LICEO DE CAGAYAN UNIVERSITY RODOLFO N. PELAEZ Blvd.

, KAUSWAGAN CAGAYAN DE ORO CITY COLLEGE OF NURSING NCM501107

Introduction Health History Medical Management Pathophysiology Nursing Assessment Chart SOAPIE

Referrals and Follow - up

Recommendation

January 12, 2013

Acute pyelonephritis is a urinary tract infection that has progressed from the lower urinary tract to the upper urinary tract. Most episodes of acute pyelonephritis are uncomplicated but hospitalization may be required. 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

Most kidney infections result from lower urinary tract infections, usually bladder infections. Bacteria can travel from the vagina or anus into the urethra and bladder. Because of the location and size of their urethra, women are more prone to have bladder infections than men. In both men and women, lower urinary tract infections may spread to the kidneys, causing pyelonephritis. Congenital abnormalities of the genito-urinary system and also kidney stones can predispose people to get pyelonephritis. Acute uncomplicated pyelonephritis include flank pain, abdominal or pelvic pain, nausea, vomiting, fever (37.8C), and/or cost vertebral angle tenderness

Fever has been strongly correlated with the diagnosis of acute pyelonephritis; thus, patients with clinical manifestations of acute pyelonephritis in the absence of fever should be evaluated for alternative diagnoses. Symptoms of cystitis may or may not be present. In some cases, the presentation may mimic pelvic inflammatory disease. Rarely, patients with acute pyelonephritis present with sepsis, multiple organ system dysfunction, shock, and/or acute renal failure.

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 trimethoprimsulfamethoxazole, while 99% were susceptible to ciprofloxacin.

The students chose this patient because her case was the most interesting among all the patients in the ward. With this patient, there were a lot of problems that can be easily identified and this caught the students interest from which health teachings and interventions are easily available. In short, her case fits best the criteria for choosing a case study. The students also want to go deeper with this kind of case and learn more from it. This study is a part of the partial requirement in the Intensive Nursing Practicum of the Fourth year college students. This may serve as a reference for each student who will encounter this case soon in their future career as professional nurses. It may also help in developing and widening the knowledge of each health care provider to be more skillful and competent in rendering care among clients with same cases.

As fourth year (N107B) nursing students of Liceo de Cagayan University, within three (3) days of nursing interventions on a client with Acute Pyelonephritis at Polymedic General Hospital, Velez, Cagayan de Oro City, the group will be able to conduct a thorough and comprehensive study of the assigned patient according to the data that was gathered through a series of interviews. The condition of the aforementioned will augment and free of possible complications from the disorder.

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 familys health history. >Perform a complete physical assessment 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 clients 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 her condition. >Build trust and gain respect among the nurses and able to deepen information about her condition. >Meet her needs in the best way possible, either physically, mentally, socially, spiritually and emotionally. >Perform self care before her discharge.

The study covers 1 day of assessment and 3 days of care during the students exposure at Polymedic General Hospital and rendered care to the patient from General ward station 7; these includes thorough assessment, giving of nursing interventions, carrying out of the doctors order, analyzing laboratory results, relating the disease condition to the anatomy and physiology of the human body and the pathophysiology of the disease. The focus of the study is from the time when the patient was admitted in the General ward until the 3rd day of the exposure and from when the patient was discharged.

Patients Profile Clients Name: Age: Address: Oriental Civil Status: Sex: Nationality: Religion: Birthday: Educational Attainment: Height: Weight:

Mrs. R. S. 29 years old Mabini, Binuangan, Misamis Married Female Filipino Roman Catholic March 14, 1983 College Level(at present) 5 feet, 2 inches 45kls

Family and Personal Health History: Heredofamilial Disease

The patients father was diagnosed with Renal Failure, and he also had High blood pressure. While the patients mother was diagnosed with type 2 Diabetes. No other trace of underlying condition was reported by the patient. Diet and Lifestyle

The patient was a non-smoker, non-alcoholic. Her diet consist of foods rich in vegetables and fruits because she loves to eat those. She seldom consumed foods rich in fats, but she was a frequent consumer of softdrinks. She doesnt exercise since she had been very busy with school and some household chores. She always slept late at night and woke up early often.

Obstetrical history The patient had 1 child who was delivered on Normal Spontaneous Vaginal Delivery at Northern Mindanao Medical Center last September 14, 2006. History of admission Prior to the admission, the patient had 2 previous admissions. One was during the delivery of her child last 2006, and the next was last August 2012.

Chief Complaint and History of present Illness: A case of Mrs. R.S., 29-year old female, married with one kid, from Mabini, Binuangan, Misamis Oriental. Two days prior to admission, patient noted to have left flank pain, associated with abdominal pain and vomiting. And one day prior to admission, pain persisted to the arms followed with an on and off fever and chills. Patient consulted admission with chief complaint of fever and flank pain.

Date of Admission: Time of Admission: Admitting Diagnosis: Attending Physician:

December 12, 2012 7:05 am Acute Pyelonephritis Dr. Apag, Riche Feliciano, MD

DOCTORS ORDER DECEMBER 12, 2012 > Admit under the service of Dr. Apag > secure consent to care > VS q4 hours >DAT > Start IVF with PNSS 1 Liter @ 20 gtts/min > For observation > for proper documentation > to monitor patients condition > to provide maximum nutrition

>IVF to follow PNSS 1 Liter @ 20gtts/min

> to provide means of giving medication and hydration > to provide means of administering medication and hydration/ and maintain fluid and electrolyte balance > to identify any abnormalities in the blood components and rule out problem CBC > to identify presence of infection
U/A

Diagnostics: > CBC, some serum >U/A MEDS: > Buscopan 1 cap IV now then q8 PRN for flank pain

Antipasmodic, used to control Drug Study secretions and free acids to stomach > medication for fever
Drug Study

>Paracetamol 500mg tab , 1 tab q4 PRN for fever > I&O qshift > Refer accordingly

> to monitor intake and renal status,

> to provide interventions

DECEMBER 13, 2012 (9:35 AM) > Start Ceftriaxone (kenaxef) 2 gram 1x dri >treatment of infections ANST then 1 gram OD >Celebrex 200mg 1 cap OD
Drug Study

Anti-inflammatory drug use to Drug Study treat pain >Increase IVF rate to 40 gtts > to replace fluid loss due to vomiting and maintain hydration >IVFTF: D5LR @ 40 gtts/min x 4cycles > for hydration and means of administering medications/ maintan fluid and electrolyte balance

3PM > May use Keptrix for to start >give Plasil 1 amp IVT now Cephalosporins/ used to treat UTI
Drug Study

Antiemetic,to decrease nausea Drug Study and vomiting .AlmgOH( Maalox) 20cc TID 30 mins

Antacid/ reduces total acid load in GI tract

> decrease IVF rate to 20 gtts/min Since the patient no longer vomit and hydration to body was met.

Drug Study

>IVFTF D5LR 1L @20 gts/min

For hydration and means of administering medications/ fluid and electrolyte balance Anticholinergics/ prevention of nausea and vomiting Cephalosporins/ it is given to the patient with UTI and lower respiratory infection. >NSAID/ given to patients with acute pain

(Buscopan) AHLBB 1 Amp IVTT now

>Ceftriaxone ( Kenacef) 1 g IV drip q12h

Celecoxib (celebrex) 200mg 1 cap OD

METOCLOPROMIDE (Plasil) 1 amp IVT >antiemetic/ to decrease nausea now and vomiting

DECEMBER 14,2012

AlmGOH (Maalox) 20cc TID 30mins P.C

Antacid/ reduces total acid load in GI tract.

CBC
Result Total WBC 14.5 Normal Range 5-10 Significance of the result WBC is greatly showing elevated

that there is an infection Total RBC Hgb Hct MCV MCH 4.5 13.9 40.3 89 30.7 3.69-5.9 11.7-14 34.1-44 70-97 26.1-33.3 Normal Normal Normal Normal Normal

MCHC
Platelet Count Neutrophils

34.5
211 89

32-35
100-390 55-62

Normal
Normal Neutrophils are the first line of defense

and

is

greatly

elevated until the immunologic response finished as

URINALYSIS
Specimen Color Appearance Random Sample Yellow Hazy Significance of the Result Normal it could mean that mucus, phosphates, bacteria, pus, or fats are spilling into your urine Glucose Protein Negative Negative Normal Normal

Reaction Specific Gravity WBC

RBC Epithelial Cells Mucous Threads Urates Bacteria

6.0 1.005 35-40

0-2 Few Few Rare Plenty

Normal urine pH Normal (Normal : <10) Infection

Normal Infection Normal Normal Infection

MEDICAT ION

CLASSIFICATION

INDICATI ON

CONTRAINDIC ATION

ADVERSE EFFECTS

NURSING RESPONSIBILITIES

Brand:

Anticholinergic/antispasm Relief of smooth muscle

- glaucoma - myasthenia gravis - paralytic ileus - pyloric

Side effects

* Asses for eye pain; d/c use * Asses for parkinsonism, extra pyramidal symptoms * Asses for urinary

Buscopan odic
AHLBB 1 Action:

include
constipation, dry mouth, photophobia, flushing, skin rash. Busopan may also cause urinary urgency and urinary retention. Less common side effects

Amp IVTT Inhibits acetylcholine at spasm of receptor autonomic sites in the

nervous gastrointes stenosis

system,

w/c

controls tinal and

- prostatic

hesitancy, retention,
palpate blader of retention occurs. * Asses for constipation * Asses for tolerance

secretions, free acids in genitourina enlargement the central receptors decreases movements. stomach; blocks ry systems - porphyria

muscunaric which involuntary

include confusion, over long term nausea, vomiting

therapy

and dizziness.

* Asses for mental status.

MEDICAT ION

CLASSIFICATION ANTI-PYRETIC

INDICATI CONTRAINDIC ON ATION

ADVERSE EFFECTS

NURSING RESPONSIBILITIES

Generic Name:

Action: Decreases fever

Relief of by mild to

Hypersensitivit Dizziness, y to headache,

> Check input and output ratio of patient. >Obtain initial vital signs of patient. >Monitor for any possible adverse reactions. >Monitor vital signs of patient regularly.

>Paracet inhibiting the amol Brand Name:

moderate acetaminophe fatigue, n. vomiting.

effects of pyrogens on pain, the hypothalamic treatment of fever.

regulating centers

>Biogesi and by a hypothalamic c Dosage: >500mg every 4 action leasing to sweating and vasodilation. Relieves pain by

hours t.i. inhibiting

d.
Route: > P.O

Prostaglandin synthesis
at the CNS but does not have anti inflammatory action because of its minimal periphreral effect on

MEDICATI ON

CLASSIFICATION

INDICATION CONTRAINDICAT ION

ADVERSE EFFECTS

NURSING RESPONSIBILITIES

Generic Name: >Ceftriaxo ne Brand Name: >Kenacef

THIRD-GENERATION CEPHALOSPORINS Action:

Treatment of

Hypersensitivity

Dizziness,

>Assess for signs and

to cephalosporins headache, fatigue, symptoms of infection vomiting. before and during treatment. >Assess and watch out for any signs of adverse effects of therapy.

susceptible and penicillins.

Inhibits bacterial cell wall infections synthesis, rendering cell wall such as osmotically unstable, leading syphylis, to cell death. typhoid

Dosage:
>1 ampule every 6 hours Route: >IVTT

fever, lower
respiratory tract infections, complicated and uncomplica ted UTI, gastroenteri tis, gonorrhea and pelvic inflammator y disease.

>Monitor VS regularly.
>Instruct patient to take medication as prescribed for length of time ordered.

MEDICATIO N

CLASSIFICATION

INDICATION

CONTRAINDICATI ON

ADVERSE EFFECTS

NURSING RESPONSIBILITIES

Celecoxib (Celebrex) DOSE/FRE Q/ ROUTE:

Analgesic; NSAID Action: Analgesic and anti-

Management Contraindicated of acute pain with allergies to sulfonamides,

Headache, dizziness, somnolence,

-Administer drug with food or after meals if gI upset occurs. -Establish safety measures if CNS or visual

celecoxib, NSAIDs, insomnia, fatigue, or aspirin, tiredness,

inflammatory activities related

200mg 1
cap OD PO

to inhibition of the COX-2

enzyme, which is activated in inflammation signs and to cause the

significant renal
impairment.

dizziness, rash,
pruritus, sweating, dry mucous membranes, stomatitis, nausea, abdominal pain, dyspepsia,

disturbances occur.
-Provide further comfort measures to reduce pain.

symptoms

associated with inflammation; does not affect the COX-1 enzyme, which protects the

lining of the GI tract and has

blood clotting and renal

flatulence, GI
bleed, neutropenia, eosinophilia, leucopenia, pancytopenia, thrombocytopenia, agranulocytosis,

functions.

decreased Hgb or
Hct, peripheral edema.

MEDICATI ON

CLASSIFICATION

INDICATIO N

CONTRAINDICAT ION

ADVERSE EFFECTS

NURSING RESPONSIBILITIES

KEPTRIX

CEPHALOSPORIN Action:

UTIs cause byE.

Hypersensitivity to cephalosporins; hyperbilirubinae

Superinfection; anaphylaxis; diarrhea; local reactions; blood

Culture infection and arrange for sensitivity test. Reconstitute with sterile water for IM injection.

Binds to one or more of the coli penicillin-binding proteins

(PBPs) which inhibits the final transpeptidation step of peptidoglycan synthesis in bacterial cell wall, thus

mic neonates. Do dyscrasias; rash, not use calcium or calciumcontaining solutions or products with or within 48 hr of ceftriaxone administration fever, pruritus; elevated transaminases and alkaline phosphatase; leucopenia, neutropenia. Potentially Fatal:

inhibiting biosynthesis and arresting cell wall assembly resulting in bacterial cell death.

due to risk of
calciumceftriaxone precipitate formation

Pseudomembran
ous colitis; nephrotoxicity.

MEDICATI ON

CLASSIFICATION

INDICATIO CONTRAINDIC N ATION

ADVERSE EFFECTS

NURSING RESPONSIBILITIES

Generic Name:

ANTI-EMETIC Action:

Gastrointe Hypersensitivit Dizziness, stinal antagonist motility y, lactation, epileptics, headache

>Assess patient GI complaints before and after administration. >Frequently monitor BP. >Monitor for possible drug induced adverse reactions. >Advise patient to avoid alcohol and other depressants that enhance sedating properties of this drug. >Instruct patient to take medication as prescribed for length of time ordered.

>Metoclo Dopamine promide Brand Name: >Plasil Dosage: >10mg IV t.i.d. Route: > I.V.

that acts by increasing disturbanc presence of GI receptor sensitivity and es. response of upper GIT tissues to acetylcholine. This causes contraction of gastric smooth of hemorrhage.

muscles,

relaxation

the pyloric sphincter and duodenal increase without gastric, bulb and

peristalsis stimulating biliary and

pancreatic secretions.

MEDICATI ON

CLASSIFICATION

INDICATIO N

CONTRAINDICA TION

ADVERSE EFFECTS

NURSING RESPONSIBILITIES

Generic Name: >AlmgOH Brand Name: >Maalox Dosage: > 20cc TID 30 mins Route: > I.V.

ANTACID Action: Maalox mixture is of a 2

Symptomat Severe ic relief of debilitation,

Gastrointestinal side effects are uncommon. Occasionally, high doses of antacids may

>Assess for allergies and preexisting conditions that may restrict the use of antacids, such as: Fluid imbalances, Renal

balanced hyperacidit kidney failure. antacids: y and as

Aluminum hydroxide is a antiflatulen slow-acting magnesium fast acting. antacid hydroxide The 2 and t to is alleviate are symptoms in of gas,

cause diarrhea or disease, Congestive constipation Heart Failure > The prolonged use of antacids in patients with renal failure

frequently

combined

antacid mixtures. Aluminum including hydroxide on its own is post-

astringent and may cause operation

constipation. This effect is gas pain balanced by the effect of magnesium which, in hydroxide, common with

should be avoided.

other magnesium salts, may cause diarrhea.

S O

Sakit akong tiyan og likod as verbalized by the patient. ~ facial grimace ~ guarding at the abdominal area ~ vomits 3-4 times

A P

Acute pain related to acute inflammation of renal tissues Long term: at the end of 1-2hrs., the pt. will be able to report pain is relieved. Short term: at the end of 30 min. the pt. will be able to report pain is controlled.

1.

Backrub done R: To provide nonpharmacological pain management.

1.

Encouraged adequate rest periods. R: To alleviate pain

1.

Breathing technique 5 minutes.

R: To alleviate and control pain.

1.

Provided quiet environment, calm activities. R: To promote comfort. 5. administer analgesic R: To relieved pain.

At the end of the interventions the patient was able to report pain is relieved.

S O

ga-sukaha lage ko as verbalized by the patient. ~ vomiting ~ nausea ~ weak ~ loose bowel movement

Deficient fluid volume related to hypermetabolic state.

Long term: at the end of 3-4hrs. the pt. will be able to back her body fluid to
normal volume. Short term:at the end of 5-10min. the pt. will be able to stable her condition.

1.

We established fluid replacement needs by encouraging fluid intake. R: To replace fluid loss.

1.

Maintained bed rest; prevent vomiting and straining at stool. R: Activity/vomiting increases intra-abdominal pressure and can predispose to further bleeding.

1.

Provided oral care. R: To prevent injury from dryness.

1.

Monitored I and O R: to ensure accurate picture of fluid status

1.

Administered IVF PNSS 1L @ 30gtts/min.

R: For fluid and electrolytes replacement.

At the end of 5-10 mins. the patients condition was stable.

Wala koy gana mokaon, kay kong mokaon ko ako raman gihapon isuka as verbalized by the patient.

~ Loss weight ~ inadequate food intake ~ weakness ~ vomiting

Risk for Imbalanced Nutrition less than body requirements related to alteration in consumption of foods Long term: At the end of the day the pts nutritional status will be stable. Short term: At the end of 8 hours the patient will be able to regained appetite.

1.

Promoted pleasant and relaxing environment.

R: To enhance food intake.

1. Promoted adequate/timely fluid intake. R: (Limiting fluids 1 hour prior to meal decreases possibility of early satiety). 1. Emphasized importance of well-balanced, nutritious intake. R: To promote wellness. 1. Provided oral care. R: To promote appetite. 1. Administered IVF PNSS 1L @ 30gtts/min. R: Serves as parenteral supplement.

At the end of 8 hours the patient was able to gained appetite.

HEALTH TEACHINGS
MEDICATIONS Instructed strict compliance to home medication regimen to prevent aggravation of the condition and to maintain normal body functioning and homeostasis. AlmgOH( Maalox) 20cc TID hyperacidity. Advised regarding the indication, precautions and side Symptomatic relief of

effects of the drugs to promote awareness.

EXERCISE

Demonstrated breathing

and

instructed to

to

perform maximum

deep lung

exercises

promote

expansion and facilitate relaxation.

Encouraged ambulation or mobilization for proper circulation. Stressed frequent position changes to prevent bed sores and promote circulation. TREATMENT Provided tepid sponge bath during periods of fever to facilitate heat loss via evaporation and conduction. Advised strict compliance to medication and dietary regimen to prevent aggravation of condition. Emphasized adequate rest periods to prevent stress or fatigue. Provided backrub to lessen pain.

 OUT-PATIENT

Instructed to have follow-up check-up one week after discharge at the OPD section, Polymedic General Hospital, to check progress, monitor condition and any complications and medications if there is a need to continue or discontinue.

DIET

Encouraged to increase fluid intake to at least 8-10 glasses per day as tolerated to maintain hydration. Advised to eat foods rich in protein and iron such as liver, meat, green leafy vegetables.

Advised to eat foods rich in carbohydrates such as rice, rootcrops, fruits, bread, to promote energy.

Proper referral is the best for the health care provider to evaluate condition of the client, whether it is improving or not. Also, for early diagnosis of any other underlying conditions. Client was instructed to have a follow-up check up with her physician in the said reccommendations in the discharge plan at the exact day and time of schedule, usually one week after discharge, even if she is already better. Client was aware of concerning symptoms, such as fever or flank pain or any unusualities occur that she was instructed to report immediately to her physician for management of the condition experience. Follow up is needed in order to check the client as well as possible side effects of certain treatments and drugs. Client is recommended to follow the treatment regimen in order to have a fast and good recovery

Providing adequate and prompt treatment assures that the client become asymptomatic and the condition does not recur. Client was instructed to follow and complete the regimen so recurrent infection is prevented. Advised to increase intake of nutritious foods like fruits and vegetables for proper nutrition and optimum health and avoid foods and drinks, which could trigger the recurrence and severity of the disease. She was instructed to increase more than the recommended fluid intake. Advised for compliance of medications prescribed to her by the doctor after being discharged. Client was recommended to perform relaxation techniques and also to avoid stress. The clients significant others were also advised to support the patient emotionally, socially, physically and spiritually. Also, having a support group is beneficial to the client.