Capitol University

Group Case Study RLE 50 Group 2

Acute Pyelonephritis

Submitted by:

Jumao-as, Janver Kee, Kenneth Lazim, Janeth Mapili, Ernesto Jr. Pedralba, Jane Raboy, Crisha Camille Rama, Jocef Ian Remotigue, Cherrylove Requinton, Lanie Rose San Gabriel, James Tumanday, Louresa

August 2012

TABLE OF CONTENTS

I. II. III.

Acknowledgement Introduction Significance of the Study to the: Nursing Education Nursing Practice Nursing Research

IV.

Objectives of the Study General Specific

V.

Profile of the patient Nursing Health History Physical Assessment

VI. VII. VIII. IX.

Anatomy & Physiology Pathophysiology Diagnostic Tests Medical and Surgical Management Medical Orders and Rationale Drug study

X.

Nursing Management Nursing Care Plan

XI. XII.

Evaluation, Results and Discussion Bibliography

Abstract

The study is about a 74-year-old, female with pyelonephritis. In this case, the patient is admitted at Capitol University Medical City last August 25, 2012 complaining of low back pain with increase frequency in urination and fever and vomiting once one day prior to admission. This study is aimed about the disease condition of the client and to know more about its manifestations, on its medical treatment and nursing treatment for us to provide the outmost and appropriate nursing care for the patient.

Acknowledgement

This case study would not have been possible without the support and cooperation of a number of people. I wish to express my gratitude to the family of our client for their kind cooperation in our assessment of the patient. Deepest gratitude are also due to my duty mates, without whose knowledge and assistance this study would not have been successful. Special thanks also to Mrs. Cristina Capistrano R.N. for the knowledge and teaching that you have imparted. Not forgetting to my beloved parents who sent me to school and are always had been there.

I would also like to convey thanks to the nursing staff of Station 2 of Capitol University Medical City for your warmly accepting us in your ward. And lastly, all the greatest thanks to our GOD. If not for HIM all of this would be impossible.

Introduction 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. More than 250,000 cases occur in the United States each year (1995 estimate), and approximately 200,000 patients require hospitalization (1997 data). Wide variation exists in the clinical presentation, severity, options, and disposition of acute pyelonephritis. (http://emedicine.medscape.com/article/245559-overview) Acute pyelonephritis usually occurs secondary to bacteria ascending from the lower urinary tract. Hematogenous spread to the kidney can occur, with acute pyelonephritis resulting from bacterial invasion of the renal parenchyma. Most bacterial data are derived from research with Escherichia coli, which accounts for 70-90% of uncomplicated UTIs and 21-54% of complicated UTIs. A complicated UTI is defined as a UTI in the presence of at least 1 of several factors that will reduce the efficacy of antimicrobial therapy, leading to failure of therapy (eg, progression to overt pyelonephritis, sepsis, renal failure, abscess formation, worsening clinical condition, resistant organism), relapse, or persistence of infection. The study is about a 74-year-old, female with pyelonephritis. In this case, the patient is admitted at Capitol University Medical City last August 25, 2012 complaining of low back pain with increase frequency in urination and fever and vomiting once one day prior to admission. This study is aimed about the disease condition of the client and to know more about its manifestations, on its medical treatment and nursing treatment for us to provide the outmost and appropriate nursing care for the patient.

SIGNIFICANCE OF THE STUDY

To the nursing education.

The significance of this study to the nursing education is in letting us students know more about the disease condition and knowing how to appropriately provide the outmost nursing care to the client with that disease condition. It significantly can be of help because it can be of good contribution the nursing education.

To the nursing practice.

The study is of great significance because it can help student nurses sharpen their skills in giving the appropriate nursing care to prepare them for the real world of nursing.

To the nursing research.

On the course of this study, there could be points, methods, new information, and updates that could be significant to the nursing field that could be of good help and may give birth to new procedures and interventions.

OBJECTIVES OF THE STUDY

SPECIFIC This case presentation seeks to provide different information about the disease to be presented and about the client being considered with the following specific objectives o Give a brief introduction about Acute Pyelonephritis together with its signs and symptoms o Discuss the theoretical framework that is related to the clients condition. o Present the clients demographic data and health history with its Gordons pattern of functioning o Present the abnormal results of the Physical Assessment made on the client. o Present the different laboratory results or test done to the client with its interpretation. Discuss the normal Anatomy and Physiology of the Urinary system. Explain the Pathophysiology of AcutePyelonephritis. Discuss the drugs prescribed to the client by a Drug Study. Present an appropriate Nursing Care Plan for the most prioritized problem o Give a Discharge Plan that the client may use upon discharge to the hospital.

GENERAL The primary concern of this study is to further enhance the understanding of Acute Pyelonephritis in congruence with the learned concepts of nursing students.

Nursing Health History

A. Biological Data Clients Name: Rosalita Opena Age: 74 years old Birthday: Jan. 2, 1938 Address: Opol, Misamis Oriental Civil Status: Married Sex: Female Nationality: Filipino Religion: Seventh Day Adventist Weight: 65 kg. Height: 165 cm. Informant: Rosalita Opena (Patient) Date of admission: August 25, 2012 Time of admission: 7:30 PM Chief complaint: High Fever and Low Back Pain Admitting diagnosis: Acute Pyelonephritis

B. Chief Complaint Patient B was rushed to Northern Mindanao Medical Center Emergency room due to right sided weakness, nausea and vomiting. Physical assessment showed muscle strength of 0/5 on the right side of the body, decreased level of consciousness and inability to verbalize a word.

C. History of Present Illness A case of Patient B, 78 years old Male, Filipino, a resident of Talakag, Bukidnon, admitted for the first time at Northern Mindanao Medical Center with a chief complaint of right sided weakness, nausea and vomiting. Morning prior to admission patient can ambulate until he sleep on the afternoon, when he woke up he cannot stand up on his own and nausea and vomiting occurred.

Past Health History On year 2010, patient has been admitted at Sabal Hospital due to shortness of breathing and was diagnosed of chronic obstructive pulmonary

disease. He was prescribed of metered dose inhaler to overcome shortness of breath.

Family History of Illness According to his significant others regarding the herido-familial history his mothers side has a history of diabetes and his fathers side has a history of hypertension.

Functional Health Pattern Upon assessment, patient cannot verbalize. He showed symptoms of fatigability, weakness and disorientation to place and time. Because of long term admission at the hospital from November 24- December 2, 2010, patient B had hospital- acquired pneumonia. His usual exercise was walking in their backyard every morning according to his family member. Patient B smoked 2 packs of cigar for 18 years and drink alcoholic beverages every night before bedtime.

Nutritional and Metabolic Pattern Patient Bs usual daily food intake before admission was 2 cups of rice and viand with a fluid intake of 3-4 glass of water a total of 720 mL every day.

Elimination Pattern Patient Bs usual bowel elimination pattern was once a day with brownish semi-formed stool without any discomfort. His last bowel movement was on August 30, 2012. His usual urinary pattern was 3 times a day with yellowish urine without any discomfort. Upon admission Patient B was ordered to have a catheter attached to urobag because of his condition.

Activity- Exercise Pattern Usual exercise was walking every morning. His leisure time was singing and playing with his grandchildren. Feeding- 1 Bathing- 4 Toileting-4 Shopping- 4 Bed mobility- 4 Dressing- 4 Grooming- 4 General mobility-4 Cooking-4 Home maintenance- 4

Sleep-Rest Pattern Patient B sleep for 7 hours but upon admission.

Cognitive-Perceptual Pattern Due to the patients age, he had impaired hearing and vision. He also had difficulties in responding to the commands of his family member.

Role- Relationship Pattern After Patient Bs wife died because of diabetes, he is now living to his sons house that was with him when the assessment conducted.

PHYSICAL ASSESSMENT Physical assessment Mouth Pallor lips and mucosa, tongue midline, missing teeth and pallor gums Pharynx Skin Neck Abdomen Cardiovascular status Back extremities Respiratory Status Head Eyes Normocephalic, closed fontanels, hair is fine Pale conjunctiva, symmetrical lids, pupils equal, slight sunken eye balls Ears Nose Normoset, no discharges in ear canal Midline septum Regular breathing pattern Uvula midline, tonsils not inflamed Pallor with smooth texture, dry skin Trachea midline, thyroids non palpable Extended abdomen Capillary refill 3 seconds, regular heart sounds upon auscultation and decrease ROM, kyphotic

Anatomy of acute pyelonephritis

The principal function of the urinary system is to maintain the volume and composition of body fluids within normal limits.

One aspect of this function is to rid the body of waste products that accumulate as a result of cellular metabolism.

Other aspects of its function include regulating theconcentrations of various electrolytes in the body fluids and maintainingnormal pH of the blood.

In addition to maintaining fluid homeostasis in the body, the urinary system controls red blood cell production by secreting the hormone erythropoietin, the urinary system also plays a role in maintaining normal blood pressure by secreting the enzyme renin. The urinary system consists of the kidneys, ureters, urinary bladder, and urethra.

The kidneys form the urine and account for the other functionsattributed to the urinary system.

The ureters carry the urine away fromkidneys to the urinary bladder, which is a temporary reservoir for the urine. The urethra is a tubular structure that carries the urine from the urinary bladder to the outside.

The kidneys are complex organs and they are vital in maintaining normal body functions. Their life-sustaining functions are crucial to maintaining homeostasis in the body, and damage to the kidneys can progress quite far before patients show clinical symptoms. End-stage renal disease, the condition known as uremia, results when the kidneys fail to perform to the patient, family members, nursing staff members, surgeons, and nephrologists. Current treatments make it possible, however, for the patient to live a productive life despite the problems and challenges associated with kidney failure.

PATHOPHYSIOLOGY
Non-modifiable risk factors *Gender Modifiable Risk Factors *High salt diet *Habit of holding back of urine

Ascending infection the urinary tract (Escherichia coli)

Infection reaches pelvis and kidney

Interstitial abscesses present in the parenchyma

Renal tubules are damage by exudates

-Fever -Chills -Nausea -Vomiting -Weakness

Inflammation of renal pelvis and kidney Acute Pyelonephritis

-Low back pain -Flank pain -Dysuria -Frequency

MEDICAL MANAGEMENT DIAGNOSTIC EXAM AND LABORATORY RESULTS

Date: August 27, 2012

COMPLETE BLOOD COUNT

Result WBC 14, 400/mm3

Normal Values 5,000-10,000/mm3

Interpretation Infection

Indications White blood cells Measures the amount of white blood cells. These immune cells form in the bone marrow to help fight infection. High levels may indicate infection. Low levels may result from treatment or disease.

URINALYSIS

Result Protein Pus cells RBC Bacteria +2 10-15 cells/hpf 30-40 cells/hpf Moderate

Normal Findings Negative 0-5cells/hpf 0-5/hpf Negative-Few

Interpretation Proteinuria Infection Hematuria Pyuria / Infection

Indication

Protein This test is based on the protein-error-of-indicators (tetrabromphenol blue) principle. At a constant pH, the development of any green color is due to the presence of protein. Colors range from yellow for negative through yellow-green and green to green-blue for positive reactions.

Heavy proteinuria usually represents an abnormality in the glomerular filtration barrier. The test is more sensitive for albumin than for globulins or hemoglobin.

Pus cells

The presence of pus cells in urine is medically termed as Pyuria and is a common symptom in a number of medical conditions. Probably the most common occurrence of pyuria can be attributed to the existence of a urinary tract infection.

RBC The presence of large numbers of RBCs in the urine sediment establishes the diagnosis of hematuria. If the dipstick is more strongly positive than would be expected from the number of RBCs, then the possibility of hemoglobinuria or myoglobinuria should be considered.

MICROBIOLOGY

CULTURE REPORT Specimen: Blood arm Smear of Culture: Findings: Gram (-) Bacilli

Date: August 26, 2012

Indication : The test itself is useful in classifying two distinct types of bacteria based on the structural differences of their bacterial cell walls

Laboratory Request
Antimicrobial Susceptibility Testing Specimen: Blood (R)arm

Results
Organism Isolated: Escherichia Coli

Ultrasound:

Right Midhepatic Length = 13.11 cm Left Midhepatic Length = 8. 68 cm Common Bile Duct = 0.40 cm Spleen = 8.57 cm Right Kidney = 12.65 * 5.82 * 5.37 cm (CT = 1.20 cm) Left Kidney = 14.70 * 6.40 * 5.45

Uterus = 4.21 * 3.12 * 2.10 cm The liver, pancreas and spleen are normal in size and configuration. Hepatic, pancreatic and splenic echoes are intact with no evident focal lesion.

Both kidneys are mildly enlarge and globular in shape. Medullary pyramids are prominent. Parenchyma is isolated to hypercholic as compared to liver and spleen respectively. No ectasia or lithiasis seen. Multiple cystic foci are seen in both kidneys, atleast 10 each and some of which are present with septations. The large on the right measures 9.78 * 8.97 * 6.61 cm (303.6 ml) the largest of the left measures 5. 94 * 6.34 * 3.56 cm ( 70 cc)

DRUG

STUDY

DRUG ORDER

Mechanism of Action

Indication

Contraindication

ADVERSE EFFECTS

NURSING RESPOSIBILITIES

Generic name: Potassium Chloride

Supplemental potassium in the form of high potassium food or potassium

For hypokalemia as prophylaxis during treatment with diuretics To prevent and treat potassium, deficit secondary to diuretics or corticosteroid therapy. Also indicated when

Severe renal impairment Severe hemolytic reactions Acute dehydration Heat cramps Hyperkalemia.

Renal insufficiency Hyperkalemia Nausea and Vomiting Irritability Muscle weakness Difficulty in swallowing

1. Some patients find it difficult to swallow the large sized KCl tablet. Administer while patient is sitting up or standing (never in recumbent position) to prevent drug-induced esophagus. 2. Follow instructions regarding dilution.

Brand name: Kalium Durule

chloride may be able to restore normal potassium levels.

Route: oral

Frequency: Every 4 hours

potassium, is depleted by severe vomiting, prolonged diuresis and diabetic acidosis.

DRUG ORDER

Mechanism of Action

Indication

Contraindication

ADVERSE EFFECTS

NURSING RESPOSIBILITIES

Generic name: Paracetamol

Inhibits prostaglandin synthesis in the CNS and blocks the pain

Fever, Relief of mild to moderate pain like headaches.

Contraindicated to patient who is allergic to paracetamol. Nephropathy

Early signs of toxicity: Anorexia, nausea, diaphoresis

1. If to be given as analgesia, assess onset, type, location, duration of pain. 2. Can be given without regards to meals. 3. Tablets can be crushed. 4. Assess temperature directly before and 1 hour after giving medication.

Brand name: Aeknil

impulse through a peripheral action. It acts on the

(excessive sweating), o generalized weakness within the first 12-24 hours. Late signs of
o o

Class: Analgesic

hypothalamic heatregulating center, producing peripheral

toxicity: Vomiting, right upper quadrant tenderness elevated liver function tests within 48-72 hours after ingestion. Antidote: Acetylcysteine.
o

Route: oral

vasodilation. It results in antipyresis and

5. If respirations are <12/min (<20/min in children), withhold the medication and contact the physician.

Frequency: q.i.d

produces analgesic effect.

DRUG ORDER

Mechanism of Action

Indication

Contraindication

ADVERSE EFFECTS

NURSING RESPOSIBILITIES

Generic name: Ceftriaxone

Bactericidal; inhibits synthesis of bacterial cell wall, causing cell

Urinary tract infections Contraindicated with (complicated and uncomplicated) caused by Escherichia coli, Proteus mirabilis, allergy to cephalosporin or penicillins. Use cautiously with renal failure, lactation, pregnancy.

CNS; headache, dizziness, paresthesia

1. Assess for presence of any of the contraindications in the patient, especially hypersensitivity through skin testing 2. Acquire baseline VS and Monitor VS frequently over the whole therapy 3. Administer the drug slowly via IVTT 4. Assess for presence of phlebitis and pain upon administration of drug, as well as

Brand name: rocephin

death.

G.I: abdominal pain, nausea and vomiting, dry mouth, diarrhea

Class: Antibiotic

Proteus vulgaris, Morganella morganii or Klebsiella

G.U: nephrotoxicity Hematologic: decreased wbc count, decreased platelets.

Route: IVTT

pneumoniae.

Frequency: Q8

other side and adverse effects. 5. Assess for consistency of stools 6. Raise side rails and encourage to remain on complete bed rest

DRUG ORDER Generic name: Omeprazole

Mechanism of Action Gastric acid pump inhibitor. Suppresses gastric acid secretion by

Indication Reduction o risk of upper G.I bleeding in critically ill patients.

Contraindication Contraindicated with hypersensitivity to omeprazole or its components.

ADVERSE EFFECTS CNS; headache, dizziness, insomnia, anxiety G.I: abdominal pain, nausea and vomiting, diarrhea

NURSING RESPOSIBILITIES 1. Administer before meals. .2.Administer antacids with, if needed. 3. Have regular medical followup visits. 4. Report severe headache, worsening of symptoms, fever, chills.

Brand name: Losec

specific inhibition of the hydrogen-potassium ATPase enzyme system

Class:

at the secretory surface

Dermatologic: Rash, dry skin Resp: URI symptoms, cough, epistaxis

Anti-secretory drug of the gastric parietal cells; blocks the final Route: IVTT step of acid production.

Frequency: OD

DRUG ORDER

Mechanism of Action

Indication

Contraindication Contraindicated with allergy to metoclopramide, GI hemorrhage, mechanical obstruction or perforation, Epilepsy. Use cautiously with previously detected breast cancer, lactation, pregnancy, fluid overload, renal impairment

ADVERSE EFFECTS

NURSING RESPOSIBILITIES

Generic name: Metoclopramide

Stimulates motility of upper GI tract without stimulating gastric, biliary, or pancreatic

Disturbance of GI motility. Nausea andvomiting

CNS: restlessness, drowsiness, fatigue, insomnia, dizziness, anxiety. CV: transient hypertension GI: nausea and diarrhea

1. Monitor BP carefully during IV administration. 2. Monitor diabetic patients, arrange for alterations in insulin dose or timing if diabetic control is compromised by alterations in timing of food absorption.

Brand name: Apo- metoclop

secretions; appears to sensitize tissues to action of acetylcholine; relaxes pyloric

Dosage: 5 mg/ml

sphincter, which, when combined with effects on motility, accelerates gastric

Class: GI stimulant Antiemetic

emptying and intestinal transit; little effect on gallbladder or colon motility; increases lower esophageal

Route: IVTT

sphincter pressure.

Frequency: Q8

DRUG ORDER

Mechanism of Action

Indication

Contraindication

ADVERSE EFFECTS

NURSING RESPOSIBILITIES

Generic name: Spironolactone

Competitively blocks the effects of aldosterone in the

Treatment for hypokalemia or prevention of hypokalemia.

Contraindicated with allergy to spironolactone, anuria, amiloride.

CNS; headache, dizziness, ataxia, confusion.

1. Report signs of hyponatremia or hyperkalemia (most likely to occur in patients with severe cirrhosis. 2. Avoid replacing fluid losses with large amounts of free water (can result in dilution hyponatremia). 3. Avoid excessive intake of high-potassium foods and salt substitutes. 4. Monitor daily I&O and check for edema. Report lack of diuretic response or

Brand name: Aldactone

renal tubule, causing loss of sodium and water and retention of

Dermatologic: rash, urticaria

G.I: cramping, dry mouth, diarrhea

Class: Potassiumsparing diuretic

potassium.

G.U: impotence, amenorrhea

Hematologic: hyperkalemia, hyponatremia.

Dosage: 25 mg.

Route: oral

Frequency b.i.d

development of edema; both may indicate tolerance to drug.

NURSING CARE PLAN

Assessment Subjective: The patient complained of flank pain. Pain scale of 7/10.

Nursing Diagnosis Acute Pain related to acute inflammation of renal tissue

Goals and Objectives Short term: At the end of 1 hour of giving nursing interventions, the patient will report decreased of pain from 7/10 to 4/10. Long term:

Nursing Interventions Independent: 1. Perform assessment each time pain occurs. Note and investigate changes from previous reports to rule out worsening of underlying conditions/development of complications. 2. Monitor vital signs. R: for baseline data. 3. Encourage verbalizations of feelings. R: to know patients perception. 4. Provide comfort measures such as back rub to provide non-pharmacologic pain management. R: to divert patients attention. 5. Encourage adequate rest. R: to prevent fatigue. Dependent 1. Administer analgesic as ordered to maximal dosage to maintain acceptable level of pain.

Evaluations After eight hours of giving nursing interventions, the patient was able to report relieve of pain.

Objectives > Restlessness >facial grimace > V/S taken as follows: T=37.8C PR= 84 bpm RR= 32 cpm BP= 130/90

At the end of 8 hours of giving nursing interventions, the patient will be able to report relief of pain.

Evaluation

Narrative Evaluation

During the day of hospital duty at Capitol University Medical Center, patient shows no sign of improvement during admission. Pulse rate and temperature remain normal, and heart rate and blood pressure remain increased.

DISCHARGE PLAN MEDICATION-Strict compliance to medication regimen-Antibiotics for 7 days (Ceftriaxone 10 mg) EXERCISE/ENVIRONMENT-instruct the client on ways hoe to maintain the cleanliness of her environment. TREATMENT-practice kegel exercise HEALTH TEACHING-Keep the genital area clean by wiping from front to back, it helpsreduce the chance of introducing bacteria from the rectal area to the urethra.-Drink more fluid 64-128 ounces. This encourage frequent urination andflushes bacteria from the bladder.-Encourage proper food handling preparation.-Do handwashing before and after urinate.-Do not delay urination when it is necessary OUT PATIENT FOLLOW UP CARE-Instruct the patient to seek or return upon experience if any sign and symptoms such as severe abdominal pain, fever, painful urination.

BIBLIOGRAPHY:

Nursing 2005 DRUG HANDBOOK---Lippincott Williams & Wilkins Nurses Pocket Guide---Marilyn E. Doenges; Mary Frances Moorhouse; Alice C. Murr Medical Surgical Nursing---Joyce Black; Jane Hokanson Hawks emedicine.medscape.com/article/242008 Karch, Amy M. 2011 Lippincotts Nursing Drug Guide http://www.medicalnewstoday.com/articles/184601.php http://www.uic.edu/classes/pmpr/pmpr652/Final/Winkler/CVD.html www.scribd.com/doc/12707514/cerebrovascular-accident http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001200/ http://www.emedicinehealth.com/emphysema/article_em.htm http://www.medicinenet.com/pneumonia/article.htm