Bicol University College of Nursing Legazpi City

A Case Study on

ACUTE PYELONEPHRITIS

Submitted by:

CHARMAINE ERICKA Q. DEL ROSARIO BSN IV C Group 3

Submitted to:

PAMELA C. OLUYA Student Head Nurse

CONCEPCION B. CLEMEA Clinical Instructor

PATIENTS PROFILE Patients Name (Initials): Age: Gender: Civil Status: Birth Date: Religion: Address: J. P. T. 33 y/o Female Married June 18, 1980 Roman Catholic Guinobatan, Albay

Chief Complaint: Admission Date: PAST HEALTH HISTORY

On and off fever December 16, 2013; 1:10 PM

The client has suffered minor illnesses such as cough and colds, and fever roughly about once a year. She has a complete immunization status and has no known allergies to food or to medications. She also hasnt experienced having an incident that endangered life and that she had not had any previous hospitalizations. The client also verbalized that she is not used to taking vitamin supplements. Right now, she is taking medications per prescription of her attending physician. No known allergy to any food and drugs (-)HPN; (-)DM; (-)Asthma Non-smoker Non-alcoholic beverage drinker

HISTORY OF THE PRESENT ILLNESS Three days prior to consultation, the client experienced mild to moderate bilateral flank pain. She then began to have fever with mild-moderate bilateral loin pain radiating to iliac fossae and suprapubic area 2 days PTC. The next day she had chills accompanied by undocumented high-grade fever. On the day of admission, she had nausea and vomiting while in the ER still along with a high-grade fever, still in moderate pain. PHYSICAL ASSESSMENT BP: 90/60 mmHg T: 38.4 C TECHNIQUE USED Inspection, Palpation NORMAL FINDINGS Varies from light to deep brown, from ruddy pink to light pink, from yellow overtones to olive, generally uniform skin temperature. P: 82 bpm R: 28 bpm ACTUAL FINDINGS ANALYSIS

BODY PARTS A. SKIN

Varies from light to Red, warm, and medium brown, flushy skin due from ruddy pink to to fever. light pink, from yellow overtones to olive, generally warm to touch.

BODY PARTS B. NAILS

TECHNIQUE USED Inspection, Palpation

NORMAL FINDINGS Convex curvature smooth texture, highly vascular and pink, prompt return of pink less than 3 seconds. Symmetrical and straight, no palpable lumps, and supple, trachea is on midline of neck, and spaces are equal on both sides. Symmetrical chest expansion, clear breath sounds. Normal rate, regular rhythm, no murmur. Symmetrical volume, pulsation. pulse full

ACTUAL FINDINGS Convex curvature smooth texture, highly vascular and pink, capillary refill of 3 seconds.

ANALYSIS

Normal

C. NECK REGION

Inspection

Symmetrical and Palpable lymph straight, with nodes indicate palpable lumps. infection.

D. LUNGS

Auscultation

Symmetrical chest expansion, clear breath sounds. No palpitation, no murmur Symmetrical pulse volume, full pulsation. Symmetrical, slightly unequal in size, without tenderness or masses. No discharge.

Normal

E. HEART

Auscultation

Normal

F. PERIPHERAL

Palpation

Normal

G. BREAST

Inspection, Palpation

Round shape, slightly unequal in size, generally symmetrical, no tenderness, masses, nodules or nipple discharge. Uniform color, rounded symmetrical contour, audible bowel sounds, tenderness, liver and bladder are not palpable. No inflammation, swelling or discharge. Equal size on both sides of the body, weakness on the lower and upper extremities.

Normal

H. ABDOMEN

Inspection, Auscultation, Percussion, Palpation

No scars seen upon inspection. Uniform in color, bladder is palpable, slightly warm and tender.

Distended bladder due to urinary retention.

I.

VAGINA

Inspection

Not inspected.

Client refused.

J.

UPPER AND LOWER EXTREMITIES

Inspection

Equal size on both sides of the body. An ongoing IVF of D5LR hooked @ right arm regulated at 30 gtts/min. Lymph nodes in

Palpable lymph nodes indicate infection.

the axilla groins palpable. BODY PARTS K. NOSE TECHNIQUE USED Inspection NORMAL FINDINGS Midline symmetrical and patent, no discharge.

and are

ACTUAL FINDINGS Midline symmetrical patent, discharge.

ANALYSIS

and no

Normal

L. EARS

Inspection

Parallel symmetrical, proportional to the size of the head, bean-shaped, skin is same color as the surrounding color, clean firm cartilage.

Parallel symmetrical, proportional to the size of the head, bean-shaped, skin is same color as the surrounding color, clean firm cartilage. Symmetrical, gums pinkish in color, lips margin is symmetrical, no lesion or tenderness.

Normal

M. MOUTH

Inspection

Symmetrical, gums pinkish in color, lips margin is symmetrical, no lesion and tenderness, without involuntary movement. Proportional to the size of the body, round with prominences in the frontal and occipital area, symmetrical in all places. White, clean, free from masses, lumps, scars, and lesions, no areas of tenderness

Normal

N. SKULL

Inspection, Palpation

Proportional to the size of the body with prominence in the frontal and occipital area, symmetrical in all places. White, clean, slightly oily, without presence of masses, lumps, scars, and lesions. Round shaped, symmetrical with no involuntary muscle movements. She has a facial grimace and feeling of discomfort.

Normal

O. SCALP

Inspection

Normal

P. FACE

Inspection

Oblong or round or square or heart shaped, symmetrical, facial expression that is dependent on the mood or true feelings and no involuntary muscle movements.

Not normal, facial grimace indicates that client is in pain.

BODY PARTS Q. EYES

TECHNIQUE USED Inspection

NORMAL FINDINGS Parallel and evenly spaced symmetrical, non-protruding, pink palpebral conjunctiva and pupils black in color, equal in size, round and constricts in response to light.

ACTUAL FINDINGS Parallel and evenly spaced, nonprotruding, pink palpebral conjunctiva. Pupils are brownish in color, equal and round; reactive to light and accommodation.

ANALYSIS

Normal

LABORATORY RESULTS Urinalysis Examination A. Color Result Yellow Reference Value Light yellow to dark amber color Interpretation Urines color may vary with the clients diet and drugs taken. Low specific gravity (<1.005) is characteristic of diabetes insipidus, nephrogenic diabetes insipidus, acute tubular necrosis, or pyelonephritis. Proteinuria shows that there is damage to the filtering capacity of the kidneys that allows large molecules to flow. Only a very small amount of protein should be excreted into the urine in a 24-hour period (normal is 0-trace). Albumin is usually the first protein to be excreted in disease conditions. Some non-disease conditions such as extreme muscle exertion and pregnancy may cause proteinuria. Some of the disease conditions which can cause proteinuria are renal disease, fever, CHF, hypertension, tumors, and others. Indicates infection Indicates infection

B. Specific Gravity

1.005

1.005 1.025

C. Protein

+4

Negative

D. Pus Cells E. Bacteria

Too numerous to count Plenty/hP+

Negative Negative

Complete Blood Count Examination A. WBC Count Result 20.6 x 109/L Reference Value 5.0-10.0x109/L Interpretation WBC is greatly elevated showing that there is an infection. Neutrophils are the first line of defense and are greatly elevated until the immunologic response is

B. Neutrophils

0.85

0.30-0.70

finished. Examination C. Lymphocytes D. Platelet Count Result 0.15 246 x 109/L Reference Value 0.20-0.40 150-350x109/L Interpretation Lymphocytes are lower than the normal range showing no signs of viral infection. Normal

ANATOMY AND PHYSIOLOGY OF THE SYSTEM AFFECTED 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 (i.e. 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. Functions of Urinary System Kidneys the kidneys regulate blood volume and composition, help regulate blood pressure, synthesize glucose, release erythropoietin, and participate in Vit. D synthesis and excrete wastes in the urine. Ureters transport urine from the kidneys to the urinary bladder. Urinary bladder stores urine Urethra discharges urine from the body. Structure of the Kidney On sectioning, the kidney has a pale outer regionthe 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. Renal Cortex The cortex is the outer part of the kidney. This is where blood is filtered. Renal Medulla where the amount of salt and water in your urine is controlled. Renal Capsule Smooth, transparent sheet of irregular connective tissue that is continuous with the outer coat of the ureter. Minor Calyx portion of the urinary collecting system within the kidney that drains one renal papilla. Major Calyx portion of the urinary collecting system within the kidney that drains several minor calyces Renal Columns are lines of the kidney matrix which support the cortex of the kidney. They are composed of lines of blood vessels and urinary tubes and a fibrous, cortical material. Renal Pyramid are conical segments within the internal medulla of the kidney. The pyramids contain the secreting apparatus and tubules. Renal Pelvis This is the region of the kidney where urine collects. Renal Papilla tip of renal pyramid projecting into a minor calyx Ureter muscular tube that serves as the duct of the kidney to carry urine to the bladder

Structure of the Nephron 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 utilising a countercurrent multiplying mechanismbasically, 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 maths 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.

PATHOPHYSIOLOGY Pyelonephritis is an inflammation of the kidney and upper urinary tract that usually results from noncontagious bacterial infection of the bladder (cystitis). It presents with dysuria (painful voiding of urine), abdominal pain (radiating to the back on the affected side) and tenderness of the bladder area and the side of the involved kidney (renal angle tenderness). In many cases there are systemic symptoms in the form of fever, rigors (violent shivering while the temperature rises), headache and vomiting. In severe cases, delirium may be present.

MEDICAL MANAGEMENT

Doctors Order: Hyoscine H amp IV stat

Generic Name: Hyoscine-N-butylbromide Brand Name: Buscopan Classification: Antispasmodic; Anticholinergic Mechanism of Action: Hyoscine-N-butylbromide (HNBB) acts by interfering with the transmission of nerve impulses by acetylcholine in the parasympathetic nervous system. Buscopan exerts a spasmolytic action on the smooth muscle of the gastrointestinal, biliary and urinary tracts. As a quaternary ammonium derivative, hyoscine-N- butylbromide does not enter the central nervous system. Therefore, anticholinergic side effects at the central nervous system do not occur. Peripheral anticholinergic effects result from a ganglion-blocking action within the visceral wall as well as from anti- muscarinic activity. Indications: Buscopan Tablets are indicated for the relief of spasm of the genito-urinary tract or gastro- intestinal tract and for the symptomatic relief of Irritable Bowel Syndrome

Presentation & Administration Intravenous (IV) 20mg in 1ml (solution) Dilute required dose to 10ml with normal saline. Inject slowly over 3-5 minutes. Compatible with the following IV fluids: Normal saline, 5% glucose glucose and sodium chloride May be given into the side arm when the above IV fluids are being infused. Store at room temperature. Protect from light. IM or SC: Inject undiluted into a large muscle mass or subcutaneously Per-orem Buscopan 10mg (white) Gastro-Soothe 10mg (white) Contraindications: Buscopan Tablets should not be administered to patients with myasthenia gravis, megacolon and narrow angle glaucoma. In addition, they should not be given to patients with a known hypersensitivity to hyoscine-N-butylbromide or any other component of the product. Adverse Effects: CNS: dizziness, anaphylactic reactions, anaphylactic shock, increased ICP, disorientation, restlessness, irritability, dizziness, drowsiness, headache, confusion, hallucination, delirium, impaired memory CV: hypotension, tachycardia, palpitations, flushing GI: Dry mouth, constipation, nausea, epigastric distress DERM: flushing, dyshidrosis GU: Urinary retention, urinary hesitancy Resp: dyspnea, bronchial plugging, depressed respiration EENT: mydriasis, dilated pupils, blurred vision, photopobia, increased intraocular pressure, difficulty of swallowing. Nursing Considerations: Drug compatibility should be monitored closely in patients requiring adjunctive therapy Avoid driving & operating machinery after parenteral administration. Avoid strict heat Raise side rails as a precaution because some patients become temporarily excited or disoriented and some develop amnesia or become drowsy. Reorient patient, as needed, Tolerance may develop when therapy is prolonged Atropine-like toxicity may cause dose related adverse reactions. Individual tolerance varies greatly Oerdose may cause curare-like effects, such as respiratory paralysis. Keep emergency equipment available.

Doctors Order:

PARACETAMOL 500mg PO q4 for fever

Generic Name: Paracetamol Brand Name: Ritemed Paracetamol Classification: Analgesics Muscle Relaxants Dosage: 500mg every 4 hours t.i.d. Route: PO

Mechanism of Action Decreases fever by inhibiting the effects of pyrogens on the hypothalamus heat regulating centers & by a hypothalamic action leading to sweating & vasodilatation. Relieves pain by inhibiting prostaglandin synthesis at the CNS but does not have anti-inflammatory action because of its minimal effect on peripheral prostaglandin synthesis. Indications Relief of mild-to-moderate pain; treatment of fever.

Contraindications Hypersensitivity Intolerance to tartrazine (yellow dye #5), alcohol, table sugar, saccharin Contraindicated with allergy to acetaminophen Adverse Effects of the Drug Stimulation, drowsiness, nausea, vomiting, abdominal pain, hepatotoxicity, hepatic seizure(overdose, Renal failure(high, prolonged doses), leucopenia, neutropenia, hemolytic anemia (long term use) thrombocytopenia, pancytopenia, rash, urticaria, hypersensitivity, cyanosis, anemia, jaundice, CNS, stimulation, delirium followed by vascular collapse, convulsions, coma, death. Nursing Intervention and Precautions Assess patients fever or pain: type of pain, location, intensity, duration, temperature, and diaphoresis. Assess allergic reactions: rash, urticaria; if these occur, drug may have to be discontinued. Teach patient to recognize signs of chronic overdose: bleeding, bruising, malaise, fever, sore throat. Tell patient to notify prescriber for pain/ fever lasting for more than 3 days.

Doctors Order:
Generic Name: Brand Name: Classification:

CEFTRIAXONE 1g q8 IV ANST
Ceftriaxone Forgram Cephalosporins

Mechanism of Action Works by inhibiting the mucopeptide synthesis in the bacterial cell wall. The beta-lactam moiety of Ceftriaxone binds to carboxypeptidases, endopeptidases, and transpeptidases in the bacterial cytoplasmic membrane. These enzymes are involved in cell-wall synthesis and cell division. By binding to these enzymes, Ceftriaxone results in the formation of of defective cell walls and cell death. Indications: Treatment of infections of the lower respiratory tract, acute bacterial otitis media, skin & skin structure infection, UTI, uncomplicated gonorrhea, pelvic inflammatory disease, bacterial septicemia, bone & joint infections, intra-abdominal infections, meningitis. Contradications: Hypersensitivity to cephalosporins. Hypersensitivity to lidocaine (IM inj)

Side Effects/ Adverse Effect Pain Induration Phlebitis Rash Diarrhea

Thrombocytosis Leucopenia Glossitis Respiratory superinfections

Nursing Considerations Assess patients previous sensitivity reaction to penicillin or other cephalosphorins. Assess patient for signs and symptoms of infection before and during the treatment Obtain C&S before beginning drug therapy to identify if correct treatment has been initiated. Assess for allergic reaction. Monitor hematologic,electrolytes, renal and hepatic function. Assess for possible superinfection: itching fever, malaise, redness, diarhhea SURGICAL MANAGEMENT

NURSING MANAGEMENT