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Introduction Pyelonephritis is a potentially organ and/or life-threatening infection which causes some scarring of the kidney with each infection and may lead to significant damage to the kidney (any given episode), such as, kidney failure, abscess formation, sepsis, or sepsis syndrome/shock/multi organ system failure.

Diagnosing and managing acute pyelonephritis is not that simple. In the age range of 5-6 years, it typically presents in the context of a symptomatic urinary tract infection (UTI) with classic upper urinary tract symptoms like Flank pain and lower back pain with or without systemic symptoms like fever, chills, abdominal pain, nausea, vomiting and signs like costovertebral angle tenderness with or with out leukocytosis. However, it can present with non specific symptoms.

A number of studies using immunochemical markers have shown that many women, who initially present with lower tract symptoms, actually have pyelonephritis. These groups of young women are often identified when short-course therapy for uncomplicated cystitis fails. In the extremes of age, the presentation may be so atypical that pyelonephritis is not in the differential diagnosis. In the infant, the presentation may be feeding difficulty or fever. In the elderly, the presentation may be mental status change or fever.

Chief Complaint Abdominal Pain

Risk Factor Assessment Non-Modifiable  Age  Gender  Race  Family History

Modifiable  Diet  Lifestyle  Elimination

Gordon’s Functional Assessment I.

Demographic Data (Biographical Data)

Client’s Name or Initial: Min, Jin Age: 14 Sex: Female Civil Status: Single Religion: Protestant Address: 213B San Nicholas Molino, Bacoor, Cavite Telephone Number: 875-15-46 Race/Nationality: Korean Usual source of medical care: University of Perpetual Help System Dalta Source and reliability of information: Patient

II. -

Reasons for seeking health: Consultation for present illness Seeking help assistance

III.

History

A. Medical History • Pediatric / Childhood / Adult illness – Urinary Tract Infection • Injuries or Accidents – None • Hospitalization – None • Obstetric History (for female clients only) – N/A • Immunization – BCG: (/) at birth (/) school entrance DPT: (/) 1st dose (/) 2nd dose (/) 3rd dose OPV: (/) 1st dose (/) 2nd dose (/) 3rd dose AMV: TT: ( ) 1st dose ( ) 2nd dose ( ) 3rd dose ( ) 4th dose ( ) 5th dose Hepa B: (/) 1st dose (/) 2nd dose (/) 3rd dose Others (varicella vaccine, influenza vaccine.): _____________________________________________________________________________ ___________________________________________________________________ •

Allergies: Food, specify: none Drugs, specify: none Chemicals, specify: none Environmental Allergies, specify: none

B. Family History Mother - History of kidney Infection

Father

Min, Jin

IV.

Functional Assessment (narrative presentation)

1) Health Perception and health management pattern. (describes how persons perceive

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patterns of health and well-being and how health is managed) Our client stated that despite her frequent night out with friends and drinking at least 3 – 5 bottles of alcohol, she still values her health by refraining from learning to smoke and doing drugs.

2) Self esteem, self concept, self perception pattern. (describes how persons perceive -

themselves, their capabilities, body image and feelings) Our client stated that she is not a shy person. She goes out to party with friends and to meet up with new ones. She is very confident of her physical appearance although she doesn’t approve of her height. She likes to join school activities like playing soccer, and being a part of the high school officers. In fact, she is in one of the pilot sections of the 2nd yr high school of perpetual help.

3) Activities/exercise pattern. (describes pattern of exercise, activity , leisure and recreation,

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includes activities of daily living, type and quality of exercise and factors affecting activity pattern) She goes to school from Mondays to Fridays and attends soccer practice after school hours. She also told us that sometimes school work gets in her way when soccer practice is being called for. And during weekends she is out with her friends partying and drinking.

4) Nutritional and metabolic pattern. (describes consumption relative to metabolic needs and

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nutrient supply; includes pattern of food and fluid consumption, condition of hair, nails mucous membrane, body temperature, height and weight) Our client said that she eats a complete meal 3 times a day, sometimes more, and she sees to it that she drinks a lot of water. And before she sleeps, she never forgets to take a bath.

5) Elimination pattern (describes patterns of excretory function – bowel bladder and skin;

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includes individual’s daily pattern, changes and disturbances) Our client said that there are no irregularities regarding her elimination pattern. Normal bowel elimination once or twice a day.

6) Sleep and rest pattern (describe patterns of sleep, rest and relaxation)

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Our client said that sometimes during weekdays she would only have 5 hours left for sleeping depending on the number of homework’s that are due on the next day. And during the weekends, she would sleep up until 12 in the afternoon so as to regain her strength and party with her friends.

7) Cognitive – perceptual pattern (describes sensory – perceptual and cognitive patterns;

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includes adequacy of sensory modes: vision, hearing, touch, taste and smell: reports of pain perception and cognitive functional abilities) Our client has no difficulty in hearing words that are near or that surrounds her and can pick sounds from outside her room. She can see things clearly that are 20 feet away from her and so as those from afar, her peripheral visions are also clearly seen. She reacts to needles and IV medicines that are to given to her. And complains of pain in her right dorsum hand where her IV site can be seen.

8) Role relationship pattern (describes pattern of role engagements and relationships;

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includes perception of major roles and responsibilities in current life situation) Our client being the only child in her family doesn’t put her into too much pressure. She can have the materials or the latest gadgets she wants, she is allowed to date Filipino boys (she is korean), and that she has a wide range of friends from high school to college.

9) Sexuality reproductive pattern (describes patterns of satisfaction or dissatisfaction with

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sexuality; includes female reproductive state) Our client said that she has not yet engaged herself to premarital sex.

10)Coping stress tolerance pattern (describes general coping pattern and effectiveness of

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coping skills in stress tolerance) Our client had related to us a tragedy that had happened before to her friend that died last year because of a car accident. She was devastated but quickly learned that even though it happened, life still goes on to those who lives.

11)Value Belief pattern (describes patterns of value, goals or beliefs that guide lifestyle

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choices and decisions) Our client does not have any particular cultural beliefs. Her motto was as long as you don’t step on others and as long as you are happy you’ll be okay.

V. Physical Assessment SYSTEM A. Vital Signs

WHAT TO ASSESS • Temperature, pulse, respiration, blood pressure

ACTUAL FINDINGS Temp:35C Pulse: 78 bpm RR: 18 cpm BP: 100/60 mmHg

B. Integumentary 1. Skin

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Color, odor, temperature, moisture, texture, thickness, mobility, turgor, vascularity, swelling, rashes

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2. Hair

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Distribution, thickness, texture, lubrication, scalp characteristics

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3. Nails

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Nail bed color, consistency,

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Pinkish white. No odor. Increased in normal temp. Good skin turgor. No swelling. No lesions. No rashes. Clear skin. Evenly distributed hair. Thick hair. Shiny hair. No dandruff. No lice infestation. Convex curvature of nail. Smooth and

thickness, shape, texture, angle between nail and nail bed, capillary refill

even texture. Good capillary refill. Intact epidermis. No lesion.

C. Head and Neck 1. Head

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Size, shape, contour

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2. Eyes

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Visual acuity, extra ocular movement, visual fields, position and alignment.

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Eyebrows: symmetry, movement, extension, quantity of hair.

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- Eyebrows are symmetrically aligned. Equal movement. Skin intact.

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Eyelashes: distribution.

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Eyelashes equally distributed, curled slightly outward.

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Eyelids: position and movement

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No edema or anything discharged

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Conjunctiva: color

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Red conjunctiva

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Pupils: equality, shape, reaction to light, accommodation

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PERRLA ( pupils equally round reactive to light accomodation )

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Auricle: position, size, texture, shape

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External auditory canal: discharge or

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Symmetrical auricles aligned with outer canthus of eyes. Dry cerumen, slight yellowish in color.

3. Ears

Smooth skull contour. No inflamed nodules. Symmetrical shape. Can see objects periphery. 20/20 visual acuity. Both eyes coordinated. Symmetrical in position.

cerumen’s color, consistency •

Hearing acuity

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Normal hearing. No lesion.

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External nose: shape symmetry, texture, skin color. Nares: shape, symmetry, discharge Mucosa: color, discharge Septum: symmetry

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Sinus: texture

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Symmetrical, uniform in color, no lesions. No discharge, no flaring. Mucosa color pink, no discharge Septum symmetrical, no lesion. Sinus not tender

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Lips: color, texture, hydration, contour.

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Pink in color, no lesions, moist, symmetrical

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Teeth: position, color, hygiene Tongue: color, position, texture, coating, mobility

32 adult teeth, white teeth. Tongue moves freely and no tenderness or lesions

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Gums: color, texture

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No retraction of gums, no lesions, no inflammations

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Pharynx: color, hydration

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pinkish

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Mobility

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Thyroid gland: movement size Lymph nodes:

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Muscles equal in size, smooth movement No discomfort when moving No palpable lymph

4. Nose

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5. Mouth

6. Neck

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• D. Thorax and Lungs

number, size, location, consistency Veins: fillings, pulsation

nodes •

No enlargement

Symmetrical Full and symmetrical chest expansion 21 cycles per minute Symmetrical position of ribs Vesicular sounds auscultated Bilateral symmetry of vocal fremitus Symmetrical chest expansion and relaxation

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Shape, symmetry Chest excursion or movement

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RR and rhythm Position of spine, lope of ribs, symmetry of scapula and costal angle Tactile fremitus or lung vibration Use of accessory muscle

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E. Breast and Axillas • • • • •

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Size, symmetry, skin, color, contour, shape Venous pattern Moles and other markings Areola: size, shape, surface characteristics Nipples: size, shape, surface characteristics and discharge Lymph nodes on each axilla: location, number, size and mobility.

F. Heart • •

Appearance of pulsation Apical pulse or

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No pulsation to the side No lift or irregularities

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Abdominal pulsation heard by auscultation

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Heart sounds: rhythm, rate loudness

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Regular rhythm

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Contour, symmetry

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Bowel sounds Percussion notes Surface characteristics distention Umbilicus: position, shape, color Normal respiratory movement

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Unblemished skin, no lesions Absent Symmetrical audible bowel sounds

G. Abdomen

• • H. Genitourinary • •

I. Musculoskletal

PMI: location, strength and synchrony with carotid pulse Abdominal aorta strength

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• • •

Male: position of scrotum, penis opening, veins Female: distribution of the pubic hair, condition of the majora and minora lavia, presence of infestation, texture, skin color, discharges, odor. Anus and perineal

Gait, stance, posture Backbone Extremities, alignment, position.

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Tymphany over the stomach No tenderness

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Evenly distributed pubic hair. No lesions, no signs of infestation, smooth texture, no discharges or foul odor.

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equal size of muscle on left and right side of the body firm, no

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Muscle strength Range of motion Muscle coordination

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Level of consciousness: language, response to stimulation, intellectual function, abstract thinking, ability to perform simple arithmetic calculations, make judgment

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J. Neurologic • •

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fasciculation, no tremors moves freely, good coordination, can tolerate full ROM impaired posture and balance, walks unaided Able to walk and do ADL. Performs with coordination and rapidity performs with accuracy demonstrates nonbilateral equal coordination able to verbalize her feelings recognizes common objects Able to identify numbers and letters.

Diagnostics and Laboratory Results The following are the deviations from normal that were gathered from the patients diagnostic and laboratory results: Lab Exams

Result

Normal values

Description

Elevated Value might Mean

Decreased Value might mean

BUN

2.0 mmol/L

Male

Blood urea nitrogen an improtant indicator of renal function but not as sensitive as creatinine clearance test. In

Impaired renal function, shock, congestive heart failure, salt & water depletion, excessive protein intake or catabolism, stress,

Impaired absorption ie. cleiac disease, liver failure r/t hepatits, poisoning, drugs, malnutrition, acromegly, syndrome of

8-25 mg/dl 2.9-8.9 mmol/ literbun Female

8-25 mg/dl 2.9-8.9 mmol/liter

chronic renal failure BUN correlates better with symptoms of uremia rather than serum creatinine

hemorrhage with GI tract, acute MI PANIC value >100mg/dl

inappropriate secretion of antidiuretic hormone, anabolic steroid use, IV feedings with overhydration

A blood test for RBC count, looks at the size, number, rate of production and composition ; the main function of RBCs is to carry oxygen from the lungs to the body tissues and transfer carbon dioxide from the tissues back to the lungs

Polycythemia, erythrocytosis,second ary erythrocytosis in many diseases, dehydration, Gaisbock's syndrome, stress, overuse of diuretics

Anemia, lymphomas,leukemi as, addison's, endocarditis, lupus,rheumatic fever

Child 1-6yo 30-40%

Part of the complete blood count and testing is done to determine red blood cell mass to determine anemia or polycythemia. This test along with the hemoglbin and RBCs are assessed to determine diagnosis

Severe dehydration, polycemia, erythrocytosis Again this test should be analyzed with other LAB results for proper diagnosis Hct >60% found with clotting of blood

Anemias, acute massive blood loss, cirrhosis, leukemia Again this test should be analyzed with other LAB results for proper diagnosis Hct

Male 3800–

Leukcocytes help fight infection in

There are 5 different types of leukocytes

AKA Leukopenia found in viral

Child 5-18 mg/dl 1.8-6.4 mmol/L

RBC

4.41 million/ mm3

Male 4.3–5.9 million/mm3 Female 4.5–5.5 million/mm3

Hct

0.36

Male 4353% Female 3747%

WBC

12.8

9800/mcl 3.8–9.8 x 10^9/L

Female 3800– 9800/mcl 3.8–9.8 x 10^9/L

Child 618yo 4.810.8

the body and also help with the immune system. WBC count is useful in determining the severity of an infection /disease

rarely does an increase in one cause all or another to increase where the main increase is will be given the type of leukocyte that is affected:lymphocytosi s neutrophilia esinophilia monocytosis and basophilia An increase in leukocytes occurs in acute infections leukemia drugs trauma accidental or surgical after splenectomy acute hemorrhage polycythemia acute hemolysis tissue necrosis Leukocytosis with NO symtoms of disease: stress exercise cold heat pain excitement anesthesia sunlight UV irradiation seizures nausea and vomiting steroid therapy blood disorders;myeloprolif erative disorders recovery from bone marrow suppression asplenia Panic lelvel >30.0

infections, overwhelming bacterial or some bacterial infections, primary bone disorders, bonemarrow depression due to medications, hyperspleenism, iron deficiency anemia, immune assoct.neutropenia, fungal infection, metastic tumor Panic level less than 0.5

Clinical Findings / Signs & Symptoms  (+) Abdominal Pain  (+) Direct Tenderness @ the ® Quadrant  (+) Rebound Tenderness  (+) Flank Pain @ the RLQ  (+) Dysuria  (+) Bowel Movement  (+) Kidney Punch @ ®  Hyper active Bowel Sounds  (+) Psoa’s Sign  (+) Obturator Sign  (+) Nausea  (+) Weight Loss  (+) Vomiting  (+) Dizziness  (+) Difficulty of Breathing

Problem List Prioritization 1) 2) 3) 4)

Hyperthermia Pain Impaired Urinary Elimination Alteration in Comfort

Nursing Diagnosis 1. Hyperthermia R/T inflammatory process AEB increased body temperature 2. Acute Pain R/T acute inflammation of renal tissue AEB verbal report and guarding behavior 3. Impaired Urinary Elimination R/T inflammation of bladder mucosa AEB Dysuria, urgency and frequency 4. Alteration in Comfort R/T present condition

Nursing Care Plan Assessment Subjective: >No Verbal cues Objective: >In a Supine position >Weak >Pale >Warm to touch >Febrile- 38.4º C

Diagnosis

Planning

Intervention

Rationale

>Hyperthermia R/T inflammatory process AEB Body temperature

>After Nursing interventions, the increased body temperature of the patient will decrease or will obtain normal body temperature range

>Monitor vital signs

>To have baseline >Goal met data and monitor >The patient patients progress maintain core temperature within normal >To control range with shivering and latest seizures and to temperature of treat underlying 35.4 º C cause

>Administer medication as ordered

>Provide supplemental oxygen

>To offset increased oxygen demands and consumption

>Administer replacement fluids and electrolytes

>To support circulating volume and tissue perfusion

>Keep patient on Bed rest

>To be comfortable and to reduce metabolic demands

>Advise parent >To promote to do TSB surface cooling > Measure and record Intake and output

>To monitor if there is a balance between Intake and output

Evaluation

Assessment Subjective >”Ang sakit ng likod kapag natayo at naihi” >painscale of 8/10 As verbalized by the patient Objective >In a supine position >(+) Guarding behavior >(+) facial grimace >slow movement

Diagnosis

Planning

Intervention

Rationale

Evaluation

>Acute Pain R/T acute inflammation of renal tissue AEB verbal report and guarding behavior

>At the end of the nursing intervention, the patient will be able to verbalize lesser pain or achieve a pain free feeling

>Assess pain: -pain scale -location -when pain is felt -when pain is relieved

>to rule out worsening of underlying condition or development of complications

>Goal partially met. >Pain was only relieved when the medication was given.

>Monitor Vital signs

> To have baseline data and monitor patients progress

>Provide comfort measures like repositioning or use of heat or cold packs

>to promote non pharmacological Pain management

>Administer analgesics as indicated to maximum dosage as needed

>to maintain acceptable level of pain

>Encourage adequate rest periods

>to prevent fatigue

>Monitor input and output

> To monitor if there is a balance between Intake and

output

Assessment Subjective >”Masakit at mahapdi kapag umiihi ako, kaya nagpipigil ako.” As verbalized by the patient Objective >In a supine position >(+) Guarding behavior >(+) facial grimace >(+) urinary incontinency

Diagnosis

Planning

Intervention

Rationale

Evaluation

>Impaired urinary elimination r/t to irritation and inflammation of bladder mucosa as evidenced by dysuria

>At the end of the nursing intervention, the patient will be able to achieve normal elimination pattern

>Assess pain: -pain scale -location -duration -intensity -presence of bladder spasm

>to assist in differentiating between bladder and kidney as cause of dysfunction

>Goal partially met. >Pain was only relieved when the medication was given.

>Monitor Vital signs

> To have baseline data and monitor patients progress >to prevent fatigue

>Encourage adequate rest periods

> To monitor if there is a balance between Intake and output

>Monitor input and output

>to help determine level of hydration > for comparison with current situation

>Determine clients usual daily fluid intake >Ascertain clients previous pattern of elimination >Check frequently for bladder

>to reduce risk of infection of autonomic hyperreflexia

distention and observe for overflow

Discharged Planning These are the discharge plans prepared to promote wellness to the patient after her stay in the Hospital: Plan •

Encouraged proper hand hygiene.

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Encouraged to drink frequently (cranberry juice has been shown to reduce the incidence of cystitis) and go on the bathroom as needed.

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Rationale •

To reduce the number of transient microorganisms.

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To wash out microorganisms that may ascends the urethra.

Taught to wipe from front to back after urination.

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To avoid contamination of the urethral opening with fecal bacteria.

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Suggest limiting intake of coffee/tea and alcohol.

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It may irritate the bladder.

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Advised to take the medications on time – as prescribe by the doctor.

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To ensure to have the best possible results from of treatment.

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Encouraged to increase fluid intake.

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When there’s an abdominal pain use a hot or warm water bottle.

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This helps wash out germs from the urinary system. To relieve the pain.

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Advise to take a shower rather than bathe in tub.

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Because bacteria in bathe may enter the urethra.

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Advise to void every 2-3 hours during the day and complete emptying the bladder.

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Advise to avoid use of harsh soaps, bubble bath, powder or sprays in the perineal area.

It prevents over distention of the bladder and compromised blood supply to the bladder wall which predispose the patient to UTI. It can cause irritation to the urethra and encourage inflammation and bacterial infection. Accumulation of perineal moisture

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•

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Advise to wear cotton rather than nylon underwear.

facilitates bacterial growth and cotton underwear’s enhances ventilation on the perineal area.

References •

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2531093

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http://www.healthscout.com/ency/68/508/main.html

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http://en.wikipedia.org/wiki/Pyelonephritis

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www.brunnerandsudartt.com

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www.mims.com

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Dancel, Louella A., Laboratory Manual and Work Book In Microbiology And Parasitology. Exercise no. 2 and 3, pages 11 - 21.

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Daniels, Rick et al., Contemporary Medical Surgical Nursing Vol.2, (2007) pages 1777-1780

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Lippincott, Williams. Nursing 2008 Drug Handbook. (2008)

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Wilson, Billie Ann et al., Nurses Drug guide Vol. 1, 2004

CASE PRESENTATION Pyelonephritis Presented by: Advincula, Roberto Miguel Agban, Serwin Gino Agbay, Janelle Marisse Agcaoili, Maureen Grace Aguedan, Arthur Jake Aguilar, Homero Aguilar, Jemelyn Aguilar, Reina Loiza Aguinaldo, Acelyn Alagos, Ronalyn Alavazo, Rommel John

Ale Ale, Princess Grace BSN 4A/ Group 3 Clinical Instructor: Ms. Michelle Seguerra R.N.