Gordon CollegeCollege of Nursing

CASE STUDYAcute pyelonephritis

Group A3

Leader:Kabigting, Alvin

Members:Laruta, Anna GraceLayug, Dexteria MerwinLegrama, Mykel MaeMiguel, Marie TheaMovilla, IanMusni, JoshuaNacor, Sherry MaeNajera, RhevaObida, Jescel Mae

Table of Contents

I. Introduction II. History Taking

a. Demographic Datab. Review of Systemc. Physical Assessment

III. Anatomy and PhysiologyIV. PathophysiologyV. Laboratory and Diagnostic ExaminationsVI. Drug StudyVII. Nursing Care PlanVIII. Discharge PlanIX. ConclusionX. Recommendation

Introduction

History Taking

a.Demographic Data

1. Patient’s profileName: Patient A Age: 20 y/oSex: FemaleAddress: Purok #@ Calapacuan, Subic, ZambalesCivil status: MarriedReligion: Roman Catholic

2. Chief Complaint: FeverDate of Admission: August 30, 2009; 6:30 pm

3. History of present illness

2 days PTA, pt. experienced undocumented high grade fever. No other associated signs and symptoms. Sought consult, hence admitted

PNCU: LHC CalapacuanLMP: February 15, 2009AOG: 28EDC: Nov. 22, 2009Menarche: 14 y/oCoitarche: 19 y/oIntensity: RegularDuration: 7 daysAmount: 2 pads fully soakedSymptoms experience: (-) dysmenorrhea# of sexual partner: 1STD: None

4. Past Medical History >No known allergy to any food and drugs (-)HPN, (-)DM, (-)Asthma Non-smoker Non-alcoholic beverage drinker

5. Personal history

6. Family History (+)HPN (-) CVD

(+) Asthma (-) blood dyscrasia (-) DM (-) CAD (-) PTB (-) Kidney failure

7. Course in the ward

DATE/TIME COURSE IN THE WARD

August 30, 20096:15 pm

The patient is a 20 year old G1 P0. Her LMP was on February 15, 2009 with an AOG of 28 weeks. She was diagnosed with Acute Pyelonephritis. She was admitted to OB ward under the service of DR. Lintao/Tubban/Roxas. She was given IVF D5Lrs 1L x 30 gtts/min., Cefuroxime 1.5 g IV ANST (750 mg IV q8), Paracetamol 300 mg IV for temp. ≥ 39°C q4 or 500 mg/tab 1tab q4 for temp. ≥ 37.8°C. she will undergo HBSAg, BUN, creatinine and urine C/S today.

August 31, 2009 The patient continues her IV and oral meds. She starts taking Isosuxprine/tab (10mg/tab) 1tab q8. The FH is 28 cm with FHT of 150 bpm. She is for pelvic ultrasound today.

September 1, 2009

The patient has FH of 28 cm with FHT of 150 bpm. She will continue her IV and oral meds. In addition to her drugs, the doctor also ordered her to take multivitamins, Ferous sulfate 1 cap OD and isosuxprene HCL 1tab q8 x 7days.

She was given last dose of Cefuroxime at 3pm and will shift to oral meds. She’s for possible discharge tomorrow.

8. Gordon’s 11 Functional Health Pattern

Gordon’s 11 Functional Health Pattern

Findings

Health Perception/ Health Management

Prior to admission, the client sees herself normal as any individual should be, even before and during the onset of pregnancy. The client may not be physically fit, but she never complained of any abnormalities regarding her health ever.The client goes to health center as soon as she had suspected

she was pregnant and then regularly for her scheduled prenatal visit. Since she got pregnant, she had been conscious about herself especially her health.Upon admission, the client had been worried not mostly about her health but the condition of her baby. She has been experiencing on and off fever for about 2 days and was told by the doctors that her baby is not doing well. By that time, she have entrusted their health to their resident doctors.

Nutritional/ Metabolic Prior to admission, the client was never been fond of eating vegetables; otherwise, she loves eating preserved and poultry products. The client has a good appetite and she usually eats four meals a day, which shows in her above normal body weight and bodily figure.Even before, until now that she is pregnant, she loves eating sweets like chocolates, ice cream and cookies. Even though advised by the community nurse to minimize eating foods high in sugar content, she still did not listen. Also, the patient prefers drinking fruit juices rather than water.Upon admission, the client still has a good appetite but is now conscious on her diet since she is worried that she might lose her baby if she would not do so.

Elimination Prior to pregnancy, the patient is able to urinate with no discomfort and has a normal bowel movement. But during pregnancy, on her second trimester, she experienced dysuria with slightly turbid yellowish colored urine. She was not alarmed back then because she only thought it was normal for pregnant women to manifest such condition. But the condition worsened and she is now experiencing flank pain. Two days before the admission, the client experienced high on and off fever and then she was admitted to San Marcelino District Hospital and was diagnosed of acute pyelonephritis and referred to JLGMH for further evaluation. She defecates dark colored stool only once a day.

Activities and Exercise The client is a housewife and practices everyday living just at home doing household chores. The daily work at home served as her exercise but it has never been enough to keep her body fit. She eats a lot but works a little and been an overweight just when she was still a child. During pregnancy, she does light activities because she is always experiencing flank pain, which gets worse as time goes by. She exercises every morning for about 30 minutes by doing brisk walking from their house to the public market and back home.Upon admission, she never got the chance to exercise and do

activities since she was advised for a bed rest for the rest of her stay in the hospital. Moreover, she didn’t like standing that much since her lower back is really painful.

Cognitive Perceptual Pattern Prior to pregnancy the patient has normal cognitive function and has a normal level of consciousness and is able to converse on every topic. The client responds appropriately to any verbal and physical stimulus and has an intact recent and remote memory period. She is able to state her condition whether it is normal or abnormal. Still there has been no deviation on her perceptual pattern during pregnancy and upon admission. But sometimes, she gets agitated by her experiencing a very painful lower back pain making her restless and irritated.

Sleep-Rest Pattern Prior to pregnancy, the patient sleeps at a range of 6-8 hours daily and is able to relax by watching TV or listening to music. The partner lives with the boy’s relative but the client does not get intimidated by his relatives, rather, she enjoys chatting with them and helping in the household chores. The client loves staying late at night together with his husband watching late night TV series. Even until she got pregnant, her sleep pattern hasn’t been changed but still gets enough rest since she wakes up late too.Upon admission the patient has been restless and irritable because of her environment and her underlying condition. That is why the couple is eager to go home as soon as the doctor says so that it is safe to go.

Self-relation and Self-perception Pattern

Prior to admission, the patient is well groomed and is able to perform proper hygiene by taking a bath daily and brushing teeth twice a day. She sees herself as a normal person and enjoys living a life with his beloved partner. She sees herself lovely as it is what she thinks her husband sees in her.During pregnancy, she has heard of many advises from their elders and relatives about proper grooming during pregnancy and has doubted that taking a bath everyday would harm their baby. So she has not looked on her personal hygiene as of importance.Upon admission, she has been concerned about her grooming and self care since she was advised to do so and that it would do well not only for herself, but also the baby she is carrying.

Role-Relation Pattern The patient lives in a nuclear type of family with her husband. But they live just beside the husband’s relatives. She is the one who’s responsible in maintaining cleanliness and order at home and spending the money. On the other hand, the husband is in charge of earning for the family, a typical kind of

family. Her husband is a good provider and performs the roles as the head of the family as well.Prior to pregnancy, she is able to state a good relation to her families and friends. But on the onset of pregnancy, she has limited her visits to her friends since it would not do her good if she would travel often. Rather, her friends and families is the one who visits her at home now.Upon admission the patient is unable to perform her role as a housewife because of hospitalization and her present condition.

Sexuality and Reproductive Pattern

The patient reports of satisfactory sexual relationship with her husband and is able to show affection to one another any time of the day. The couple is open about their intimate relation and is loving sexual intercourse before pregnancy. The couple boasts of an active sexual lifestyle and shows no sign of cheating.The client is a newlywed and she and her husband had been eager to have a child. But still, this will be her first pregnancy so she is the most doubtful and afraid of all. Upon pregnancy the patient is unable to engage in any sexual activity as they thought it would not be appropriate and also due to her present illness. But still, the patient’s husband and her relatives are able to show love by visiting the patient frequently.

Coping-Stress Tolerance Pattern

The couple did not have any problems regarding their relationship but more on financial. The couple saves for their upcoming addition to the family and is thrifty in anything they do. This issue doesn’t do much trouble with regards to the couple.On the onset of pregnancy, the client’s stress tolerance have lowered since she is experiencing bodily function changes that a normal pregnant woman experiences. She still copes with the frequent SOBs and easy fatigability.

Values-Belief Pattern The patient is born Catholic which she inherited from her parent. They always go to the Church every Sunday making it their family day. They value their faith in God despite of what they are facing. For them, God is important and sees the current condition as one of the hindrances God has given them that they should overcome.

b.Review of SystemIntegumentary System:

Good skin turgor

(-) pallor Normal capillary refill (<2 secs.) (+) rashes of both upper extremities

Endocrine System: (+)polyuria (+) urinary frequency

Respiratory System: (+) SOB (+) DOB on sitting position RR = 23 cpm

Cardiac System: (+) Palpitations PR = 73 bpm BP = 110/70 mmHg

Gastrointestinal Tract: (+) constipation Diminished bowel sounds (+) abdominal distress FHT = 140 bpm

Genitourinary Tract: (+) Polyuria (+) Dysuria Turbid yellow colored urine

Musculoskeletal System: (+) Body malaise

Neurologic System: (+) Weakness (+) Drowsiness (+) Restlessness and irritability

c.Physical Assessment

ACTUAL NORMAL INTERPRETATIONSKIN Light brown

complexion Uniform in color Moist Good skin

turgor(<2sec.) (+) rashes on

both hands

Varies from light to deep brown

Generally uniform except in areas exposed to the sun.

Moisture in skin folds and axillae

Good skin turgor

The client has normal skin, having no signs of dehydration and congestion. But the client has rashes on both hands that can be a sign of an adverse reaction to a drug.

HAIR black, thin, dull hair

(+)Hair fall evenly

distributed (+) dandruff, (-)

lice (-) lesion, (-)

scars

Color varies upon the race.

Thick, silky, resilient hair evenly distributed

(-) dandruff, (-) lice

(-) lesion, (-) scars

The client has signs of poor hair and scalp hygiene. Presence of dandruff and thin and dull hair shows dry and unhealthy scalp. Other than that, client shows normal signs.

SKULL Rounded (normocephalic)

Symmetrical Smooth skull

contour (-)nodules, (-)

masses

Rounded (normocephalic & symmetrical with frontal, parietal, and occipital prominences)

Symmetrical Smooth skull

contour (-)nodules, (-)

masses

The client shown no deviation in the structure of the skull.

FACEEyes structuresa.) eyebrow

b.) eyelids

c.) conjunctiva

d.) pupil

Symmetric facial movement

Hair evenly distributed

Symmetrically aligned

Equal movement Skin intact No discoloration Lids close

symmetrically Palpebral fissures

equal in size (-)edema/

(-)tenderness Shiny, smooth &

pink conjunctiva Black in color (+) PERRLA

Symmetric facial movement

Hair evenly distributed

Symmetrically aligned

Equal movement

Skin intact No discoloration Lids close

symmetrically Palpebral

fissures equal in size

(-)edema/ (-)tenderness

Shiny, smooth & pink conjunctiva

Varies color depend on race

(+) PERRLA

Eyebrows are normal and intact.

Eyelids are normal and symmetrical showing no signs of abnormalities.

Conjunctivas are normal and intact.Pupils are normal.

EARS Color same as facial skin

Symmetric Aligned with the

outer canthus of eyes

Mobile, firm (-)tenderness Pinna recoils

after folded (-)discharge Able to hear

sound on both ears

Color same as facial skin

Symmetric Aligned with the

outer canthus of eyes

Mobile, firm (-)tenderness Pinna recoils

after folded (-)discharge Able to hear

sound on both ears

The ears showed no signs of abnormalities.

NOSE Symmetric & straight

(-) discharge Uniform in color (-) tenderness, (-)

lesions Pink mucosa Intact nasal

septum & in midline

Able to determine mild aroma

Patent nares

Symmetric & straight

(-) discharge Uniform in color (-) tenderness,

(-) lesions Pink mucosa Intact nasal

septum & in midline

Able to determine mild aroma

Patent nares

The nose is aligned and normal, and the nares are patent and functioning well.

MOUTHa.) lips

b.) buccal mucosa

c.) teeth & gums

Uniform pink in color

Soft, moist, smooth texture

Symmetriy of contour

Ability to purse lips

Uniform pink in color

Moist, smooth, glistening & elastic texture

32 adult teeth Smooth light

Uniform pink in color

Soft, moist, smooth texture

Symmetriy of contour

Ability to purse lips

Uniform pink in color

Moist, smooth, glistening & elastic texture

32 adult teeth Smooth, color

Lips are moist and intact showing a normal couture and function.

Buccal mucosa is normal and intact.

Gums are intact and teeth are complete

d.) tongue

yellow, shiny enamel

Pink gums No retraction of

gums central position pink in color moves freely (-) nodules

varies from white to light yellow, shiny enamel

Pink gums No retraction of

gums central position pink in color moves freely (-) nodules

with no seen plaque formation.

Tongue is aligned perfectly and functioning well.

NECK Muscle equal in size

Head is centered (-) palpable

lymphnodes

Muscle equal in size

Head is centered

(-) palpable lymphnodes

Neck is aligned centrally and normal, with no palpable masses.

THORAX Chest symmetric Spine vertically

aligned Skin intact Uniform

temperature Chest wall intact (-) tenderness, (-)

masses Symmetric chest

expansion (+) dyspnea at

sitting position Lower back pain Even breath

sounds

Chest symmetric Spine vertically

aligned Skin intact Uniform

temperature Chest wall intact (-) tenderness,

(-) masses Symmetric chest

expansion Even breath

sounds

Dyspnea is normal on pregnant women since the diaphragm is pushed upward by the increasing size of the uterus. The back pain is caused by the client’s underlying condition. The client is suffering from acute pyelonephritis and as a result of the kidney tissues necrosis, pain is present.

BREAST Rounded shape Slightly unequal

in size Skin uniform in

color Skin smooth &

intact Fullness of breast

(firm) Dark colored

areola

Rounded shape Slightly unequal

in size Skin uniform in

color Skin smooth &

intact Dark colored

areola (-) tenderness,

(-) nodules

According to the client, her breast had enlarged since she got pregnant, this is normal for the client is getting ready to lactate. Other than that, the client has normal breasts.

(-) tenderness, (-) nodules

ABDOMEN Light brown in color

Round shape Vertical dark line

at the center (+)linea negra

(+) bowel sound (+)FHT (141bpm) (+)fetal parts

(upon palpation)

Light brown in color

Round shape (+) bowel sound

The client can now be heard of the Fetal heart tone and fetal parts can be palpated. The fetus is presented on a cephalic presentation.

UPPER EXTREMITIES

Equal in size on both sides of the body

(-) contractures Smooth

coordinated movement

Equal strength (+) rashes on

both hands. (+) edema,

redness, warm to touch skin at the IV site((+)inflammation)

Good capillary refill (<2 sec)

Equal in size on both sides of the body

(-) contractures Smooth

coordinated movement

Equal strength Good capillary

refill (<2 sec)

The client shows no signs of abnormalities in the upper extremities. But the client has rashes on both extremities than can be a reaction to a drug taken.

GENITALIA (-) discharge (as verbalized by the client)THIS AREA HAVE BEEN REFUSED TO BE EXAMINED

LOWER EXTREMITIES

Equal size in both side of the body

(-) contures (+) occasional

numbness (-) Homan’s sign Good capillary

refill (<2 sec)

Equal size in both side of the body

(-) contures (-) Homan’s sign Good capillary

refill (<2 sec)

The client has normal lower extremities and no signs of congestion or formation of thrombophlebitis.

Anatomy and Physiology

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 the concentrations of various electrolytes in the body fluids and maintaining normal 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 functions attributed to the urinary system. The

ureters carry the urine away from kidneys 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.

CHANGES OF THE URINARY SYSTEM DURING PREGNANCYThe kidneys must work extra hard excreting the mother's own waste products plus those of the fetus. There is an increase in urinary output and a decrease in the specific gravity. The patient may develop urine stasis and pyelonephritis in the right kidney. This is due to pressure on the right ureter resulting from displacement of the uterus slightly to the right by the sigmoid colon. Frequent urination is a complaint during the first through third trimester. As the uterus rises out of the pelvic cavity in early pregnancy, pressure on the bladder decreases and frequency diminishes. When lightening occurs during the final weeks of pregnancy, pressure on the bladder returns to cause frequency.

Laboratory and Diagnostic Examinations

A. SEROLOGY-IMMUNOLOGY 26 August 2009

TEST RESULT REF. VALUES-MTD/CUT-OFF index

INTERPRETATION

HBsAg Non-reactive SD/QIA (Rapid Test) The client has not been exposed to the hepatitis

virus.Syphilis Non-reactive SD/QIA (Rapid Test) The client has not been

exposed to the bacteria Treponema pallidum.

B. Microscopic Examination 30 August 2009

Examination Result Reference Value Interpretation

Color Yellow ----- Urine’s color may vary with the client’s diet and drugs taken.

Transparency Turbid Clear Turbidity shows that there is presence of large diameter molecules that is not seen in normal urine. This turbidity is caused by the presence of large amounts of WBCs.

Specific Gravity 1.010 1.001 – 1.035 Client’s urine’s specific gravity is within normal range.

Reaction Acidic ----- Urine’s pH is usually acidic to maintain an environment that is not conducive for bacterial

growth, client’s urine pH is normal.

Protein +1 Negative Proteinuria shows that there is damage to the filtering capacity of the kidneys that allows large molecules to flow.

Ketone -------Others -------

C. Microscopic Examination 30 August 2009

Examination Result Reference Value InterpretationWBC Too

numerous(0-2/hpf) WBC is greatly elevated that

shows a recent immunologic response from an infection.

RBC 0-1 (0-1/hpf) RBC is within normal range.Epithelial cells Few Epithelial cells should not be

seen in a normal urine but urine samples are usually

contaminated since the client doesn’t follow the mid-stream

clean catch.Renal epithelial cells ----------

A Urates/ Phosphates ----------Bacteria Many Bacteria are present in large

amount showing the infection was caused by a bacterium.

Mucus threads ---------Crystal ---------

D. Hematology 30 August 2009

Examination Result Reference Value InterpretationBlood type “B” Rh(+)Hgb 106 F: 120-150 Hemoglobin count is below the

normal range and the client is already taking iron

supplements to correct the condition.

Hct 0.32 F:0.30-0.40 Hematocrit is within normal range showing no signs of

dehydration or congestion.WBC Count 20.39 x 109/L 5.0-10.0x109/L WBC is greatly elevated

showing that there is an infection.

Neutrophils 0.88 0.30-0.70 Neutrophils are the first line of defense and is greatly elevated until the immunologic response

is finished.

Lymphocytes 0.12 0.20-0.40 Lymphocytes are lower than the normal range showing no

signs of viral infection.Eosinophils --------MonocytePlatelet

320x 109/L 150-350x109/L

Reticulocyte count ---------- 28-32 pgMCH ---------- 82-98 flMCV ----------

E. Clinical Chemistry 30 August 2009

Examination Result Reference Value InterpretationBUN 1.55mmol/L 1.7-8.3 Client’s BUN has a slight

lowering beyond the normal range showing that the kidney

is still functioning well in cleansing the blood.

Creatinine 42 umol/L 35.4-123.8 Creatinine level is within normal range

Discharge Plan

For the client to be discharged, he needs to be physically, mentally and emotionally stable. For this to be obtained, the researchers developed a discharge method. These are the following:

Medications Advice patient to continue taking medications needed (noting on medication that should

not be able to discontinue abruptly) to maintain a normal functioning of the body and maintain homeostasis. The treatment regimen ordered by the doctors must be followed strictly and should not be stopped to prevent the aggravation of the condition. The full course of antibiotics should be followed. (At least 7 days.)

Advice the patient to observe the any reaction towards the given medications and signs that needs to call the attention of the physician.

Exercise Discuss to the client importance or help client develop a program of exercise and

relaxation techniques as tolerated.

Teaching Moreover, a teaching plan that affect client’s holistic wellness should be done in order

to maintain an environment that is conducive for health promotion.

Home Medications Always instruct the client the proper dosage of the drug to be given, frequency, and

route of administration. Proper emphasis on important parts is best to remember the teachings.

Also instruct relatives on some drug’s precautions before administration to prevent adverse reactions of the drug.

OPD Schedule Proper referral is 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.

Diet

Proper execution of client’s diet is very important so informing and instructing client about proper meals to be given to the client and increasing oral fluid intake is important.

Conclusion

Recommendation