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CASE STUDY Acute pyelonephritis
Leader: Kabigting, Alvin Members: Laruta, Anna Grace Layug, Dexteria Merwin Legrama, Mykel Mae Miguel, Marie Thea Movilla, Ian Musni, Joshua Nacor, Sherry Mae Najera, Rheva Obida, Jescel Mae
Table of Contents
III. IV. V. VI. VII. VIII. IX. X.
Introduction History Taking a. Demographic Data b. Review of System c. Physical Assessment Anatomy and Physiology Pathophysiology Laboratory and Diagnostic Examinations Drug Study Nursing Care Plan Discharge Plan Conclusion Recommendation
Introduction History Taking a.Demographic Data
1. Patient’s profile Name: Patient A Age: 20 y/o Sex: Female Address: Purok #@ Calapacuan, Subic, Zambales Civil status: Married Religion: Roman Catholic 2. Chief Complaint: Date of Admission: Fever 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 Calapacuan LMP: February 15, 2009 AOG: 28 EDC: Nov. 22, 2009 Menarche: 14 y/o Coitarche: 19 y/o Intensity: Regular Duration: 7 days Amount: 2 pads fully soaked Symptoms experience: (-) dysmenorrhea # of sexual partner: 1 STD: 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 August 30, 2009 6:15 pm COURSE IN THE WARD 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. 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. 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.
August 31, 2009
September 1, 2009
8. Gordon’s 11 Functional Health Pattern Gordon’s 11 Functional Health Pattern Health Perception/ Health Management Findings 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
Activities and Exercise
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. 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. 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. 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.
Cognitive Perceptual Pattern
Self-relation and Selfperception Pattern
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. 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. 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. 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.
Sexuality and Reproductive Pattern
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. 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. 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. 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. 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 System
Integumentary 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
SKIN 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 Color varies upon the race. Thick, silky, resilient hair evenly distributed (-) dandruff, (-) lice (-) lesion, (-) scars Rounded (normocepha lic & symmetrical with frontal, parietal, and occipital
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.
black, thin, dull hair (+)Hair fall evenly distributed (+) dandruff, (-) lice (-) lesion, (-) scars
Rounded (normocephal ic) Symmetrical Smooth skull contour
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. The client shown no deviation in the structure of the skull.
(-)nodules, (-) masses FACE Eyes structures a.) eyebrow Symmetric facial movement Hair evenly distributed Symmetricall y 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
c.) conjunctiva d.) pupil
Color same as facial skin Symmetric Aligned with the outer canthus of eyes Mobile, firm (-)tenderness
prominences ) Symmetrical Smooth skull contour (-)nodules, (-) masses Symmetric facial movement Hair evenly distributed Symmetricall y aligned Equal movement Skin intact No discoloration Lids close symmetricall y Palpebral fissures equal in size (-)edema/ (-)tenderness Shiny, smooth & pink conjunctiva Varies color depend on race (+) PERRLA Color same as facial skin Symmetric Aligned with the outer canthus of eyes Mobile, firm (-)tenderness
Eyebrows are normal and intact.
Eyelids are normal and symmetrical showing no signs of abnormalities.
Conjunctivas are normal and intact. Pupils are normal.
The ears showed no signs of abnormalities.
Pinna recoils after folded (-)discharge Able to hear sound on both ears Symmetric & straight (-) discharge Uniform in color (-) tenderness, (-) lesions Pink mucosa Intact nasal septum & in midline Able to determine mild aroma Patent nares 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 yellow, shiny enamel Pink gums
Pinna recoils after folded (-)discharge Able to hear sound on both ears Symmetric & straight (-) discharge Uniform in color (-) tenderness, (-) lesions Pink mucosa Intact nasal septum & in midline Able to determine mild aroma Patent nares 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 varies from white to
The nose is aligned and normal, and the nares are patent and functioning well.
MOUTH a.) lips
Lips are moist and intact showing a normal couture and function.
b.) buccal mucosa
Buccal mucosa is normal and intact.
c.) teeth & gums
Gums are intact and teeth are complete with no seen plaque formation.
No retraction of gums central position pink in color moves freely (-) nodules
Muscle equal in size Head is centered (-) palpable lymphnodes 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 Rounded shape Slightly unequal in size
light yellow, shiny enamel Pink gums No retraction of gums central position pink in color moves freely (-) nodules Muscle equal in size Head is centered (-) palpable lymphnodes Chest symmetric Spine vertically aligned Skin intact Uniform temperature Chest wall intact (-) tenderness, (-) masses Symmetric chest expansion Even breath sounds
Tongue is aligned perfectly and functioning well.
Neck is aligned centrally and normal, with no palpable masses. 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.
Rounded shape Slightly unequal in size
According to the client, her breast had enlarged since she got pregnant, this is
Skin uniform in color Skin smooth & intact Fullness of breast (firm) Dark colored areola (-) tenderness, (-) nodules Light brown in color Round shape Vertical dark line at the center (+)linea negra (+) bowel sound (+)FHT (141bpm) (+)fetal parts (upon palpation) 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 ((+)inflammat
Skin uniform in color Skin smooth & intact Dark colored areola (-) tenderness, (-) nodules
normal for the client is getting ready to lactate. Other than that, the client has normal breasts.
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.
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 LOWER EXTREMITIES
ion) Good capillary refill (<2 sec) (-) discharge (as verbalized by the client) AREA HAVE BEEN REFUSED TO BE EXAMINED Equal size in Equal size in The client has normal lower both side of both side of extremities and the body the body no signs of (-) contures (-) contures congestion or (+) (-) Homan’s formation of occasional sign thrombophlebitis numbness Good (-) Homan’s capillary refill . sign (<2 sec) Good capillary refill (<2 sec)
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 PREGNANCY The 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 HBsAg Syphilis RESULT Non-reactive Non-reactive REF. VALUES-MTD/CUTOFF index SD/QIA (Rapid Test) SD/QIA (Rapid Test) INTERPRETATION The client has not been exposed to the hepatitis virus. The client has not been exposed to the bacteria Treponema pallidum.
B. Microscopic Examination 30 August 2009 Examination Result Reference Value Interpretation
Specific Gravity Reaction
1.001 – 1.035 -----
Urine’s color may vary with the client’s diet and drugs taken. 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. Client’s urine’s specific gravity is within normal range. Urine’s pH is usually acidic to maintain an environment that is not conducive for bacterial growth, client’s urine pH is normal. Proteinuria shows that there is damage to the filtering capacity of the kidneys that allows large molecules to flow.
C. Microscopic Examination 30 August 2009 Examination WBC Result Too numerous 0-1 Few Reference Value (0-2/hpf) Interpretation WBC is greatly elevated that shows a recent immunologic response from an infection. RBC is within normal range. Epithelial cells should not be seen in a normal urine but urine samples are usually contaminated
RBC Epithelial cells
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 Blood type Hgb Result “B” Rh(+) 106 Reference Value F: 120-150 Interpretation Hemoglobin count is below the normal range and the client is already taking iron supplements to correct the condition. Hematocrit is within normal range showing no signs of dehydration or congestion. WBC is greatly elevated showing that there is an infection. Neutrophils are the first line of defense and is greatly elevated until the immunologic response is finished. Lymphocytes are lower than the normal range showing no signs of viral infection.
WBC Count Neutrophils
20.39 x 109/L 0.88
Eosinophils Monocyte Platelet
Reticulocyte count MCH MCV
28-32 pg 82-98 fl
E. Clinical Chemistry 30 August 2009 Examination BUN Result 1.55mmol/ L Reference Value 1.7-8.3 Interpretation Client’s BUN has a slight lowering beyond the normal range showing that the kidney is still functioning well in cleansing the blood. Creatinine level is within normal range
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.
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