMENT THEORY
FREUD’S HUMAN DEVELOPMENT THEORY
KOHLBERG’S MORAL THEORY
FOWLER’S STAGES OF FAITH
STAGE Stage 8 – Maturity stageIntegrity versus despair
Stage 5 - Genital Stage (Puberty and after)
Stage 2 – PostconventionalUniversal Ethical Principle Orientation
Stage 5 – Synthetic – Paradoxical-consolidative
DEFINITION Acceptance of worth and uniqueness of one’s life, and acceptance of death.
Energy is directed toward full sexual maturity and function and development of skills needed to cope with the environment
Decisions and behaviors are based on internalized rules, on conscience rather than social laws, and on self-chosen ethical and abstract principles that are universal, comprehensive, and consistent.
Awareness of truth from a variety of viewpoints
OUTCOME POSITIVE RESOLUTIONThe client stated that he is unique on his own way and he demonstrates readiness of death.
POSITIVE RESOLUTIONThe client showed full sexual maturity and development of skills needed to cope with the environment.
POSITIVE RESOLUTIONThe client showed self-chosen ethical.
POSITIVE RESOLUTIONThe client showed awareness of truth from a variety of viewpoints by stating that God exists.
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IV. ANATOMY AND PHYSIOLOGY
Urinary System
The kidneys are essentially regulatory organs which maintain the volume and composition of body fluid by filtration of the blood and selective reabsorption or secretion of filtered solutes.
The kidneys are retroperitoneal organs (located behind the peritoneum) situated on the posterior wall of the abdomen on each side of the vertebral column, at about the level of the twelfth rib. The left kidney is slightly higher in the abdomen than the right, due to the presence of the liver pushing the right kidney down.
The kidneys take their blood supply directly from the aorta via the renal arteries; blood is returned to the inferior vena cava via the renal veins. Urine (the filtered product containing waste materials and water) excreted from the kidneys passes down the fibromuscular ureters and collects in the bladder. The bladder muscle (the detrusor muscle) is capable of distending to accept urine without increasing the pressure inside; this means that large volumes can be collected (700-1000ml) without high-pressure damage to the renal system occurring.
When urine is passed, the urethral sphincter at the base of the bladder relaxes, the detrusor contracts, and urine is voided via the urethra.
Structure of the kidney
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On sectioning, the kidney has a pale outer region- the cortex- and a darker inner region- the medulla.The medulla is divided into 8-18 conical regions, called the renal pyramids; the base of each pyramid starts at the corticomedullary border, and the apex ends in the renal papilla which merges to form the renal pelvis and then on to form the ureter. In humans, the renal pelvis is divided into two or three spaces -the major calyces- which in turn divide into further minor calyces. The walls of the calyces, pelvis and ureters are lined with smooth muscle that can contract to force urine towards the bladder by peristalisis.
The cortex and the medulla are made up of nephrons; these are the functional units of the kidney, and each kidney contains about 1.3 million of them.
The nephron is the unit of the kidney responsible for ultrafiltration of the blood and reabsorption or excretion of products in the subsequent filtrate. Each nephron is made up of:
A filtering unit- the glomerulus. 125ml/min of filtrate is formed by the kidneys as blood is filtered through this sieve-like structure. This filtration is uncontrolled.
The proximal convoluted tubule. Controlled absorption of glucose, sodium, and other solutes goes on in this region. The loop of Henle. This region is responsible for concentration and dilution of urine by utilizing a counter-current multiplying mechanism- basically, it is
water-impermeable but can pump sodium out, which in turn affects the osmolarity of the surrounding tissues and will affect the subsequent movement of water in or out of the water-permeable collecting duct.
The distal convoluted tubule. This region is responsible, along with the collecting duct that it joins, for absorbing water back into the body- simple math will tell you that the kidney doesn't produce 125ml of urine every minute. 99% of the water is normally reabsorbed, leaving highly concentrated urine to flow into the collecting duct and then into the renal pelvis.
Urine Formation
The kidneys collect and eliminate wastes from the body in a three-step process:
Glomerular filtration- filtering the blood that flows through the kidney’s blood vessels, or glomeruli. Tubular reabsorption- reabsorbing filtered fluid through the minute canals (tubules) that make up the kidney. Tubular secretion- release of the filtered substance by the tubules.
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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 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.
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PATHOPHYSIOLOGY
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Modifiable Factors
- Diet- Lifestyle- Occupation
Urinary stasis and Bacterial GrowthIn the bladder
Pressure changes to have Incompetent ureterovesical
Incompetent emptying of the bladder and
ureterovesicular reflux
Contamination of the ureters with bacteria
Non-modifiable FactorsAge >50Nephrolithiases
Bacteria reach renal pelvis and multiply
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Phagocytosis
Inflammatory response
Infection in renal pelvis
(Pyelonephritis)
Blood flow is locally increased
Lymphocytes, Neutrophils, Macrophages
Inflamed tissue reaches nociceptors
Interstitial infiltration of WBC
Pyrogens releaseINFLAMMATION
Abscess formation
Stimulates pain receptors
NauseaPAINVomiting
PYURIA
Blood vessels near the site of injury are dilated
Febrile
Increase temperature set point of hypothalamus
Cell damage to renal parenchyma
Increase permeability of capillaries
Plasma leak from bloodstream into
tissueEdema in renal tissue
Definition of disease
Pyelonephritis is an ascending urinary tract infection that has reached the pyelum (pelvis) of the kidney (nephros in Greek). If the infection is severe, the term "urosepsis" is used interchangeably (sepsis being a systemic inflammatory response syndrome due to infection). It requires antibiotics as therapy, and treatment of any underlying causes to prevent recurrence. It is a form of nephritis. It can also be called pyelitis.
A. Modifiable Factorsa. *Hygiene – Inadequate Perineal hygiene can increase the risk of having Pyelonephritis.b. *Environment – exposure to bacteria in the environment which can lead to the disease.c. *Diet - High salt, fats and cholesterol diet predispose a person to Pyelonephritis since this diet will alter urine production and enhance bacterial
growth.d. Sedentary lifestyle – Increase risk of having Pyelonephritis, or having Kidney stones.e. *Occupation – Exposure to bacteria in certain occupations can increase the risk of acquiring Pyelonephritisf. Habit of holding back the urineg. Pregnancyh. Sexual intercourse ≥ 3 times per week in the previous 30 daysi. New sexual partner in the previous yearj. Bladder catheterization
B. Non Modifiable Factorsa. Age >50 – persons above 50 years are at risk to develop Pyelonephritis. This is due to degenerative changes in body system.b. Gender (female) – female patients are more prone to Pyelonephritis before the age of 65years. This is due to decrease level of sexual activity.c. Diabetesd. Vesicoureteral refluxe. HIV infection and low CD4+ cell counts
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C. Signs and Symptomsa. *Flank Pain - Flank pain refers to pain in one side of the body between the upper abdomen and the back.
- Flank pain often means kidney trouble. If flank pain is accompanied by fever, chills, blood in the urine, or frequent or urgent urination, then a kidney problem is the likely cause.
b. *Back Pain (Low) - Pain felt in your lower back may come from the spine, muscles, nerves, or other structures in that region.c. Chills with Shakingd. Severe Abdominal Pain - Abdominal pain is pain that you feel anywhere between your chest and groin. This is often referred to as the stomach region
or belly.- Occurs occasionally
e. *Fever - Higher than 102 degrees Fahrenheit- Persists for more than 2 days
f. Malaise - generalized feeling of discomfort, illness, or lack of well-being.g. Confusion - Mental changes or confusion may be the only signs of a urinary tract infection in the elderly.h. *Skin Changes - Flushed or reddened skin
- Moist, warm skini. *Urination problems
- Blood in the urine- Cloudy or abnormal urine color- Foul or strong urine odor- Increased urinary frequency or urgency- Need to urinate at night (nocturia)- Painful urination- Increased pus in the urine
j. *Nausea and Vomiting – usually associated with pain
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V. REVIEW OF SYSTEM
Systems of a human body work in union with one another, failure of a system can cause alterations in other system function.
Circulatory System & Lymphatic System
The Circulatory system works hand in hand with the Renal System. The renal system helps in controlling the presence of fluids in the body. The infection of the kidneys, the WBC’s to the blood becomes elevated. The body temperature increases because of the inflammation. The respiratory system compensates to the increased temperature. Fluids and electrolytes are regulated by the kidneys. Change in its function can cause change in acid base balance in the body. Chills is a defense mechanism of the body in order to fight pathogens inside the body, it has a bactericidal effect.
Respiratory System
The respiratory system compensates to the increased temperature and increased need of oxygen of the body.
Muscular System
Due to the sensation of the lower back pain, the client cannot spare his energy because of the general feeling of discomfort.
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Gastrointestinal System
Nausea is the body's way of reacting to an infection or condition. Vomiting is often related to or preceded by nausea, but both nausea-without-vomiting and vomiting-without-nausea are possible.
Body Areas Related to Disease
Integumentary System Moist and warm skin Lower back and Flank pain Fever
Urinary System Increased WBC, RBC, Pus in the urine
Gastrointestinal System Presence of nausea and vomiting
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VI. PHYSICAL ASSESSMENT
Name: Mr.RDL
Age: 67y/o
Date of assessment: September 16, 2010
Time of assessment: 10:00 am
Weight 67.5 kg
Height 5’5’’ft
Body mass index (BMI) 24.76
Description Normal
(according to: Kozier, p.1175 box 45-2 )
Temperature 37.8° C
Pulse rate/cardiac rate 76 bpm
Respiratory rate
19 cpm
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BODY PART
ASSESSED
TECHNIQUE NORMAL FINDINGS ACTUAL FINDINGS REMARKS
1. Height INSPECTION Body Mass Index Categories: Underweight = <18.5Normal weight = 18.5-24.9 Overweight = 25-29.9 Obesity = BMI of 30 or greater
5’5" ft.
BMI: 24.76
Normal
2. Weight INSPECTION 67.5 kg. Normal
A. GENERAL APPEARANCE
3. Body built, height
and weight
INSPECTION Proportionate Proportionate Normal
4. Posture and gait,
sitting and walking
INSPECTION Relaxed, erect posture, coordinated
movement
Relaxed, erect posture, coordinated
movement
Normal
5. Overall hygiene and
grooming
INSPECTION Clean, neat, no bad odor Has slight bad odor Deviation from normal
due to poor hygiene
Body and breath
odor
INSPECTION No body odor, no breathe odor No unusual body odor Normal
1. Signs of distress in
posture or facial
INSPECTION No distress No distress Normal
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expression
2. Obvious signs of
health or sickness
INSPECTION Healthy appearance Healthy appearance Normal
3. Attitude INSPECTION Cooperative Cooperative Normal
4. Affect/mood
appropriateness of
responses
INSPECTION Appropriate to situation Responses are appropriate to situation Normal
Quantity and quality
of speech
INSPECTION AND
PALPATION
Understandable, moderate pace Speech is understandable and in
moderate pace
Normal
B. INTEGUMENTARY
1. Skin INSPECTION Generally uniform in color except for
areas most expose to sun, no edema,no
lesions,warm to touch, moisture on
skin folds and when pinched should
spring back to previous state
Dark brown and uniform in color ; no
edema; presence of lesion specifically
scar on the left palm (4 inches); warm to
touch , moist skin;skin slowly springs
back previous state when pinched
Deviation from normal
due to presence of
lesion
2. Nails INSPECTION,
PALPATION
Nail curvature is convex; pink nail bed;
blood brings back after performing a
blanch test of less than 3 seconds
Nail curvature is convex, smooth texture;
nail bed is pink in color; capillary refill
of 2 seconds
Normal
3. Skull INSPECTION,
PALPATION
Normocephalic; symmetric; no nodules
and depressions; no tenderness
Small, rounded with smooth skull
contour; no nodules, masses and
depressions noted; no tenderness
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4. Hair and Scalp INSPECTION,
PALPATION
Thick and resilient hair, evenly
distributed; scalp must be white in
color and have no redness, rashes, lice,
nits, or dandruff
Thin white hair, not evenly distributed,
no redness, no tenderness or masses;
somewhat oily; no signs of infestations
Normal
5. Face INSPECTION Facial movements are symmetric;
symmetric or slightly symmetric facial
features
Facial movements are symmetric Normal
C. EYES
1. Eyebrows INSPECTION Hair evenly distributed; skin intact;
eyebrows symmetrically aligned; equal
movement
Hair evenly distributed; skin intact;
eyebrows symmetrically aligned; equal
movement
Normal
2. Eyelashes INSPECTION Evenly distributed; downward or
outward curl
Evenly distributed; short straight Normal
3. Bulbar and palpebral INSPECTION,
PALPATION
Bulbar: transparent: Bulbar: transparent: capillaries are
present
Normal
4. Conjunctiva INSPECTION Capillaries sometimes present
Palpebral; shiny and smooth
Palpebral: shiny and smooth and pinkish
in color
Normal
5. Sclera INSPECTION White White Normal
6. Cornea INSPECTION Transparent Transparent Normal
7. Pupils INSPECTION Black in color; equal in size; round;
reactive to light and accommodation
Reactive to light and accommodation;
black in color, round and smooth
Normal
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8. Lacrimal glandINSPECTION/PALPATION
No edema or tearing No nodules, masses, and lesions; no
tenderness
Normal
9. Extraocular Muscles INSPECTION Coordinated movement Coordinated movement and in good
alignment
Normal
10. Visual Fields The client can see the object in
periphery
The client can see the object in periphery Normal
11. Visual acuity Able to read news print Not able to read news print (far sighted) Deviation from normal
due to degeneration and
old age
D. EARS
1. Auricles INSPECTION
/PALPATION
Color same as facial skin; symmetrical;
aligned with the outer canthus of the
eyes; pinna recoils after folded
Color same as facial skin; symmetrical;
aligned with outer canthus of the eyes,
pinna recoils after it is folded
Normal
2. External canal INSPECTION No discharge With presence of ear wax Normal
3. Hearing acuity INSPECTION Normal voice tones audible; able to
hear ticking of watch on both ears
Respond normally to normal voice tones;
able to hear the ticking of the clock on
both ears
Normal
E. NOSE
Nasal Septum INSPECTION Nasal septum intact in midline Nasal septum intact and in midline Normal
Patency of Airways PALPATION Air moves freely in and out of the
nasal cavity
Air moves freely in and out of the nasal
cavity
Normal
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Sinuses PALPATION Not tender No note of tenderness Normal
F. MOUTH
1. Lips INSPECTION Uniform in color; soft, moist, smooth
texture
Uniform in color; soft, moist, smooth
texture
Normal
2. Buccal Mucosa INSPECTION Uniform pink color Pinkish in color Normal
3. Teeth INSPECTION Smooth, shiny, white teeth enamel, 32
adult teeth
Presence of dentures (23), yellowish Deviations from normal
due to Missing teeth,
brown or black
discoloration of the
enamel.
4. Gums INSPECTION /
PALPATION
Pink gums, moist firm texture Pink gums, moist firm texture Normal
5. Tongue INSPECTION /
PALPATION
Central position, pink in color, moves
freely
Pink in color, Has raised papaillae Normal
6. Uvula INSPECTION Uvula vibrates when speaking; midline
possition
Uvula vibrates when speaking; midline
possition
Normal
7. Tonsils INSPECTION Pink and smooth, no discharge, normal
size or not visible
Pink and smooth, not visible Normal
8. Gag Reflex INSPECTION Present Present, upon observation the patients
gag reflex is noted and it always occur
Presence of gag reflex
is evident due to nausea
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G. NECK AND LYMPH NODES
1. Lymph nodes INSPECTION /
PALPATION
No tenderness and masses No nodules and masses; no swollen
lymph nodes
Normal
2. Trachea INSPECTION /
PALPATION
Central placement in midline of the neck Located midline in neck Normal
Thyroid INSPECTION /
PALPATION
Lobes are not palpable No visible masses or enlargement Normal
H. THORAX
1. Posterior and
Anterior Thorax
INSPECTION/
PALPATION/
AUSCULTATION
Symmetric; ratio of 1:2 to the anteroposterior part;
spine vertically aligned; no tenderness; equal
respiratory excursion; bilateral vocal fremitus; no
abnormal breath sounds
Symmetric; ratio of 1:2 to the
antteroposterior part; no tenderness;
equal respiratory excursion; Without
adventitious breath sounds, has left
lower flank pain
Deviation from
normal due to
inflammation
I. UPPER EXTREMETIES
1. Motor strength INSPECTION Equal strength on each body side Equal strength on each body side Normal
2. Muscle Tone PALPATION Normally firm Poor muscle tone Deviation from
normal(Atonic) due
to old age
3. Presence of lesions, INSPECTION No lesions; no deformities; no tenderness No lesions; no deformities; no Normal
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deformities
anndvaricosities
tenderness
J. LOWER EXTREMETIES
1. Motor strength INSPECTION Equal strength on each body side Equal strength on each body side Normal
a. Muscle Tone PALPATION Normally firm Poor muscle tone Deviation from
normal(Atonic) due
to old age
b. deformities and
varicosities
no tenderness
MUSCULOSKELETAL SYSTEM
1. K. MUSCLES
2. Inspect for the
muscles size
INSPECTION Equal strength on each body side Equal strength on each body side Normal
3. Muscle and tendon
Contractures
INSPECTION Normally firm Normally firm Normal
4. Muscle tonicity PALPATION Normally firm Poor muscle tone Deviation from
normal(Atonic) due
to old age
ABDOMEN
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Skin integrity INSPECTION Hyperpigmentation in some areas There are some hyperpigmented areas in the abdomen
Normal
Contour and symmetry
INSPECTION Flat, rounded Rounded Normal
Abdominal movement
INSPECTION Symmetric movements Symmetric movements Normal
Bowel sounds AUSCULTATION Audible bowel sounds Bowel sounds are audible Normal
Abdominal tenderness
PALPATION No tenderness No tenderness but presence of pain upon palpation
Deviation from normal due to disease process
5. L. BONES
6. Structures and
deformities of the
skeleton
INSPECTION Normally firm No deformities Normal
7. M. RANGE OF
MOTION
8. Upper extremities INSPECTION Painless, Effortless No pain Normal
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9. Lower extremities INSPECTION Painless, Effortless No pain Normal
VII. DIAGNOSTIC PROCEDURES AND LABORATORY TESTS
39
Diagnostic laboratory procedures
Date ordered and Date result
in
Indications or purpose
Actual Result Normal values (unit used in the
hospital)
Analysis and interpretation of the results
Nursing Responsibilities
Urinalysis September 14, 2010
The urinalysis provides important clinical information on kidney function and helps diagnose other diseases.
The purposes of this diagnostic procedure are to check for certain metabolic end products which indicate particular disease and to observe physical, chemical, and microscopic characteristics which indicate disease or damage to the urinary tract itself.
Physical Examination:
Color: yellow
Character: slightly turbid
Chemical Examination:pH:4.0
Specific gravity: 1.020
Albumin: Positive
Color: amber- yellowCharacter: clear
pH: 4.6 – 8.0
Specific gravity: adult: 1.005 – 1.030Albumin: Negative
Within normal
Presence of infection due to crystals formation.
Acidic (pH measurements are useful in determining metabolic or respiratory disturbances in acid-base balance. It varies with a person’s diet, tending to be acidic in people who eat meat but more alkaline in vegetarians. pH testing is also useful for the classification of urine crystals.)
Within normal
Above normal Presence of albumin due to high protein consumption.
PRE: Explain the procedure to the patient. Give a clean vial.
DURING: Instruct the patient to use a piece of clean cotton moistened with lukewarm water or antiseptic wipes to cleanse the head of the penis and the urethral meatus (opening). After the area has been thoroughly cleansed, they should use the midstream void method to collect the sample. Instruct the patient to urinate a small amount into the toilet bowl to clear the urethra of any contaminants. Then void directly into the specimen bottle. About 1–2 ounces of urine. Remove the container from the urine stream without stopping the flow.
POST: Cap and label the specimen container. Instruct the patient that he may
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Sugar: Negative
Microscopic Examination:RBC: 80-90 hpf
Epithelial Cells: ModerateCrystals: ModeratePus cells: 2.0-2.5
Mucus threads: Many
Bacteria: Moderate
A.Urates: Moderate
Sugar: Negative
RBC: 0-4 hpf
Epithelial Cells: OccasionalCrystals: ModeratePus cells: 1-2
Mucus threads: negative to +2
Bacteria: Negative
A.Urates: Few
Within normal
Above normal (Red cells and hemoglobin may enter the urine from the kidney or lower urinary tract. Testing for blood in the urine detects abnormal levels of either red cells or hemoglobin, which may be caused by excessive red cell destruction, glomerular disease, kidney or urinary tract infection, malignancy, or urinary tract injury.)
Within normal
Within normal
Above normal Indication of infection.
Above normal Indication of infection.
There is presence of bacteria that indicate infection.
return to normal activities after collecting the sample and may start taking any medications that were discontinued before the test.
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Above normal Presence of infection due to crystals formation.
42
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Diagnostic laboratory
procedures
Date ordered and Date result
in
Indications or purpose
Actual Result Normal values (unit used in the hospital)
Analysis and interpretation of
the results
Nursing Responsibilities
KUB UTZ
(Kidney, Ureter, Bladder Ultrasound)
September 16, 2010 KUB is typically used to investigate gastrointestinal conditions such as a bowel obstruction and gallstones, and can detect the presence of kidney stones. The KUB is often used to diagnose constipation as stool can be seen readily. The KUB is also used to assess positioning of indwelling devices such as ureteric stents and nasogastric tubes. KUB is also done as a scout film for other procedures such as barium enemas.
RK: 9.6x3.8x3.6 cm CT 1.5
LK: 10.3x5.5x5.2 cm CT 1.7
There are calcific densities seen in both kidneys the largest measuring 1 cm seen in the upper pole of the right kidney. There is dilatation of the left pelvocalyces. The urinary bladders are well distended and echo free.
Normal KUB x-ray films show two kidneys of a similar size and shape, no renal calculi (stones), and a normal bowel gas pattern
Nephrolithiases bilateral
SPelvocaliectasis, Left
Negative urinary bladder
PRE:
Encourage the patient to eat food regularly.
Instruct the patient to drink about 1 bottle of clean water and avoid urinating 1 hour prior examination.
DURING:
Explain to the patient that the examination would be done while their bladder extremely enlarged (so that their bladder is full to clearly view).
Ask the patient to wear a hospital gown.
POST:
No special aftercare treatment or regimen is required for a KUB study.
VIII. MEDICAL MANAGEMENT
A. IVF, BT, NEBULATION, NGT, TPN, OXYGENATION THERAPHY, ETC.
Medical Management
Treatment
Date Ordered/Date Performed/
Date Changed or DC
General Description Indications/Purposes Client’s response to the treatment
Nursing Responsibility
Plain Lactated Ringer’s Solution (PLR) 1 liter regulated @ 30 gtts/min
Date ordered:September 14, 2010
11:06 am 1 bottle
consumed
September 14, 20107:15 pm
1 bottle consumed
September 15, 20101:15 pm
1 bottle consumed
Plain Lactated Ringer’s Solution is a non-pyrogenic solution for fluid and electrolyte replenishment in single dose containers for intravenous administration.
Lactated Ringer's solution is often used for fluid resuscitation after a blood loss due to trauma, surgery, or a burn injury. Previously, it was used to induce urine output in patients with renal failure.
Client responded to treatment without any allergic/anaphylactic reactions.
Pre: Do not administer
simultaneously with blood through same administration set because of the likelihood of the coagulation.
Check and clean the site for IVT.
During: Check site for presence of
inflammation Check the regulation of drops. Assess patient for reaction of
the IVF.
Post: Check the effectiveness/reaction
of fluid administered to the client.
Assess for side or adverse effect.
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B. DRUGS
Generic Name/Brand Name
Date ordered, take/given
Route of administration,
General action,Classification,
Indications/Purpose
Client response to the medication, actual
Nursing Responsibilities
45
Date changed dosage, frequency Mechanism of action side effectsCiprofloxacin Ordered:
September 14, 20108:00 pm
Date Given:September 15, 2010
8:00 am
thru IV 200 mg q 12
Inhibits bacterial DNA synthesis by inhibiting DNA gyrase in susceptible gram-negative and gram positive organisms.
- Anti-bacterial
It is usedto treat urinaryinfections causedby bacteria such asE. coli.
The are no actual side effects noted on the patient.
Prior: Check doctor’s order Advise patient not to take the drug with dairy products alone During: Instruct the patient to stop taking drug and notify prescriber at first sign of rash. After: Tell patient to report rash, visual changes, severe GI problems, weakness, and tremors.
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Paracetamol- Acetaminophen
Ordered/Given:September 14, 201012:00 pm, 6:00 pm12:00 am, 6:00 pm
oral 500 mg q 6
PRN
Pain relief may result from inhibition of prostaglandin synthesis in CNS, with subsequent blockage of pain impulses.
- Anti-pyretic- Analgesic
Mild to moderate pain caused by muscle ache.
The client felt relieved on the medication given. It helps lessen the pain and lower the fever of the patient.
Prior:
Check the doctor’s order
Inform patients with chronic alcoholism that drug may increase risk of severe liver damage.
During:
Tell patient not to use drug concurrently with other acetaminophen-containing products.
After:
Advise patient to report if fever or other symptoms persist despite taking recommended amount of drug.
Potassium Citrate Ordered/Given: oral The aim of the Treatment of Severe allergic Prior:
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September 14, 20108:00 am, 6:00 pm
September 15, 20108:00 am, 6:00 pm
September 16, 20108:00 am, 6:00 pm
TID treatment is to restore the level of the urinary citrate and to increase the pH of urine to 6-7. It is recommended to take the tablets 30 minutes after meals.
patients with renal lithiasis and hypocitraturia.
reactions (rash; hives; itching; difficulty breathing; tightness in the chest; swelling of the mouth, face, lips, or tongue); black, tarry stools; confusion; severe stomach pain; tingling of hands or feet; vomit that looks like coffee grounds; weakness.
Must not be administered to patients receiving potassium-sparing diureticsDuring:Tablets must be swallowed and not allowed to dissolve in mouth.After:Explain to the patient not stop taking potassium citrate without first talking to his doctor because it can worsen the condition.
48
C.DIET
Type of diet Date startedDate changed/D/C
General description Indications/ Purpose Specific foods taken Client’s response to the diet
Nursing Responsibilities
Low sodium diet
Started:September 14, 2010
A low sodium diet contains fewer than 2 grams (2,000 milligrams) of sodium each day. People with certain medical conditions such as high blood pressure, kidney disease, and heart problems can benefit from a diet that is low in sodium.
Reducing salt intake may help manage blood pressure and prevent water retention.
Sodium controls fluid balance and maintains blood volume and blood pressure.
140 grams of sugar apple
120 g of banana 1 g of lanzones
(2 pcs) 3 g of grapes ( 5
pcs) 1 serving of
ampalaya and kalabasa (1 cup)
Prior:The client responded by being aware on his choice of food
During:High in salt foods were prohibited.
Prior:Explain to the patient the importance of the diet.During:Advise patient to eat fresh fruits and vegetables which are generally low in sodium while in the hospital.After:Instruct the family not to add salt to food while cooking or before eating. Teach family members to taste food before adding salt.
49
50
Type of diet Date startedDate changed/D/C
General description Indications/ Purpose Specific foods taken Client response to the diet
Nursing Responsibilities
Low cholesterol diet
Started:September 14, 2010
This diet is designed to reduce fat and cholesterol blood levels.
Decrease dietary cholesterol
Limit sodium intake
8 grams of pandesal
130 grams of eggnog cookies
1 cup porridge 75 g of
ensaymada
Prior: The client
continues to eat fatty food even in the hospital. During:
The client responded by being aware on his choices of food and adjusted to it.
Prior:Explain to the patient the purpose and importance of the diet.During:Monitor the food choices of the patient.After:Instruct and explain to the patient to lower the intake of saturated fats, since consuming foods with these fats could raise cholesterol levels and can acquire heart disease.
D. EXERCISE
Type of Exercise GeneralDescription
Indications/Purpose
Client’s response to the activity/ exercise
Nursing responsibility
Ambulatory Exercise Ability to walk from place to place independently with or without assistive device.
Exercise to promote good circulation.
Prevent pressure ulcer. Avoid bed sores.
Prior to hospitalization: The client can perform his daily activities without hesitations, and whenever he experience weakness he dance to minimize the stress.
During hospitalization: During hospitalization the client can’t perform those activities that he can perform before, because he experience pain and discomfort.
Prior: Encourage the client to do
the said exercise. Assess for client’s capacity
in performing the exercise. Explain the importance of
exercise for the client.
During: If needed, assist client
while performing the exercise
Monitor client’s condition while doing it.
Check if the client is performing the exercise correctly.
After: Check for the effectiveness
of exercise to the client
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Type of Exercise General
Description
Indications/
Purpose
Client’s response to the activity/ exercise
Nursing responsibility
Range of Motion
To move joints including upper and lower extremities in certain manner to promote good circulation.
These exercises reduce stiffness and help keep your joints flexible. The "range-of-motion" is the normal amount your joints can be moved in certain directions. If your joints are very painful and swollen, move them gently through their range of motion
Prior to hospitalization:
The client can easily perform this type of exercise without any hesitation because he doesn’t feel any weakness in terms of his physical abilities.
During Hospitalization:
During hospitalization the client can’t perform those activities that he can perform before, because he experience pain and discomfort.
Prior:
Encourage the client to do the said exercise.
Assess for client’s capacity in performing the exercise.
Explain the importance of exercise for the client.
During:
If needed, assist client while performing the exercise
Monitor client’s condition while doing it.
Check if the client is performing the exercise correctly.
After:
Check for the effectiveness of exercise to the client
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PRIORITIZATION OF NURSING DIAGNOSIS
53
DIAGNOSIS RATIONALE
Acute pain
Acute pain was given the highest priority because when resolved, it could enhance the capability of the patient to adhere to her treatment regimen. It is the problem that the client perceives more than the rest.
Hyperthermia
Hyperthermia is the second priority because temperature is the compensatory mechanism of pain from infection. According to Maslow temperature is the first priority.
Risk for InfectionRisk for infection is the last priority since there’s only a chance that the patient might be infected by microbes due to his insufficient knowledge about his condition.
IX. NURSING CARE PLAN
ASSESSMENTNURSING
DIAGNOSISSCIENTIFIC
KNOWLEDGEPLANNING IMPLEMENTATION RATIONALE EVALUATION
Subjective: “Masakit ang tagiliran ko.” As verbalized by the client.
Objective: Guarding
behavior Positioning
to avoid painPain Scale: 7/10 (10 being the most painful) Facial
grimace Irritability
Acute pain related to disease process as manifested by 7/10
Increase permeability of capilliaries
Plasma leak from bloodstream into tissue
Edema (Swelling)
Inflamed tissue reaches nociceptors
Stimulates pain receptors
SHORT TERM GOAL:After 15 minutes of nursing intervention, demonstrate use of relaxation skills and diversional activities
LONG TERM GOAL:After 2 to 4 hours of
Independent: Provide comfort
measure like back rub or deep breathing exercises.
Encourage relaxation techniques such as reading and music therapy
Encourage adequate rest periods
Encouraged client to drink at least 8 glasses of water a day
Encouraged client to void frequently
Reduces muscle tension, promotes relaxation, and may enhance coping abilities
To distract attention and reduce tension
To prevent fatigue
to promote renal blood flow and flush the bacteria from the urinary tract
to empty the bladder completely
SHORT TERM GOAL:After 15 minutes of nursing intervention, the client was able to demonstrated use of relaxation skills and diversional activities
LONG TERM GOAL:After 2 to 4 hours of nursing intervention, the client’s pain scale was reduced to
54
PAIN
nursing intervention, the client’s pain scale is reducing to 6/10.
Dependent: Administer
medications as indicated e.g. analgesics and antibiotics.
because bacterial counts is reduced, decrease urinary stasis and prevent recurrence of infection
To maintain acceptable level of pain
6/10.
55
ASSESSMENT NURSING DIAGNOSIS
SCIENTIFIC KNOWLEDGE
PLANNINGNURSING
INTERVENTIONRATIONALE EVALUATION
SUBJECTIVE:“ Nilalagnat ako ang pakiramdam ko” as verbalized by the client
OBJECTIVE:
skin is warm to touch and moist
Vital Signs: Temperatur
Hyperthermia related to inflammatory process
Lymphocytes, Neutrophils, Macrophages
Pyrogens
Increase tempreture set
point of hypothalamus
LONG TERM GOAL:After 2 to 3 days of nursing intervention, the client will be free of complication such as irreversible brain/neurological damage, acute renal failure
INDEPENDENT: Measure and record
temperature at least every 4-6 hours or whenever a change in condition occur(e.g. chills, change in mental status)
Use the same site and method device for temperature measurement for given client
recognizing the pattern of fever can help determine the cause
to ensure the temperature trends are assessed accurately. A different in the
LONG-TERM GOAL:After 2 to 3 days of nursing intervention, was able to be free of complication such as irreversible brain/neurological damage, acute renal failure
SHORT-TERM
56
e: 37.8 C Pulse Rate:
76bpm Respiratory
Rate:19cpm
Febrile
SHORT TERM GOAL:After 1 to 2 hour/s of nursing intervention, the client will be able to maintain core temperature within normal range
Instruct to increase fluid but avoid liquid that contains alcohol, caffeine, or any liquids that contains large amount of sugar
Note the presence or absence of sweating as body attempts heat loss by evaporation, conduction and diffusion
Increase fluid intake, usually 8-10 glasses of water per day
Promote complete
site of temp measurement result in a significance in temp. reading
presence of alcohol can promote diuresis, causing waterloss
increased metabolic and diaphoresis associated to fever causes loss of body fluid.
this replenishes water loss during diaphoresis
to reduce
GOAL:After 1 to 2 hours of nursing intervention, the client was able to maintain core temperature within normal range.
57
bed rest
Perform TSB( after chills) per doctor’s order
DEPENDENT
Administer antipyretic medication(paracetamol)
possible fatigue and oxygen consumption
this action helps to lower patient’s temperature
part of pharmacologic treatment to reduce fever
58
ASSESSMENTNURSING
DIAGNOSISSCIENTIFIC
KNOWLEDGEPLANNING IMPLEMENTATION RATIONALE EVALUATION
59
Subjective:Ø
Objective:- Poor
hygiene- pyuria
Risk for infection related to insufficient knowledge to avoid exposure to pathogens
WBC, enter tissue and begin to engulf
bacteria
INFLAMMATION
Abscess formation
PYURIA
LONG TERM GOAL:After 5 hrs. of nursing intervention occurrence, the client will demonstrate techniques, lifestyle changes to promote safe environment
SHORT TERM GOAL:After 1 hr. of nursing intervention occurrence, the client will verbalize understanding of individual causative/risk factor
Note risk factors for of infection
Observe for localized signs of infection at insertion sites of invasive lines, sutures, surgical incisions/wounds
Monitor client’s visitor/caregivers for respiratory illnesses. Offer mask and tissues to client/visitor who are coughing/sneezing
Stress proper use of personal protective equipment by staff/visitors, as by staff/visitors, as dictated by agency policy
Maintain sterile technique for all invasive procedures.
To prevent having such infection
It can be the portal of entry of microorganism.
To limit exposures, thus reduce cross-contamination
LONG TERM GOAL:After 5 hrs. of nursing intervention occurrence, the client was able to demonstrated techniques, lifestyle changes to promote safe environment
SHORT TERM GOAL:The client verbalized understanding of individual causative/risk factor.
X. DISCHARGE PLANNING
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MEDICATIONS
Medications prescribed by the physician include: Ciprofloxacin, 250 mg taken orally every 12 hours. This drug is use to treat infections caused by susceptible gram-negative bacteria. Paracetamol, 500 mg taken orally every 6 hours PRN. This drug is use to manage pain. Potassium Citrate, taken orally, every 6 hours.
Instruct the client to take the antibiotic for 7-14 days as prescribed.Patient was advised to continue home medications to maintain a normal functioning of the body and to maintain homeostasis.The treatment regimen ordered by the physician must be followed strictly and should not be stopped to prevent aggravation of the condition.
EXCERCISE
Instruct patient to do active range of motion (R.O.M.) to restore normal body functions.Advise the patient to do light exercise, such as walking to limit fatigue.
TREATMENT
Instruct patient to follow the health teaching provided by the health educator, including all medications for faster recovery.
HEALTH TEACHING
Instruct the patient to clean genital area to help reduces the chance of introducing bacteria to the urethra.Emphasize proper hand washing.Drink for at least 10-12 glasses of fluid daily. This encourages frequent urination and flushes bacteria from the bladder.Drink two glasses of water at bedtime awakening to prevent urine from becoming too concentrated during night.Avoid coffee, tea, cola, alcohol and other fluids that are urinary irritants.Void every 2-3 hours during the day and completely empty the bladder. This prevents over distension of the bladder and compromised supply to the bladder wall.Avoid restraining when you feel the urge to urinate.
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OUTPATIENT FOLLOW-UP CARE
Instruct the patient to seek or return after a week at Emilio G. Perez Memorial District Hospital- Out-Patient Department. Getting adequate rest during the client’s first week at home will do reach to prevent the possibility of this complication.
DIET
Advise the patient to maintain low salt and low cholesterol diet as ordered by the physician.Instruct patient to have proper diet especially foods rich in Vitamin (Citrus fruits; orange) and increase fluid intake.
SPIRITUAL
Seek God’s help and guidance by means of praying and holding their faith to our Almighty God.
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XI. CONCLUSION
In this case study, Acute Pyelonephritis was given more understanding by proponents. It has been noted that acute pyelonephritis is a potentially organ- and/or life-threatening infection that may lead to significant damage to kidney, abscess formation, or even multi-organ system failure which the nurse should monitor and watch-out for. By this, early detection of the illness seemed necessary for it can prevent complications or even death.
The case study has enabled us to obtain comprehensive learning, and help us in identifying and understanding the possible problems that compromise the health of the patient, fortunate nursing care interventions was developed the physical, mental and emotional well-being of the patient. Its goal has been met through objectives that have been specially focused on both the client and student’s welfare.
XII. BIBLIOGRAPHY
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Focus on pathophysiology: Bullock Henze
Medical Surgical Nursing: Brunner Suddarth
Pathophysiology concept of altered health States: Carol Mattson
The PDR pocket guide prescription drugs
PDD’s Nursing Drug Guide
The Pill Book 13th edition
Nurse’s pocket guide edition 12: Alice C. Murr
Nursing Care Plan edition 7th: Marilynn E. Doenges
Fundamentals of Nursing: Barbara Kozier
Fundamentals of Nursing: Potter Perry
WEBSITES: www.google.com www.yahoo.com www.wikipedia.com www.scribd.com
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