Vivivian Pyelonephritis

CHAPTER ONE
ASSESSMENT OF PATIENT AND FAMILY
1.0 Introduction
According to Weller (2010), assessment is the gathering of information about a patient’s
psychological, physiological, sociological, and spiritual status by a nurse. Nursing assessment
is the first step in the nursing process.
The information is collected from patient and family through observation, interview, physical
examination, laboratory investigation and x-ray report.
The data is then analyzed to arrive at the patient’s problem so that the nurse can determine
the possible ways of nursing the patient back to an independent life.
1.1 Patient’s Particulars
According to Weller (2010), particulars of a patient are the facts or details about them which
are written down and kept as record.
Mrs. A.O is a 45 year old woman born on 16th August, 1972 to Mr. K.O and Mrs. A.D. who
are all alive. She was born in Japekurom, a town within the Jaman South Municipal, where
she currently resides in a house with the address JP 450I. She is married to the Mr. A.Y.B,
who is a teacher by profession. Mrs. A.O is a police officer stationed at the Japekurom Police
Station, in the Jaman South Municipal. She is a Christian who worships with the Roman
Catholic Church. Mrs. A.O does not have a child. According to Mrs. A.O. Her highest level
of education is tertiary education, when she enrolled in Polytechnic education in Sunyani.
After completion, she then decided the join the Ghana police force. She speaks Twi, English
and a little bit of French. Mrs. A.O. is fair in complexion, 1.74metres in height and 74kg in
weight with no physical impairment or tribal marks on the face. Even though she does not
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have a child, she and the husband, Mr. A.Y.B has adopted a child, Y.A who is 12 years old.
Her next of kin is her junior sister, Miss Y.O.
1.2 Patient’s Family Medical History
According to patient, there are no known hereditary diseases such as Asthma, Diabetes
Mellitus, Mental illness, sickle cell disease or Hypertension in the family. She also said that,
there are no chronic and infectious conditions like cancer, tuberculosis, epilepsy and leprosy
in the family. Patient also was not aware of any allergy to any food or drugs to any member
of her family.
However, she said that sometimes the family members do experience minor illness like
common cold, headache and fever which they treat by using over the counter drugs and
usually go to the hospital when symptoms persist for long period. (Based on this, I educated
and advised them against the use of over the counter drugs and told them to go to the
hospital any time they fall ill). Patient affirmed that, people who died in her family are
largely due to old age or accident. According to patient she has being admitted twice at the
St. Mary’s Hospital, in Drobo. On both occasions, she was pregnant and suffered
spontaneous abortion. She lost her pregnancy on both occasions. The main source of her
family’s medical treatment is orthodox.
1.3 Patient’s/Family Socio-economic History
Mrs A.O is a police officer by profession and her husband is a professional teacher.
According to patient, her husband support her fully economically. Their combined income is
used for the upkeep of the house and to care for their adopted child. Patient also said that she
is the main bread winner of her family, as she takes care of her two younger sisters and her
parents. She and her husband has managed to buy a taxi. The only source of extra income she
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earns is from the daily sales the driver of their taxi brings to them. In times of difficulty, Mrs.
A.O falls on her colleagues at work or takes loan from the bank.
Patient, her husband and their adopted child, are all enrolled on the National Health Insurance
Scheme. Mrs. A.O said she does not attend church on regular basis due to the nature of her
work but she is a choir member of her local church. But she tries to attend church on any
weekends that is she is off duty. Also on weekends that she is off duty, she attends weddings
and funerals. According to Mrs. A.O it is wrong in the community for the young to disrespect
the elderly. As a security personnel, she believes in discipline.
1.4 Patient’s Developmental History
According to Weller (2010), development refers to the biological, physiological and
emotional changes that occur in human beings between birth and the end of adolescent as the
individual progress from dependency till increasing autonomy.
Also Weller (2010), describes maturation as the process of becoming completely developed
mentally and emotionally.
Moreover Weller (2010), describes growth as an increase in the size, amount or degree of
something.
Mrs. A.O said, her mother told her that, she delivered her at the St. Mary’s Hospital per
spontaneous vaginal delivery. Her mother had no problem during puerperium. She also
mentioned that, she was immunized against the six childhood killer diseases. A mark on her
deltoid muscle indicated immunization of bacille calmette guerin which is given against
tuberculosis. According to Mrs A.O, she did not experience any serious diseases that could
have impeded her development whiles growing up. According to Mrs. E A., She was told by
her mother that she started sitting up in her sixth month and could walk by the twelfth month.
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According to Mrs. A.O, she started schooling at 5 years and she attended primary school at
the Presbyterian Primary and Junior high school in Japekurom. She then continued her
education at the Drobo secondary school. After completing Drobo Secondary School, she
could not continue to tertiary immediately because her parents were in difficulty financially.
She did menial jobs before she was able to gather money and continue her tertiary education
at the Sunyani Polyclinic. Mrs. A.O said, growing up she had a dream of being a banker but
due to certain circumstances beyond her control, she enrolled in police service after
completing Polyclinic.
Mrs. A.O developed her secondary sexual characteristics such as development of breast,
growing of hair in the armpit and around the pubic areas as early as 12years. She experienced
her menarche at age fifteen (15) and had regular menstrual flow and a normal 28 days cycle.
Patient does not have wrinkled skin or grey hair.
According to Erikson’s theory of psychosocial development (1959), there are eight distinct
stages with each possible results, thus either success or failure personality. These are;
1. Trust versus mistrust (birth to 1year)
2. Autonomy versus shame and doubt (2 to 3years)
3. Initiative versus guilt (3 to 5years)
4. Industry versus inferiority (6 to 11years)
5. Identity versus role confusion (12 to 18years)
6. Intimacy versus isolation (19 to 40years)
7. Generativity versus stagnation (40 to 65years)
8. Integrity versus despair (65 to death)
Mrs. A.O is within the seventh stage; generativity versus stagnation (40 to 65years) during
middle adulthood, we establish our carriers, settle down within a relationship, begin our own
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families and develop a sense of being a part of a bigger picture. We give back to society
through raising our children, being productive at work and becoming involved in community
activities and organizations. By failing to achieve these objectives, we become stagnant and
feel unproductive. Through my interaction with my patient, I found out that, she has achieved
generativity. This is because even though she doesn’t have a child of her own, she is giving
back to the society by taking care of an adopted child, to make the child prominent person in
future.
1.5 Patient’s lifestyles / hobbies
Mrs. A.O said she normally wakes up at 5:30am. She says a prayer before her first oral
hygiene. She then empties her bowel and takes her morning bath normally with warm water.
Her favourite soap is “Geisha” soap because she claims it makes her skin soft. Her favourite
toothpaste is pepsodent because she claims it contains all the necessary ingredients that
makes her teeth strong. She eats her breakfast with her family and leaves home for work
between 7:00am and 7:30am. She normally goes to work early because of the nature of her
work. Her usual break fast include beverages, wheat, oat or maize porridge with butter bread.
She normally have heavy food such as banku for lunch and rice in the evening. Her favourite
food is Banku and Okro Stew. She normally close in the evening around 5pm to 6pm.
Patient has no known allergies for food or drugs. She takes three square meals a day with
snacks in-between. She baths in the evening and brush her teeth before going to bed to keep
herself clean. Patient claimed that due to the nature of her, especially when they go on the
field to work(standing by the road side) and due to the attire she wears to work, she normally
keep her urine even if she feels the urge to urinate till she returns to the office or till she
closes home. She was advised against such behaviours as it may cause a lot of health
problems. According to patient she does not share personnel items such as towel, tooth brush
etc with her husband Mr. A.Y.B or their adopted child Y.A.
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She does not smoke nor drink alcohol. At her leisure hours, she normally watches television
and sometimes read newspapers. His favourite television programmes are African movies,
telenovelas and television news. On weekends when she does not go to work, she performs
personal household chores. She likes to attend social gatherings like naming ceremonies and
funerals. Patient’s usually uses both verbal and non-verbal communication styles such as eye
movement and gestures to speak to people to desist from doing certain things. Patient is kind
and an extrovert. She likes honest, discipline and hard work people. She pays the fees of her
adopted child, gives financial support to her siblings, and her parents alike. My personal
impression about the patient is that, she is very generous, discipline and kind person.
1.6 Patient’s Past Medical/Surgical/Obstetric History
According to Mrs. A.O, she didn’t have any childhood illness like measles, whooping cough,
diphtheria, etc. Patient normally experiences minor ailments likes headache, diarrhoea,
common cold, cough and malaria which are always treated with drugs bought from the
pharmacy shop and sometimes treated on outpatient basis at the hospital. Mrs A.O. has
never experienced any allergies.
According to Mrs. A.O she experienced her menarche at age fifteen (15) and had regular
menstrual flow and a normal 28 days cycle. Mrs. A.O said she has being pregnant twice but
both pregnancies resulted in spontaneous abortion and she was admitted for further care at the
hospital. Mrs. A.O said she does not use any form of contraceptive since she is still expecting
to get pregnant again.. She said she has never being diagnosed of any sexually transmitted
disease.
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1.7 Patient’s Present Medical History
According to Mrs. A.O, she was doing well until three ago (17/07/2018) when she started
experience headache, fever and backache. She initially bought an over the counter drug from
a licensed chemical shop but the symptoms persisted. She also started having pains when
urinating. Due to the progressive nature of the symptoms, patient sought permission from
work and attended the hospital on the 20Th July, 2018 at around 9:15am. Patient came in the
company of a colleague from work. Her vital signs were checked and recorded at OPD as
Temperature -37.8oc.
Pulse -95 bpm.
Respiration -21cpm.
Blood pressure -110/80mmHg.
Weight -74kg
Patient was examined by Dr. Ayamga at the OPD and was subsequently admitted to the ward
for nursing and medical management of pyelonephritis.
1.8 Admission of Patient
On 20/07/2018 at 12pm, Mrs. A.O was admitted to the females ward of the f St Mary’s’
hospital, Drobo per ambulatory from outpatient department accompanied by an OPD nurse
and patient’s work colleague. Patient was conscious and well orientated to time place and
persons. Patient’s folder was collected from the OPD nurse and her name was mentioned to
ascertain and confirm the identity of the patient. Mrs. A.O was immediately made
comfortable in an already prepared simple bed in females ward with bed number F6. Upon
assessment patient complain of painful urination, pains at back (flank pains), lower
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abdominal pains and frequent passing of urine. Patient also complain of chills and fever. It
was also observed that patient was very anxious. I introduced myself to the patient and her
accompanying colleague. Mrs. A.O . particulars were documented into the admission and
discharge book and daily ward state.
Vital signs was checked and recorded as follows
Temperature - 37.9oc
Pulse - 84bpm
Respiration - 21cpm
Blood Pressure - 110/60mmHg
SPO2 - 97%
Laboratory investigations requested on admission were
Blood for Full blood count
Blood for malaria parasite
Urine for Routine examination
Venereal Disease Research Laboratory (VDRL) for syphilis.
Blood sample was taken, sample bottle labelled and sent to the laboratory for the
investigations to be carried out.
Patient was placed on the following medications;
Intravenous Ciprofloxacin 400mg twice daily for 2 days
Intravenous Metronidazole 500mg three daily for 2 days
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Tablet diclofenac 50mg three times daily for 5 days
Infusion Normal Saline 2Litres within 24hours
Since patient is registered with the national health insurance scheme, all drugs were
procured from the pharmacy without any payment. An intravenous cannula was inserted and
intravenous medications commenced.
Patient was then informed about daily ward routine such as medication, ward rounds and
visiting hours. Also patient was orientated to the ward and it’s environ. They were
introduced to other patients at the ward, shown the toilet, bathroom, the playground and also
to the nurses’ station. Since there was no restroom in the ward, patient was encouraged to eat
by Her bedside. Items to be used at the ward during their stay such as towel, bucket, spoon
and bowl were also mentioned to the colleague who accompanied her to the ward.
After these interventions, permission was sought from the ward in-charge to use the patient
for my case study and she agreed. After 30 minutes of admission, patient’s husband
Mr.A.Y.B had come around. I then introduced myself to the patient/family that, I am a
student nurse of Nursing Training College, Seikwa, conducting a study at the hospital. I then
made it known to them my desire to use Mrs. A.O for the care study. I explained to them
holistic care will be rendered to them to ensure speedy recovery. I told them that, as part of
my training, final year students are to take a patient each, nurse him or her from the time of
admission till time of discharge and home visits. The patient and family accepted and
promised their cooperation and readiness to give me any information needed for my study.
They were informed that her hospitalization was temporal and that she will be discharged as
soon as her condition gets better. They were also informed that, as part of my care, I would
visit their home whiles patient was on admission and after she has been discharged. I choose
to write my care study on pyelonephritis because it is very common in women due to the
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risk of contamination of the urethral meatus from fecal soiling. I wanted to know more
about this condition and to holistically nurse a patient who was suffering from this ailment
and also to apply the lesson from the study to myself since I am a woman.
1.9 Patient’s Concept Of Illness
Patient believed her condition is as a result of microorganisms that has entered her body. She
didn’t attribute the disease to any spiritual force. She expressed fears that the condition may
get worse and ay prevent her from getting pregnant if due treatment are not administered. She
was reassured that the treatment she is being given will result in her quick recovery and
discharge home soon.
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1.10 Literature Review On Pyelonephritis
Review Of The Anatomy Of The Kidneys
Gross Structure
Diagram of the kidney (Macroscopic)
Hinkle & Cheever (2014)
According to Waugh & Grant (2014), the kidneys lie on the posterior abdominal wall, one on
each side of the vertebral column, behind the peritoneum and below the diaphragm. They
extend from the level of the 12th thoracic vertebra to the 3rd lumbar vertebra, receiving some
protection from the lower rib cage. The right kidney is slightly lower than the left, probably
because of the considerable space occupied by the liver.
Each kidney presents a bean-shape appearance with lateral convex and a medial concave
border. In the centre of the concave border, is a deep longitudinal fissure called the helium
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where the renal arteries enter and the ureters and renal veins leave the kidneys. Each kidney
is covered by a fibrous capsule which provides a firm smooth covering.
Each kidney measures about 11cm long, 6cm wide, 3cm thick and weighs 150g.
Longitudinal Section Of The Kidneys
In the view of Waugh & Grant (2014), the three general regions observed if the kidney is
divided longitudinally are:
Renal Cortex
This is a reddish brown layer of tissue immediately below the capsule and outside pyramids.
The renal cortex and renal pyramids constitute the renal parenchyma (functional portion)
Renal Medulla
This is darker in colour and consists of striated cone- shaped masses called renal pyramids. It
is the innermost layer. The renal pyramids vary in number but averagely 12. The bases of the
pyramids are directed towards the cortex while the apex projects towards the renal pelvis
where it forms a papilla. The base summit of each papilla resembles a sieve with a variable
number of openings through which urine flows into the calyx of the renal pelvis.
Renal Pelvis
This is a funnel shaped sac which forms the upper extended and expanded portion of the
ureters. It receives the urine by the calyces, which are cup- shaped extension of renal pelvis.
Blood Vessels Of The Kidney
The pathway of blood flow through the kidney is an essential part of the process of urine
formation. Blood from the abdominal aorta enters the renal artery, which branches
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extensively within the kidney into smaller arteries. The smallest arteries give rise to afferent
arterioles in the renal cortex From the afferent arterioles, blood flows into the glomeruli
(capillaries), to efferent arterioles, to peritubular capillaries, to veins within the kidney, to the
renal vein, and finally to the inferior vena cava.
Functions Of The Kidneys
According to Waugh, et al (2006), the kidneys performs the function of forming and
excreting urine and in doing so, the following vital functions of the body are achieved:
(i) Excretion of protein metabolic wastes
(ii) Excretion of toxins and certain drugs
(iii)Maintenance of blood volume and fluid balance in the body
(iv) Maintenance of blood pH by excreting acids and preventing the loss of bases
The kidneys also:
(i) Participate in vitamin D synthesis
(ii) Secret the enzyme rennin when there is a fall in blood pressure which combines with
plasma proteins (globulins) to form angiotensin which raises the blood pressure.
Definition Of Pyelonephritis
Pyelonephritis, as defined in the Bailliere’s Nurses’ dictionary, is an inflammation of the
renal pelvis and renal substances characterised by fever, acute loin pain, and increased
frequency of urination, with the presence of pus and albumin in urine.
According to Beers, M.A., et al (2009) it is defined as a bacterial infection of one or both
kidneys.
Again Hinkle & Cheever (2014) defines pyelonephritis as a bacterial infection of the renal
pelvis, tubules and interstitial tissue of one or both kidneys.
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Incidence
The condition is common in women than men. It is relatively high in female infants and
children due to faecal soiling and Escherichia coli contamination of urethral meatus. It
frequently occurs in pregnant women due to urine stasis incurred by the pressure from the
enlarging uterus and atonia of the ureters as a result of the progesterone effect. In male, in
later years of life, it is generally associated with defective urinary drainage as a result of
prostatic enlargement.
Pathophysiology
The urinary tract, from the kidneys to the urethral meatus, is normally sterile and resistant
to bacterial colonization despite frequent contamination of the distal urethral with colonic
bacteria. Mechanisms that maintain the tract’s sterility include urinary acidity, emptying of
the bladder at micturition, ureterovesical and urethral sphincters.
About 95% of Urinary tract infections (UTIs) occur when bacteria ascend the urethral to the
bladder, and the case of acute uncomplicated pyelonephritis, ascend the ureter to the kidney.
The remainder of UTIs are haematogenous –systemic infection can result from UTIs
particularly in the elderly.
Causes
According to Walsh, M. 2008, the predominant causative organism is Escherichia coli. Other
causative agents are the proteus species, staphylococci, klabsiella or streptococci
Predisposing Causes
According to Hinkle & Cheever (2014), however attributed the following as predisposing
causes of pyelonephritis;
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(i) Obstruction to the flow of urine from the kidney may be the result of renal calculi,
neoplasm, and stricture of the ureter due to pressure.
(ii) Defective urinary drainage and reflux of urine from the bladder into the ureters.
(iii)Immunosuppression and immunodeficiency such as HIV/ AIDS
(iv) Sex : the incidence is greater in females than males
(v) Pregnancy
(vi) Instrumentation of the urinary tract such as catheterization
(vii) Age : the condition usually occurs in early childhood than adult life
(viii) Diabetics Mellitus in which there is general susceptibility of infection.
(ix) Bladder tumours and
(x) Benign prostate hyperplasia
Diagnostic Investigation
(i) History of patient
(ii) Presenting signs and symptoms
(iii) Urine culture and sensitivity tests are performed to determine the causative organisms
so that appropriate antimicrobial agents can be prescribed.
(iv) Blood tests (Full blood count)are also performed to check for elevated white blood
cells or bacterial in the blood
(v) Ultrasound study or computed tomography scan may be performed to locate any
obstruction in the urinary tract
(vi) Intravenous pyelography will detect renal calculi and structural abnormality
(vii) Cystoscopy to directly visualise the bladder and ureters for any abnormality,
strictures or obstruction and to take urine samples directly from the kidney to evaluate
its function
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Types
Pyelonephritis can be acute and chronic according to Smelter, et al (2008).
Acute Pyelonephritis
According to Smelter, et al (2008), it is a sudden inflammation caused by bacterial. It
primarily affects the interstitial area and the renal pelvis or, less often, the renal tubules.
Signs And Symptoms
According to Smelter, et al (2008), the signs and symptoms of acute pyelonephritis are as
follows;
(i) Leukocytosis is a raised white blood cells above the normal range. It occurs in
response to the disease condition.
(ii) Bacteriuria is the presence of bacteria in urine.
(iii) Pyuria refers to urine which contains pus due to the inflammatory process.
(iv) Dysuria is described to be burning sensation felt during urination as a result of a
urinary tract infection.
(v) Tenderness of the bladder area and the side of the involved kidney (costevertebral
angle tenderness) which may be elicited by performing the kidney punch.
(vi) Polyuria is a condition characterised by the passage of large volumes of urine (at least
2.5L over 24 hours). Pyelonephritis can impair the kidney’s ability to concentrate
urine, increasing the the daily output of urine.
(vii) Nausea and vomiting result from accumulation of metabolic waste, including acid
which the diseased kidneys are unable to excrete.
(viii) Malaise is a general feeling of illness as a result of decreased production of red
blood cells.
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(ix) Flank pain and low back pain; it occurs because the kidney’s outer covering (renal
capsule) is stretched because of the disorder that produces swelling of the kidney
tissue.
(x) Fever is increase temperature due to inflammatory process.
(xi) Chills; violent shivering while the temperature rises due to inflammatory process.
Medical Treatment
Treatment objectives
· To relieve symptoms
· To eradicate causative agent
· To prevent complications
· To identify patients with abnormalities of the genito-urinary tract
Non-pharmacological treatment
· Liberal oral fluids to encourage good urinary output
· Personal hygiene and proper cleaning after defaecation
(Evidence rating: C)
In mild/moderate cases
· Ciprofloxacin, oral, 500 mg 12 hourly for 7 days
· Co-amoxiclav, oral, 1g or 625mg 12 hourly for 5 -7 days
Or
Cefuroxime, oral, 500mg twice daily for 5-7 days
In severe cases
· Ciprofloxacin,IV, 400mg 12 hourly for 7 days
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Gentamicin, IV, 40-80mg 12 hourly for 7 days
Or
Ceftriaxone, IV, 1-2g daily for 7 days
Analgesics i.e paracetamol, diclofenac, brufen etc may be prescribed depending on the
severity of pain
Intravenous Infusions are prescribed and patients are encouraged to take at least 3l daily
unless there is complete obstruction of urinary drainage.
Treatment will depend on severity of infection as well as the age of the patient
Antibiotics are started as soon as the doctor suspects pyelonephritis and urine and blood
samples have been taken for laboratory tests. The choice of drugs and its dosage may be
modified based on the laboratory test results, how sick the person is.
Patient with acute uncomplicated pyelonephritis are most often treated on an outpatient basis
if they are not exhibiting dehydration, nausea or vomiting or symptoms of sepsis.
For outpatients, a 2 weeks course of antibiotics is recommended. Commonly prescribed
agents include ciprofloxacin, gentamycin with or without ampicillin or a third generation
cephalosporin.
Pregnant women may be hospitalised for two or three days of parenteral antibiotics therapy.
Oral antibiotics agents may be prescribed once the patient is afebrile and showing signs of
clinical improvement.
After the initial antibiotic regimen, the patient may need antibiotic therapy for up to 6 weeks
if evidence of relapse is seen. A follow up urine culture is obtained 2 weeks after completion
of antibiotic therapy to document clearing of the infection.
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Complication
According to Smelter, et al (2008), repeated bouts of acute pyelonephritis may lead to
chronic pyelonephritis.
Chronic Pyelonephritis
According to Smeltzer, et al (2008), it is the persistent kidney inflammation that can scar
the kidneys and may lead to chronic renal failure. This disease is most common in urinary
obstruction or vesicoureteral reflux.
Signs And Symptoms
(i) Polyuria is a condition characterised by the passage of large volumes of urine. The
disease condition can impair the kidney’s ability to concentrate urine, increasing the
daily output of urine.
(ii) Polydepsia is sustained increase in water intake due to Polyuria.
(iii)Loss of appetite due to nausea and vomiting which come as a result of accumulation
of metabolic waste, including acids which the diseased kidneys are unable to excrete.
(iv) Fatigue; results from decreased production of red blood cells.
(v) Weight loss due to loss of appetite.
Complication
End Stage Renal Failure
Acute pyelonephritis is usually manifested by enlarged kidneys with infiltration of
inflammatory cells. Abscesses may be noted on the renal capsule. Eventually atrophy and
destruction of tubules and glomeruli may result. When it becomes chronic, the kidneys
become scarred and non- functioning leading to end stage renal failure.
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Renal Calculi
It results from the chronic infection with urea- splitting.
Hypertension
This is due to sodium and water retention and malfunction of the renin- angiotensin-
aldosterone system.
Formation of kidney stones
This arises from chronic infection with urea-splitting organisms
Medical Management
Long time use of prophylactic antimicrobial therapy may help limit recurrence of infection
and renal scarring. Impaired renal function alters the excretion of antimicrobial agents and
necessitates careful monitoring of renal function especially if drugs are potentially toxic to
kidneys. The choice of antimicrobial agent is based on which pathogen is identified through
urine culture. If the urine cannot be made bacteria-free, nitrofurantoin or TMP-SMZ may be
used to suppress bacterial growth.
Nursing Management
Rest And Sleep
1. During the acute phase of illness, complete bed rest is ensured.
2. Patient is nursed in a well ventilated room with good lighting system.
3. Dirty linen or soiled linen is changed and crumpled sheets are straightened to improve
patient’s comfort.
4. All nursing care activities are coordinated in order not to disturb the patient.
5. Visitors are restricted when patient is asleep.
6. Provide and ensure privacy when performing procedure
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Observation
1. Intake and output is monitor to prevent fluid retention.
2. Patient is weighed daily to determine weight gain or loss.
3. The frequency, colour and consistency of urine and vomitus is observed.
4. Patient’s level of pain is assessed and intervene appropriately.
5. Vital sign is checked 4 hourly and recorded.
6. The therapeutic and adverse effect of administered drugs is observed.
Position And Pain Relief
1. The patient is assisted to assume a comfortable if not contraindicated.
2. Moist, warm compresses and warm baths are encouraged.
3. The patient is provided with diversional therapy like watching television.
4. Prescribed analgesic is administered.
Fluid Balance Restoration
1. Patient is encouraged to take copious fluid if not contraindicated to flush out the urinary
tract and replace lost fluids.
2. Administer IV fluids as prescribed
3. Monitor intake and output of fluid administered.
4. Avoid coffee, tea, colas, alcohol, and other fluids that are urinary tract irritants.
Elimination
1. Patient is assisted to assume a normal position for voiding provided with bedpan or
urinal during the acute phase.
2. Complete bladder emptying is encouraged
3. Intermittent catheterization may be done if indicated.
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Activity and Mobility
Physical activity is necessary to maintain muscle tone. Passive and active exercise is
encouraged to prevent urinary stasis as tolerated by the patient.
Personal Hygiene
1.Patient is encouraged to maintain perinea hygiene to prevent spread of infection or re-
infection.
2. Good and proper disposal of waste materials is ensured to prevent spread infection to
others.
3.Proper hand hygiene should be encouraged in patient to prevent spread of infection.
4. Patient should be taught to clean the perineum and urethral meatus from front to back. This
will help reduce concentrations of pathogens at the urethral opening and, in women, the
vaginal opening.
Diet
1. Patient is encouraged to take soft, high calorie diet with adequate vitamin and mineral
supplement.
2. Patient is encouraged to take low salt diet to minimize water retention and low fat
diet.
Prevention
Some cases of pyelonephritis can be prevented by prompt recognition and treatment of
minor bladder infection that, if left untreated, may progress to more severe condition.
Prompt and complete treatment of bladder infections may prevent development of cases of
pyelonephritis. Chronic or recurrent urinary tract infection should be treated thoroughly.
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Keep the genital area clean. Wiping from front to back help reduce the chance of introducing
bacterial from rectal area to urethra.
Urinating immediately after sexual intercourse. This may help eliminate any bacterial that
may have been introduced during sexual activity. Drink more fluids. This encourages
frequent urination and flushes bacterial from the bladder.
Health Education
i. The patient is educated to clean the urethral meatus and perineum thoroughly from
front to back after each bowel movement to reduce the concentration of pathogens at
the urethral and vaginal openings in women.
ii. Patient is taught to void 3 to 4 times during the day and completely empty the bladder
to prevent over distension of bladder.
iii. Patient is taught to take liberal amount of fluids daily to flush out the bacterial from
urinary tract.
iv. Patient is also taught to avoid coffee, alcohol and other fluids that are urinary tract
irritants.
v. Diabetic patient and pregnant women’s follow up should include a urine culture at the
completion of antibiotic therapy to ensure that bacterial are no longer present in the
urine.
vi. Male patients are advised to do regular examination of the prostate gland and report
any enlargement.
vii. Patient is taught to consult health care providers regularly in cases of recurrence of
signs and symptoms and signs of complication.
viii. Patient is taught to take prescribed medication.
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ix. Patient is educated on the importance of completing the course of prescribed
antibiotics.
1.11 Validation Of Data.
Weller (2009), explained validation as the extent to which a measure, indicator or data
collection possesses the quality of being sound or true as far as it can be judged. The data
collected from Mrs A.O was validated based on the fact that counter interviews with patient
husband revealed the same responses. Also the doctor’s notes, nurses’ notes, investigations and
their results, literature review of the condition and observation made on Mrs. A.O alongside
information strongly confirmed the data collected.
Other books also support the signs and symptoms that were presented. Also the information
gathered during home visits helped in validating the data as they were all in line with those
given by the patients.
In view of the information gathered, it is clear that the data collected is appropriate for writing
a care study.
24
CHAPTER TWO
ANALYSIS OF DATA COLLECTED
2.0 Introduction
According to Weller (2009), Analysis is a careful examination of something in order to
understand it better or find out what it consists of. This chapter deals with the comparison
between the data collected from the patient and relatives with standards as stated in the
literature review and standard treatment in the text books to identify any deviation from
normal in order to give the necessary nursing intervention to improve the health status of the
patient. Also patient/ family strengths and health problems are identified as well as the
corresponding nursing diagnosis.
2.1 Comparison Of Data With Standards
The results from laboratory investigation, history or signs and symptoms manifested by the
patient are carefully analysed, comparing them with standard measures to aid in diagnosing
the patient’s condition. It comprises;
1. Comparism of data with standard
2. Patient/Family strength
3. Health problems
4. Nursing diagnosis
Tests/ Diagnostic Investigations
Test (medical) is a kind of medical procedure performed to detect, diagnose, or monitor
disease processes, susceptibility and determine a course of treatment.
25
A diagnostic investigation is a procedure performed to confirm or determine the presence of
disease in an individual suspected of having the disease usually following the report of
symptoms or based on the results of other medical tests.
The following were the medical tests and investigations which were requested of Mrs A.O
throughout her 5 day stay at the hospital and the table below compares the requested tests and
investigations, their various normal values and results as well as the interpretation and
remarks. It included;
I. Full Blood Count
II. Blood Film for malaria parasites
III. Urine routine examination
IV. Venereal Disease Research Laboratory (VDRL) for syphilis.
Table 1: Diagnostic investigation requested for patient as compared with literature
review
Diagnostic investigations according to Diagnostic investigations requested for

literature review patient
1 Urine culture and sensitivity tests/ routine Urine routine examination was done for
examination patient
2 Full blood count Full blood count was ordered for patient
3 Ultrasound study or computed tomography Test was not ordered for patient
scan
4 Intravenous pyelography Test was not ordered for patient
5 Cystoscopy Test was not ordered for patient
6 Presenting signs and symptoms Patient was examined and history was
taken
Investigations carried out on patient to confirm diagnosis were Urine routine examination,
Full blood count and presenting signs and symptoms of the patient. However, Full blood
26
count, Intravenous pyelography and Cystoscopy were not ordered for patient and as such
were not done for patient. Patient was diagnosed with pyelonephritis based on urine routine
examination, full blood count and most importantly presenting signs and symptoms presented
by patient.
Venereal Disease Research Laboratory (VDRL) to rule out syphilis and malaria parasite
estimation to rule out malaria were carried out but were not stated in the literature review.
Details of the test carried out on the patient have been presented in table 2.
27
Table 2: Diagnostic investigations carried out on Mrs. A.O
DATE SPECIMEN INVESTIGATION RESULT NORMAL VALUES INTERPRETATIONS REMARK
20/07/2018 Blood Venereal Disease Negative Negative Absence of treponema no treatment ordered
research laboratory palladium. This shows patient
(VDRL) does not suffer syphilis
20/07/2018 Blood Malaria parasites Negative There should be no Normal, no malaria parasite No treatment was given.
malaria parasite in the was seen in the blood.
blood.
20/07/2018 Blood White blood cells 12.3 x109/L 4.0-10.0 x109/L WBC count was slightly IV metronidazole 500mg
high indicating infection given to combat infection.
Red blood cell 4.6 x 10/l 3.9 -6.5 x 10/l No treatment was given
count Normal
Neutrophils count 46% 40-75% Normal No treatment was given
Haemoglobin levels 13.1 g/dl 11.-16.5g/dl Normal No treatment was given
Haematocrit 42% 40-54% Normal No treatment was given
28
Table 2: Diagnostic investigations carried out on Mrs. A.O continue
DATE SPECIMEN INVESTIGATION RESULT NORMAL INTERPRETATIONS REMARK

VALUES
20/07/ Urine Urine routine Sugar Negative Negative Normal No treatment ordered
Ketone Negative Negative Normal No treatment ordered
2018 examination
Bilirubin Negative Negative Normal No treatment ordered
Specific gravity 1.020 1.005-1.030 Normal No treatment ordered
PH 6.0 5.0-8.0 Normal No treatment ordered
Blood Negative Negative Normal No treatment ordered
Protein Positive Negative Shows the presence of Antibiotics ordered
inflamed kidney
Nitrite Negative Negative Normal No treatment ordered
leukocytes Positive (+) Negative Presence of WBC in urine Antibiotics ordered
Epithelial cells 15 less than 5 High epithelial cells
indicate contamination Antibiotics ordered
with skin flora
Pus 30/1 1/1 -Above normal
Colour Straw Straw -Indicates dilution of urine Antibiotics ordered
No treatment ordered
29
b. Causes of Patient’s condition
With reference to the causes and predisposing factors of pyelonephritis in the literature
review, it can be said that patient’s condition was caused by refusing to empty her bladder
even when she has the urge to urinate. This causes reflux of urine from the ureter to the
kidney. Patient was advised on the effects of such behaviour.
c. Clinical features/signs and symptoms
Comparison of clinical features exhibited by patient with those outlined in literature review.
Table 3 below shows the comparison of the clinical features.
Table 3: Clinical manifestations exhibited by patient compared with those in the
literature review.
Clinical Features in Literature Clinical Features Exhibited By Patient
Review
Fever Patient had fever (37.8 ◦C) and chills
Pyuria Patient urine contained pus upon laboratory
investigation
Malaise Patient experience general body weakness
Pain in the flank area This was experienced by patient
Headache Patient experienced headache
Increased frequency of micturition This was experienced by patient
Costovertebral angle tenderness This was not experienced by the patient
Dysuria and nocturia Patient experienced both nocturia and dysuria
Cloudy urine Patient’s urine was straw in appearance
30
Leukocytosis White blood cells had increased upon
laboratory investigation
Nausea and vomiting Patient did not vomit or have nausea
From the above comparism, Mrs A.O exhibited most of the signs and symptoms discussed in
the literature review.
d. Treatment given to Patient.
Treatment (medical/surgical) is referred to as a therapy intended to stabilize or reverse a
morbid process or state. Treatment may be pharmacologic, using drugs; surgical, involving
operative procedures; or supportive, building the patient’s strength. It may be specific for the
disorder, or symptomatic to relieve symptoms without affecting a cure.
The following were the treatment which was given to Mrs. A.O during her 5 day
hospitalization period
Tablet Diclofenac 50 three times daily for 5 days
Infusion Normal saline 2l within 24 hours
Tablet Ciprofloxacin 500mg twice daily for 5 days
Tablet Metronidazole 400mg three daily for 7 days
31
Table 4 below shows the treatment given to Mrs. A.O compared with those in the literature
review
Table 4: Comparison of treatment outlined in the literature review with those given to
Mrs. A.O
Treatment according to literature review Patient’s drug administered
Antibiotics i.e Gentamycin, Ciprofloxacin or IV ciprofloxacin 400mg bd for 2 days,
Cefuroxime Tablet ciprofloxacin 500mg bd for 5 days,
IV Metronidazole 500mg tid for 2 days,
Tablet Metronidazole 400mg tid for 5
days were prescribed for patient
Intravenous infusions IV Normal Saline 2L was prescribed
Analgesics Tablet diclofenac 50mg tid for 5 days
Comparing the medical treatment under the literature review to that of Mrs. A.O, patient
received all the treatment necessary for speedy recovery from pyelonephritis and to prevent
complications.
Table 5 below shows the pharmacology of drugs given Mrs. A.O
32
Table 5.0: Pharmacology of Drugs given to Mrs. A.O
Date Drug Dosage/Route of Classification Desire effect/Action Actual effect Side effect/ Remarks
administration of Drug
20/07/ 400mg three times Synthetic Prevention and treatment Therapeutic effect of Nausea, vomiting and
2018 Metronidazole daily for 5 days orally Antibiotic of bacterial infection. drug was observed as nephrotoxicity. Patient did not
there was remission of experience any of these. None was
500mg three times for signs and symptoms of observed
2 days, Intravenous infection
20/07/ Infusion 2 litre for 24 hours Isotonic To correct dehydration Patient fluid and Circulatory overload, pulmonary
2018 Normal saline Intravenously solution and maintain electrolyte electrolyte balance was oedema.
balance maintained None observed
20/07/ Ciprofloxacin 500mg bd x 5 days Antibiotic To combat infection Patient was treated from Flatulence, nausea, vomiting,
2018 Oral typhoid infection dyspnoea, constipation, headache,
400mg bd for 2 days abdominal pain. None was observed
20/07/ Capsule 50mg tid for 5 days Non-Steroidal Analgesic, Antipyretic. Reduced patient’s Dizziness, headache, constipation,
2018 Diclofenac Anti- Helps to reduce the pain sensitivity to pain as Black or blood tarry stools.
inflammatory of patient verbalized by the patient. . None was observed
drugs.
33
Complication
With reference to the literature review, my patient did not exhibit any complication such as
renal calculi, hypertension, kidney stones and renal failure throughout the period of
hospitalization because patient was admitted early to the hospital and immediate treatment
was given which resulted in his early recovery.
2.2 Patient / Family Strengths
According to Lewis (2010), strength is the quality of being strong. This involves activities the
patient can perform and those the family can also perform in helping the patient recover. The
under mentioned strengths were identified in my patient and family.
1. Patient’s pain subsides when analgesics are served
2. Patient’s body temperature reduces when antipyretics are administered
3. Patient is able to express her fears and anxiety about disease condition
4. Patient can take small amount of food served
5. Patient can sleep at least 3hours in the night
6. Patient is willing to learn about disease condition.
2.3 Patient/Family’s Health Problems
The patient/family’s problem means, the difficulties they faced because of the disease condition
.The following were the actual and potential health problems identified with the patient during
the period of hospitalization. They include;
1. Patient experienced pain when urinating (20/07/2018)
2. Patient had high body temperature (37.9oc) (20/07/2018)
34
3. Patient was anxious about disease condition (20/07/2018)
4. Patient had loss of appetite (21/07/2018)
5. Patient complain of sleeplessness (21/07/2018)
6. Patient had inadequate knowledge on disease condition (22/07/2018)
2.4 Nursing Diagnoses
A nursing diagnosis is a clear and definite statement of the patient’s health status that can be
influence by nursing interventions. It is derived from a validated, critically analysed and
interpreted dated collected during assessment. Conclusions are drawn regarding the patient’s
needs, problems, concerns or human responses. The nursing diagnosis, once identified,
provides a central focus for reminder of the stages that is based on the nursing process. The
plan of care is designed, implemented and evaluated, hence making it possible to give
comprehensive health care to the problems.
This is done by identifying, validating and responding to specific health problems. The
nursing diagnosis also provides an efficient method of communicating the patient’s health
problems (www.nursesnanda.com).
The following nursing diagnoses were made on Mrs. A.O
1. Acute pain related to inflammation and infection of the renal tubules or renal pelvis of
kidney (20/07/2018)
2. Thermoregulation imbalance (pyrexia) related to infectious process (20/07/2018)
3. Anxiety related to unknown outcome of disease condition (20/07/2018)
4. Risk for altered nutritional pattern (less than body requirement) related to loss of
appetite (anorexia) (21/07/2018)
5. Sleep pattern disturbance (insomnia) related to flank pain and nocturia (21/07/2018).
35
6. Knowledge deficit related to lack of inadequate information on causes, signs and
symptoms and prevention of disease condition (22/07/2018).
36
CHAPTER THREE
PLANNING OF PATIENT/FAMILY CARE
3.0 Introduction
According to Hinkle & Cheever (2014), planning is the development of goals and outcomes as
well as a plan of care designed to assist the patient in resolving the diagnosed problems and
achieving the identified goals and desired outcomes. A forward date is also set for evaluation
of whether or not the goals have been achieved. This is the third stage of the nursing process
which entails planning of nursing care of the patient in accordance with the problem
identified. This is where strategies are designed to treat, eliminate or prevent the patient’s
problem. Here, objectives are set with their necessary interventions.
3.1 Objectives For Patients And Family Care
The following objectives were set for patient and family care during the period of
hospitalization to help solve their health problems identified.
1. Patient will be relieved of anxiety within 24 hours.
2. Patient will be relieved of discomfort (pain in the flank) throughout period of
admission.
3. Patient will maintain a normal body temperature within 48 hours
4. Patient will regain her normal eating pattern within 48 hours
5. Patient will have normal sleeping pattern within 48 hours.
6. Patient will gain adequate knowledge on her condition within 2 hours
Table 6 below shows the nursing care plan for my patient.
37
Table 6: Nursing care plan for Mrs. A.O
Date/ Nursing Objectives/Outcome Nursing orders Nursing interventions Date/ Time Evaluation Sign
Time diagnosis criteria
Acute pain Patient will be 1.Reassure patient 1.Patient was reassured that she will 25/07/2018 Goal fully met
20/07/2018 be relieved of pain as patient
related to relieved of discomfort
2.Assist patient to assume a 2.Patient was assisted to assume a 9am verbalised
inflammation (pain in the flank)
1pm comfortable position recumbent position relieve of pain
and infection of within 24 hours as 3.Apply warm, moist 3.Warm, moist compresses were and relaxed
compresses to the flank area applied to the flank area every 4 hours facial expression
the renal tubules evidenced by:
every 4 hours
or renal pelvis (a)Relaxed facial
4.Encourage patient to take 4.Patient was encouraged to take
of kidney expression warm baths warm baths
5.Encourage bed rest 5.Adequate bed rest was encouraged
(b)Patient verbalizing
6.Provide diversional therapy 6.A radio was tuned on to her
absence of pain in the
favourite station as a form divertional
flank therapy
7.Encourage patient to drink at 7. Patient was encouraged to drink at
least 3L of litres each day least 3litres of water every day.
8.Serve prescribed analgesics 8.Prescribed analgesics(Diclofenac)
was served
38
Table 6: Nursing care plan for Mrs. A.O continue
Date/ Nursing Objectives/Outcome Nursing orders Nursing interventions Date/ Evaluation Sign
Time diagnosis criteria Time
20/07/2018 Thermoregulation Patient will attain 1.Reassure and explain all 1.Patient and family were reassured that 22/07/2018 Goal fully met as
normal body procedures to patient and temperature will return to normal range. evidenced by
imbalance 1pm
1pm temperature within 48 family patient’s
oc
(pyrexia) 37.9
hours as evidenced by 2.Check and record 2.Patient’s temperature was checked and temperature
related to i. Nurse observing temperature recorded every 30 minutes for 1 hour reducing from
that patient’s 3.Tepid sponge patient 3.Patient was tepid sponged with tepid 37.9 oC to 36.3oC
infectious process
temperature falls water whenever the temperature was when temperature
within the normal above 37.2℃ checked and
range (36.20C-37.20C) 4.Apply cold compresses 4.Cold compresses were applied to the patient’s body
after checking the forehead and armpit feeling warm
vital signs 5.Serve cold drinks 5.Patient was served with cold drinks when touched.
ii. Patient’s body not such as coca cola drink.
feeling warm when 6.Assist patient to put on 6.Patient was assisted to wear light cotton
touched light clothes clothing
7.Open nearby windows 7.nearby windows were opened to allow
adequate ventilation
8.Serve prescribed 8.Prescribed antipyretic(Diclofenac) was
antipyretic served
39
20/07/2018 Anxiety Patient will be 1. Reassure patient about speedy 1.Patient was reassured that, with their 21/07/2018 Goals fully met as
recovery. cooperation and compliance to
1:20pm related to relieved of anxiety treatment regimen, the condition can 1:20pm patient and family
within twenty four be controlled verbalizing they

unknown
2. Educate patient on the need for 2. Patient was educated on the need for
outcome of hours (24 hours) as hospitalization. hospitalization are not anxious
3. Explain all procedures that will 3. Procedures that were performed on
disease evidenced by;
be performed on the patient to the patient were explained to her to
1.The nurse observing her gain her cooperation
condition 4. Encourage patient to ask 4. Patient was encouraged to ask
patient having a questions about condition. questions about condition.
5. Provide simple and straight 5. Simple and straight forward answers
cheerful facial forward answers to their were given to their questions promptly
expression. questions promptly and tactfully. and tactfully.
6.Introduce to her other patients 6.Other patient’s recovering from the
2. Patient verbalizing who have suffered from the same same condition was introduced to her
condition and are recovering
they are no more
7. Monitor physiological 7.Physiological response such as
anxious responses, such as tachypnea, palpitations, headache, restlessness etc
palpitations, dizziness, headache, was observed for the degree of fear and
tingling sensations, and anxiety patient was facing
behavioral cues, such as
restlessness
40
21/07/2018 Risk for Patient will be able 1.Reassure patient that she will 1. Patient was reassured that she will 23/07/2018 Goal fully met as
to regain her normal regain her normal eating pattern be able to regain her normal eating
8am altered 8am patient was able to
appetite and interest pattern and appetite.
nutritional consumed more
in food within 48 2. Assess patient’s preferences 2.Meals were planned with patient
pattern (less hours as evidenced with food and plan diet with considering her likes and dislikes than half plate of
by: patient.
than body meal served her
1. The patient 3. Maintain adequate oral 3. Patient mouth was cared for early in
requirement)
verbalizing that she hygiene to stimulate her appetite the morning and in the evening after
related to loss can eat well. super.
2. The nurse 4. Provide companionship at 4. Patient’s husband was present at
of appetite
observing that patient mealtime to encourage nutritional mealtime to encourage patient to eat.
(anorexia)
can tolerate at least intake
half of 5. Remove unpleasant articles 5. Unpleasant articles like bedpan and
meal served from patient’s sight. vomits bowl were removed
6. Serve food attractively and at 6. Meals were served attractively at
regular intervals to the patient regular intervals to patient.
41
21/08/2018 Sleep pattern Patient will regain 1. Reassure Patient that she will 1.Patient was reassured that she will 23/07/2018 Goal fully met
8:30am her normal regain her normal sleeping regain her normal sleeping pattern. 8:30am as evidenced by
disturbance
pattern.
sleeping pattern nurse
(insomnia) 2. Educate patient to urinate 2. Patient was educated to urinate
within 48 hours as observation
before going to bed. before going to bed.
related to
evidenced by : Patient sleep for
3. Educate patient to reduce 3. Patient was educated to reduce
flank pain and 1.Patient intake of fluids containing natural intake of fluids containing natural 6 hours at night
diuretics such as tea at night. diuretics such as tea at night. uninterrupted.

nocturia. verbalizing she had
4. Educate patient to eat early 4. Patient was educated to eat early
a sound sleep
before going to bed. before going to bed.
2.Nursing observing 5. Explain the physiology of 5.Physiology of frequent micturition
that patient sleeps for frequent micturition to patient. was explained to the Patient
6. Administer prescribed 6. Prescribed analgesics (tab
6 hours at night
analgesics and monitor its Diclofenac) was served and its
uninterrupted
therapeutic effect. therapeutic effects were observed.
42
22/07/2018 Knowledge Patient will gain 1. Reassure patient /family that 1. Patient /family were reassured that 22/07/2018 Goal fully met as
adequate knowledge with detailed information they detailed information on patient and family
11am deficit related will have understanding of pyelonephritis will be given for 1pm
on the disease gave correct
pyelonephritis better understanding.
to lack of
condition within 2 2. Schedule time with patient and 2. Time was scheduled with patient answers to
inadequate hours as evidenced relatives to educate them on and relatives to educate them on questions asked
pyelonephritis. pyelonephritis.
by; on pyelonephritis
information 3. Make patient comfortable by 3. Patient was made comfortable by
1. Patient / family lying in bed whiles relatives lying in bed whiles relatives and the and patient/
on causes, and the nurse sit by bedside. nurse sit by bedside.
being able to answer family verbalizing
4. Assess patient and family 4. Patient and family knowledge on
signs and some questions on understanding on
knowledge level on pyelonephritis was assessed.
pyelonephritis pyelonephritis the information
symptoms and
correctly and 5. Correct any misconception and 5. Accurate information on the given them
prevention of provide accurate information predisposing causes, signs and
2.Patient/family
on the predisposing causes, symptoms, prevention, drug
disease verbalizing signs and symptoms, management and lifestyle
understanding on the prevention, drug management modification were provided to
condition
information given and lifestyle modification correct misconceptions
6. Invite questions and answer 6. Questions were invited and tactfully
them.
them tactfully. answered.
7. Give patient pamphlets on 7. Pamphlets on pyelonephritis were
pyelonephritis to read given to patient
43
CHAPTER FOUR
IMPLEMENTATION OF PATIENT AND FAMILY CARE
4.0 Introduction
According to McIntosh (2013), implementation is the process of starting to use a plan or
system. This chapter gives a detailed description of how the actual nursing orders set up were
carried out to solve the health problems of Mrs. A.O and her family from the day of admission
till discharge. It also includes the preparation of the patient and family towards discharge,
home visit to the patient’s community and rehabilitation.
4.1 Summary of actual nursing care rendered to Mrs. A.O and family
The nursing care rendered to Mrs. A.O started from the day of admission which was
20/07/2018 and continued till the day the patient was discharged 25/07/2018. The nursing care
was aimed at comforting the patient, improving airway patency, ensuring rest and conserving
energy, maintaining adequate hydration, providing patient with adequate knowledge on the
condition, helping patient consume adequate dietary intake to promote recovery as soon as
possible with no complications. The nursing care rendered to the patient on daily basis is
summarized as follows:
First day of admission (Day of admission) 20/07/2018
On 20/07/2018 at 12pm, Mrs. A.O was admitted to the females ward of the f St Mary’s’
hospital, Drobo per ambulatory from outpatient department accompanied by an OPD nurse
and patient’s work colleague. Patient was conscious and well orientated to time place and
persons. Patient’s folder was collected from the OPD nurse and her name was mentioned to
ascertain and confirm the identity of the patient. Mrs. A.O was immediately made comfortable
in an already prepared simple bed in females ward with bed number F6.
44
Upon assessment patient complain of painful urination, pains at back (flank pains), lower
abdominal pains and frequent passing of urine. Patient also complain of chills and fever. It was
also observed that patient was very anxious. I introduced myself to the patient and her
accompanying colleague. Mrs. A.O. particulars were documented into the admission and
discharge book and daily ward state.
Vital signs was checked and recorded as follows
Temperature - 37.9oc
Pulse - 84bpm
Respiration - 21cbm
Blood Pressure - 110/60mmHg
SPO2 - 97%
Laboratory investigations requested on admission were
Blood sample was taken, sample bottle labelled and sent to the laboratory for the investigations
to be carried out.
Patient was placed on the following medications;
45
Tablet diclofenac 50mg three times daily for 5 days
Infusion Normal Saline 2Litres within 24hours
Since patient is registered with the national health insurance scheme, all drugs were procured
from the pharmacy without any payment. An intravenous cannula was inserted and intravenous
medications commenced.
Patient was then informed about daily ward routine such as medication, ward rounds and
visiting hours. Also patient was orientated to the ward and it’s environ. They were introduced
to other patients at the ward, shown the toilet, bathroom, the playground and also to the nurses’
station. Since there was no restroom in the ward, patient was encouraged to eat by her bedside.
Items to be used at the ward during their stay such as towel, bucket, spoon and bowl were also
mentioned to the colleague who accompanied her to the ward. As part of the discharge plan,
patient and relatives were told that the hospital is a temporal home and that the patient will be
discharge home if the condition improves.
At 1pm, during assessment of patient, she complained of flank pains. A nursing diagnosis of
acute pain related to inflammation and infection of the renal tubules or renal pelvis of kidney
was formulated and an objective was set to help relieve patient of the pains within 24 hours.
The following nursing orders were then carried out within the set period. Patient was reassured
that she will be relieved of pain with the care been rendered. Patient was assisted to assume a
recumbent position because she felt comfortable in such position. Warm and cold compressors
were interchangeably applied to the flank area every 4 hours. Patient was then encouraged to
take warm baths. Adequate bed rest was ensured by encouraging patient to rest in bed and also
restricting visitors from disturbing patient when she was sleeping. A radio and television set in
the ward was tuned on and her favourite program (Kuuchi ran) tuned in as a form divertional
46
therapy. Patient was encouraged to drink at least 3litres of water every day and finally
prescribed analgesics (Diclofenac 50mg) was served.
On admission, patient complain of fever. When temperature was checked, patient’s body
temperature was 37.9oc. A nursing diagnosis of thermoregulation imbalance (pyrexia) 37.9oc
related to infectious process was formulated. An objective was set to ensure patient will attain
normal body temperature within 48 hours. In order to achieve the set objectives, these orders
were carried out; firstly, patient and family were reassured that temperature will return to
normal range. Patient’s temperature was checked and recorded every 30 minutes for 1 hour and
recorded accordingly. Patient was tepid sponged with tepid water whenever the temperature
was above 37.2℃. Cold compresses were applied to the forehead and armpit. Patient was then
served with cold drinks i.e coca cola drinks. Moreover, patient was encouraged and assisted to
wear light cotton clothing. Nearby windows were opened and the fans in the ward switched on
to ensure adequate ventilation. Prescribed antipyretic (Diclofenac 50mg) was served and its
therapeutic effect monitored.
Patient’s husband, Mr. A.Y.B brought jollof rice and chicken from a restaurant for patient but
she could not eat much of it. Patient and family were observed to be anxious as she was asking
questions about the prognosis of the disease condition. Therefore at 1:20pm, on the day of
admission, patient was diagnosed as anxiety related to unknown outcome of disease condition.
An objective was set to ensure she was relieved of anxiety within twenty four hours. Firstly,
patient was reassured that, with their cooperation and compliance to treatment regimen, the
condition will be successfully treated. Also, patient was educated on the need for
hospitalization and all procedures that were performed on the patient were explained to her to
gain her cooperation. Patient and family was then encouraged to ask questions about condition.
To ensure patient and family comprehended everything said to them, simple and straight
forward answers were given to them. Other patient’s recovering from the same condition was
47
introduced to her. Physiological response such as palpitations, headache, restlessness etc was
observed for the degree of fear and anxiety patient was facing.
At 2pm, vital signs was checked and recorded. At 5:00pm, during the visiting hours, patient
was visited by her colleagues at work. They brought her assorted drinks and also prayed for
her. Patient had yam and kontomire stew for her supper and she could eat all. Patient was
encouraged to take warm bath in the night. At 10pm, vital signs was checked again and
charted. IV metronidazole (flagyl) 500mg was set up. Patient retired to bed immediately
afterward.
Second day of admission (21/07/2018)
According to the night nurses patient had interrupted sleep pattern. This was confirmed by
patient herself, who said she could not sleep very well. Patient finally woke up at 5:30am. Her
personal hygiene activities such as brushing of her teeth, bathing, toileting and grooming were
all done in the morning. During the morning visiting time, patient was visited by Y.A (patient’s
adopted daughter), who brought her breakfast from the house. Patient ate little amount of the
breakfast (which was weanimix, milk and bread) served. Morning vital signs were checked
and recorded as
Temperature 36.7 degrees celsius
Pulse 76 beats per minute
Respiration 18 cycles per minute
Blood pressure 110/60 mmHg
IV Metronidazole 500mg, IV Ciprofloxacin 400mg, Infusion Normal saline were set up and
Tablet diclofenac 50mg was also served. Drugs therapeutic and adverse effects were closely
monitored.
48
At 8am, upon interaction with the patient, patient complained of loss of appetite. Nursing
diagnosis of risk for altered nutritional pattern (less than body requirement) related to loss of
appetite (anorexia) was made. An objective was set to be achieved within 48 hours to ensure
patient regain her normal appetite and interest in food. Patient was reassured that she will be
able to regain her normal eating pattern and appetite with the measures been put in place.
Meals were planned with patient considering her likes and dislikes. Patient mouth was cared
for early in the morning and in the evening after super. Also, patient’s husband was present at
mealtime to encourage patient to eat and all unpleasant articles like bedpan and vomits bowl
were removed. Meals were served attractively at regular intervals to patient.
At 8:30am, patient also complained of interrupted sleep pattern due to the flank pains and also
increased frequency of eliminating her bladder within the night. Sleep pattern disturbance
(insomnia) related to flank pain and nocturia was the nursing diagnosis formulated for patient.
An objective was set to ensure patient regained her normal sleep pattern within 48 hours.
Patient was reassured that she will regain her normal sleeping pattern. Patient was educated to
urinate before going to bed. Patient was educated to reduce intake of fluids containing natural
diuretics such as tea at night. Patient was also educated to eat early before going to bed.
Physiology of frequent micturition at night was then explained to the patient. Prescribed
analgesics (tab Diclofenac) was served and its therapeutic effects were observed.
At 9am, ward rounds was conducted by Dr. Ayamga. Patient’s full blood count, malaria
parasite test and , Venereal Disease Research Laboratory (VDRL) test were ready but the urine
routine examination test was not ready. Upon revision of patient’s laboratory investigations,
where were ordered on the first day of admission, Venereal Disease Research Laboratory
(VDRL) for syphilis was negative, Blood for malaria parasite was negative and Blood for Full
blood count showed white blood cells was 12.3 x 109/l, red blood cell was 4.6 x 10/l,
Haemoglobin levels was 13.1 g/dl. This showed white blood cell count was slightly high.
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Patient was reviewed and no new treatment was added to patient drug regimen. Patient was
continue the previous antibiotics that she was being managed on. Patient was also to take at
least 3l of water daily.
At 12pm, patient was served with gari, beans and ripe plantain. She was able to eat a handful of
the food served and she had “hollandia” drink after wards. Patient was encouraged to interact
with the other patients at the ward.
At 1pm, patient was assessed to ensure if goal set on the day of admission to relieve patient of
anxiety had being met. Goal set was fully met as Mrs. A.O verbalised that she was no more
anxious and she looked cheerful also. Vital signs was then checked and recorded accordingly.
Patient was then encouraged to take a nap during the afternoon.
At 6pm, patient had rice and kontomire stew for supper. She was able to eat half of the food
served to her. Evening medications were then served and patient was encouraged to take her
evening bath. After that, vital signs were checked and recorded at 10pm. Patient was
encouraged to empty her bladder before going to bed. Patient then retired to bed at around
10:30pm.
Third day of admission (22/07/2018)
On this day, patient woke up about 5:30am, brushed her teeth and took her bath and emptied
her bowel. Her bed was laid and the locker cleaned. Patient and the night nurse affirmed that
patient had a good night sleep with no complaints. Her vital signs were checked and recorded
in the vital sign chart at 6:30am as;
Blood pressure 110/80mmHg
Temperature 36.70c
Pulse rate 87bpm

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Respiration 24cpm
After the vital signs, patient was served with breakfast which was corn porridge and bread. Due
medications such as IV metronidazole 500mg, IV Ciprofloxacin 400mg and tablet diclofenac
50mg were all served and charted on the medication chart. The therapeutic and adverse effects
of the drugs were closely observed.
Routine ward rounds was then conducted by Dr. Ayamga. This time patient’s urine routine
examination results were available. Review of the urine routine examination showed the
presence of leukocytes and pus in urine. Other results such as sugar, ketone, bilirubin, nitrite
and protein were all negative. Patient was encouraged to drink more water daily (at least 3l per
day) and since patient had completed her IV antibiotic drugs, oral Ciprofloxacin 500mg twice
daily for 5 days and tablet Metronidazole 400mg three times daily for 7 days. Drugs were
procured from the pharmacy and patient was reassured. Patient was then encouraged to rest. At
11am, upon interaction with patient, it was realised patient had little or no knowledge at all on
the causes, prognosis, signs and symptoms and treatment plan for pyelonephritis. Nursing
diagnosis of knowledge deficit related to lack of inadequate information on causes, signs and
symptoms and prevention of disease condition. An objective was set to ensure patient had
adequate knowledge on the disease condition within 2 hours. Nursing orders carried out
included, Patient and family were reassured that detailed information on pyelonephritis will be
given for better understanding. Time was scheduled with patient and relatives to educate them
on pyelonephritis. Patient was then made comfortable by lying in bed whiles relatives and the
nurse sat by bedside. Patient and family knowledge on pyelonephritis was assessed. Accurate
information on the predisposing causes, signs and symptoms, prevention, drug management
and lifestyle modification were provided to correct misconceptions. Questions were invited and
51
tactfully answered. Finally, pamphlets on pyelonephritis were given to patient to ensure she is
able to refer from it even when she is discharged.
At 1pm, patient was evaluated to know if objective set to ensure patient had adequate
knowledge about disease condition. Goal was fully met as patient and family gave correct
answers to questions asked on pyelonephritis.
Mrs. A.O had took rice and groundnut soup as her lunch, as Patient’s food was served
attractively, and was encouraged to chew food slowly and allowing time to swallow to enhance
digestion.
At 1pm, patient was evaluated to know if objective set to ensure patient had adequate
knowledge about disease condition. Goal was fully met as patient and family gave correct
answers to questions asked on pyelonephritis.
Also at 1pm, the goal set on the 20/07/2017 to ensure patient’s temperature returned to normal
was evaluated. Goal was fully met patient’s temperature reducing from 37.9 oC to 36.3oC when
temperature checked and patient’s body feeling warm when touched. Other nursing orders to
ensure patient gained her appetite, normal sleep pattern and also be relieved of pains were all
continued.
At 5:30pm, during the evening visiting hours, patient was visited by the head of the police
command at the Japekurom Police station, together with her other colleagues. Patient was
grateful for their visit and she thanked them for the visit.
Patient had fufu and groundnut soup for her supper. Vital signs was checked and recorded and
tablet ciprofloxacin 500mg and tablet metronidazole 400mg were administered. Patient was
then encouraged to take her evening bath, brush her teeth and eliminate her bladder before
retiring to bed. Patient slept around 9pm.
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Fourth day of admission. (23/07/2018)
On the fourth day of admission, Mrs. A.O woke up at 5:20 am, performed oral hygiene and
took her bath. Patient looked very cheerful and relaxed. Patient did not lodged any complain.
Patient took porridge and bread as her breakfast.
Patient’s condition was good since the problems which were identified were all being worked
on so as to relieve her of all of them and possibly prevent complications from setting in.
At 6:00 am patient’s vital signs were checked and recorded as follows;
Temperature 35.7 degrees celsius
Due medications i.e tablet diclofenac 50mg, tablet ciprofloxacin 500mg and tablet
metronidazole 400mg were all served and the therapeutic and adverse effect was monitored.
At 8am, the objective set on the 21/07/2018 to ensure patient regained her normal appetite was
evaluated. Goal was fully met as patient was able to consumed more than half plate of meal
served her and patient verbalised improved appetite. Also at the same time patient verbalised
that she could sleep uninterrupted during the night. This meant that objective set on the
21/07/2018 to ensure patient regained her normal sleeping pattern was met fully met. Routine
ward rounds was conducted at 9am by Dr. Ayamga. No new complains were lodged by patient.
Due to this no knew treatment was added to patient’s treatment plan.
After the ward rounds, patient was informed of my intention to visit her house the next day.
She readily accepted and gave me directions to her house. Patient claimed she was very
53
popular in her community because of her profession as a police woman. Vital signs was
monitored at 2pm and 10pm with no abnormalities and they were duly recorded. Patient took
fufu and groundnut soup as her supper. Evening medications were served and patient retired to
bed after taking her bath.
Fifth day of admission (24/07/2018)
On the fifth day of admission, patient woke up at 5:20 am, brushed her teeth and took her bath
all without assistance. According to the night nurses patient had a sound sleep. Patient took
tom brown and bread as her breakfast.
Mrs. A.O vital signs were checked and recorded as follows;
Temperature 36.1 degrees Celsius
Due medications were administered and charted appropriately. Patient looked very cheerful.
Patient was reviewed by Dr. Ayamga during ward rounds and patient lodged no new complain.
Patient was to be observed for the next 24 hours and she was likely to be discharged the
following day. Patient was informed of the doctor’s decision and she was very happy.
At 11am, patient was encouraged to rest in bed. Patient was then informed and she repeated the
directions to her house again. At 11:30am, while patient was on admission, the first home visit
to patient’s house was made and I returned to the ward at 1pm.
Patient’s due medications were administered and documented at 3:00 pm as well as vital signs
were checked and recorded as follows:
54
Temperature 36.70c
Pulse rate 87bpm
Respiration 24cpm
At around 6:00pm, patient was served with rice and tomato stew with fish as supper. Patient
was served with his due medication and documented at 10:00pm.
At 10:00pm her vital signs were checked and recorded as follows:
Temperature 35.70c
Pulse rate 82bpm
Respiration 24cpm
Patient retired to bed after watching the ward television with other patient at the ward.
Sixth day of admission (Day of discharge) 25/07/2018
On this day, patient woke up at 5:30am and was looking very well and very relaxed in bed. She
had a warm bath and also performed oral hygiene after which patient was served with a cup of
porridge and bread of which she was able to eat all the food served. Patient did not lodged any
complain upon enquiry. Due medications were served and charted appropriately on the
medication sheet.
Vital signs were checked and recorded as:
Temperature 36.3℃
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Due medications i.e tablet diclofenac 50mg, tablet ciprofloxacin 500mg and tablet
metronidazole 400mg were all served and the therapeutic and adverse effect was monitored.
At 9am, goal set on the 20/07/2018 to ensure patient was free from pains was evaluated. Goal
was fully met as patient verbalised relieve of pain and she had relaxed facial expression.
During ward rounds, Mrs. A.O was duly discharged by Dr. Ayamga. Patient was placed on
Tablet Ciprofloxacin 500mg for 5 days, tablet diclofenac for 5 days and tablet
metronidazole400mg for 7 days. Patient was informed of the doctor’s decision and drugs were
procured from the pharmacy. Patient his husband, Mr A.Y.B and informed him that she had
being discharged. Mr. A.Y.B came to the ward after 5 minutes.
Mrs. A.O. was scheduled to come back for review on 1/08/ 2018 and was encouraged on the
need for the review. Patient was encouraged to report to the hospital earlier than the scheduled
review date if she feels the condition was relapsing. Arrangements were made with patient and
her family about my second home visit on the 28/07/ 2018.The doctor prepared and signed the
discharge summary. Patient was given a 4 day off duty slip to send to her superiors at work to
ensure she stayed at home and fully recover from her ailment. Patient’s date of discharge,
diagnosis and state of his condition were entered into the Admission and Discharge book and
daily census sheet. I helped them to pack their belongings. Mrs. A.O’s folder was sent to the
accounts and billing office for clearance. Since patient is holder of the national health
insurance scheme, patient only had to pay 7ghc as per the hospital’s policy. Patient and family
thanked the staff and the student nurses on duty for her quick recovery. They were then
accompanied to the road side. They took a taxi and I bade them goodbye. The bed linen was
56
removed and discarded into a receptacle to be taken to the laundry and the bed was disinfected
as well as the side locker with a 0.5% bleach solution and left dry.
4.2 Preparation of the Patient/Family for Discharge and Rehabilitation.
Preparation of a patient and family for discharge and rehabilitation is necessary and important
in comprehensive nursing care to ensure an adequate self-care at home. This was started from
the day of admission and till the day patient was discharged. Mrs. A.O was reassured that her
condition would stabilize with treatment being given.
In my effort towards preparing patient for discharge, patients house was visited on the
fifth day of admission. This was done in order to acquaint myself with his home environment,
check for any potential health problems in order to help meet their health needs by giving them
health education and making suggestions on how to improve their health status.
Mrs. A.O and her family were educated on her condition (pyelonephritis), with regards to the
predisposing factors, sign and symptoms, drug used for management, lifestyle modifications
and complications.
Diet
She was advised to take in liberal amounts of fluids to flush out her system. She was also
advised to eat adequately balanced diet, not to eat very late in the night and to avoid sleeping
right after eating. They were educated to eat a lot of fruits and vegetables. Patient was also
encouraged to avoid caffeinated drinks.
Personal hygiene
Ensure patients hygienic needs are equally met as other medical needs of the patient are
established. The following measures can be followed;

57
Patient was instructed to keep the perianal area as clean as possible by gently cleansing with
warm water and then drying with absorbent cotton wipes. Patient was advised to wipe her anus
from front to back to prevent any infection. Patient was advised to void whenever she had the
urge without delay. Moderate exercise was encouraged to ensure patient stay active. She was
encouraged to urinate before going to bed.
Drugs and Review
The patient was advised to continue the medication or treatment regimen at home as prescribed
to prevent relapse of the disease condition.
The side effects and also the therapeutic effects of the drugs were explained to her. She was
asked to come for review on 01/08/2018.
Finally, in order to ensure continuity of care and to establish rehabilitation, I informed her of
my subsequent home visits, and encouraged her to visit the hospital any time aside the review
date, when she is not feeling well.
4.3 Follow-Up /Home Visit/ Continuity Of Care
This involves caring for the patient and family in the comfort of their homes, identifying
factors which may have contributed to patient’s condition and the resources available for
continuity of care.
It also helps to prepare the home before the patient is discharged to prevent future recurrence
of the condition.
First Home Visit (24/07/2018)
On the fifth day of patient’s admission, patient’s home was visited while she still on admission.
The objective for the visit was to be familiar with patient’s home environment, whilst gathering
enough information that will be relevant in the care and education of the client. The visit was
58
also to validate any data collected from Mrs A.O and her relatives and to identify any factor
that has contributed to her illness.
Mrs. A.O vividly gave me the direction to her house and also the description of her house. At
11:30am, I took a “Kumkum”(commercial tricycle) from the hospital to patient’s house at
Japekurom. The journey took 15 minutes from the hospital to the patient’s community. I got
off from the ‘’kumkum” and then asked for the direction to the Methodist Church from
someone who was standing nearby. I walked a few distance from the road side to the where the
church was located. Patient’s house was located about two house behind the Methodist Church.
When I got to the house, I knocked and I was welcomed by Mr. A.Y.B. He said the wife had
told him I will be visiting their house and as such he sought permission from work to be in the
house to receive me. I was warmly welcomed and seat was offered. Mr. A.Y.B offered me a
drink and he asked my mission for the visit. I explained my reason for the visit. During my
interaction with him I used that opportunity to observe the environment. The house is built of
blocked and roofed with iron sheets. There is fence around the around and the house is painted
only in the inside and not the outside.
The house has three bed rooms, a hall, toilet, bathroom and a kitchen. Mrs A.O, her husband
Mr. A.Y.B and their adopted daughter T.A are the only people who live in the house. Even
though the house has access to pipe born water, Mrs A.O has a large barrel in which they
temporarily store water. The barrel had a well fitted lid. They also have a plastic rubber with
well fitted lid in which they keep their refuse. The method of refuse disposal is dumping which
is used by the entire community and it’s about 500metres away from their house. I educated
him on water, food and environmental hygiene to help them improve their health. I asked
permission to enter the room and it was given. It was released that the two rooms didn’t have
mosquito net but was well ventilated because it had enough windows. Mr A.Y.B was educated
on the importance of the usage of mosquito nets. I sought permission to leave and he saw me
59
off. I walked to the road side and boarded a taxi back to the hospital to continue care of patient.
I immediately went to the ward to let my patient know I was back. Her attention was drawn to
some of the health problems identified in their house and the necessary education was given.
Second Home Visit (28/07/2018)
On the 28th July, 2018, the second home visit was made to Mrs. A.Y.B’ home. The objective of
the visit was to assess the health status of the patient after discharge, to remind patient and
family of review date/day, to find out whether what I said during the first home visit had been
put into action and to stress on the need for completion of treatment regimen.
I got to the house at 3:30 pm and met Mrs. A.O with T.A alone in the house. I was welcomed
by the family, they offered me a seat and I thanked them. They asked of my mission, and I said
I was there to check on Mrs. A.O. and assess her condition at home and to make sure she was
taken her medications as prescribed. When I inquired about Mr. A.Y.B, Mrs. A.O said her
husband had gone to work and will be home soon.. I assessed her to find out if she was still
experiencing flank pains, dysuria or nocturia. Patient said she was not feeling any pain or
having nocturia. I also assess her general condition. Mrs. A.O’s condition was fair. On a quick
look around, I noticed that they now slept in mosquito nets. Mrs. A.O also said she now voided
any time she felt the urge to urinate. Her medications were inspected and it was found that she
had being taking her drugs as prescribed. Patient was then congratulated and Mrs. A.O was
encouraged to take the remaining medications as prescribed. She was advised to take adequate
amount of water daily. I reminded them again on the need to maintain good personal and
environmental hygiene and also the review date as scheduled on 1/08/2018. Mrs A.O promised
to come for review as scheduled. Mrs A.O and family were informed that I will be handing
them over to the community health nurse during my third home visit for continuity of care.
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After chatting for about thirty minutes, I sought permission to leave. They escorted me to the
road where I took a taxi and came back to Drobo.
Review day (1/08/2018)
The review day was on 1/08/2018 and the patient came to the hospital alone. 8:00am. Patient
said she had to report back to work that was why she came to the hospital very early. Patient
looked well and cheerful. The patient was assisted to collect her folder .
Vital signs were checked and recorded as
Temperature-36.7 degrees celsius
Pulse-76bpm
Respiration-20cpm
B.P.-130/70mmHg
Patient was then accompanied to see medical officer for review. On examination and
interaction with the doctor, the patient made no complains. She was encouraged to finish her
medications as prescribed and take in at least 3Litres of water daily. Patient was also
encouraged to report to hospital anytime she felt pain when urinating or felt flank pains. She
was educated to void anytime she had the urge also. Education was also given on the need to
eat fruits and vegetables to aid healing. No new drugs were prescribed for patient.
After the consultation, patient was accompanied to the road side where she boarded taxi to her
work. I told her of my last home visit and remaindered her that I will be terminating care and she
will be handed over to a community nurse for continuity of care. I bade her goodbye.
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Third Home Visit (4/08/2018)
The last home visit was made on 4/08/2018. The main aim of the visit was to find out how
Mrs. A.O. and her family members were doing and to terminate the care by handing them over
officially the community health nurse who is to continue with the care.
I went in the company of Mrs. Mavis Osei, a community who works at the public health unit
of the Ghana Health Service in Drobo. Patient and family were happy on seeing me in the
company of the community health nurse. They were all fine with no complains. The
environment was in good order. They were educated on the need for periodic medical check-
ups, stress reduction, drug regimen and dietary regimen. Patient was also reminded on the signs
and symptoms and prevention of pyelonephritis. Patient was also encouraged to continue
taking adequate amount of fluid daily and to empty her bladder as soon as she has the urge.
Patient was educated to seek medical help early anytime she was sick and to avoid over the
counter drugs.
I therefore introduced the community health nurse Mrs Mavis Osei to them, who promised to
do the follow up visit and give any health information which would be needed by patient and
family.
Though it was a difficult task, terminating care with the family, I did my best to make them
aware that I am just ending the interaction officially but I am always at their service whenever
the need arise. They expressed their profuse gratitude to me for the holistic care rendered to
Mrs. A.O throughout the period from admission to that day. They also told me I was always
welcomed to pass by anytime I was in the vicinity. I took the opportunity to thank them for
their cooperation. Care was officially terminated. We sought permission to leave and they
accompanied us to the road side where we took a car to Drobo.
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CHAPTER FIVE
EVALUATION OF CARE RENDERED TO PATIENT AND FAMILY
5.0 Introduction
Evaluation in simple terms is the outcome of nursing actions against the anticipated goals and
it is the final step in the nursing process, (Smeltzer and Bare, 2010). It entails the continuous
assessment of the care and finding out whether the set objectives for meeting family/patient
health needs have been achieved. The chapter gives information about the statement of
evaluation, amendment of nursing goals and the termination of the care rendered to my patient
and family.
5.1 Statement of Evaluation
Throughout the period of admission of Mrs A.O., six health problems were identified and
objectives were set to solve them. Below is the summary of the interventions carried out and to
what extent the goals were met.
1. Patient of relieved of flank pain
On the day of admission (20.07/2018) at 1 pm, Mrs. A.O complain of flank pain. A nursing
diagnosis of acute pain related to inflammation and infection of the renal tubules or renal pelvis
of kidney was formulated and an objective was set to help relieve patient of the pains within 24
hours. The following nursing orders were then carried out within the set period. Patient was
reassured that she will be relieved of pain with the care been rendered. Patient was assisted to
assume a recumbent position because she felt comfortable in such position. Warm and cold
compressors were interchangeably applied to the flank area every 4 hours. Patient was then
encouraged to take warm baths. Adequate bed rest was ensured by encouraging patient to rest
in bed and also restricting visitors from disturbing patient when she was sleeping. A radio and
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television set in the ward was tuned on and her favourite program (Kuuchi ran) tuned in as a
form divertional therapy. Patient was encouraged to drink at least 3litres of water every day
and finally prescribed analgesics (Diclofenac 50mg) was served.
On the day of discharge (25/07/2018), At 9am, goal set on the 20/07/2018 to ensure patient
was free from pains was evaluated. Goal was fully met as patient verbalised relieve of pain and
she had relaxed facial expression.
2. Patient attained normal body temperature
On admission(20/07/2018) at 1pm, patient complain of fever. When temperature was checked,
patient’s body temperature was 37.9oc. A nursing diagnosis of thermoregulation imbalance
(pyrexia) 37.9oc related to infectious process was formulated. An objective was set to ensure
patient will attain normal body temperature within 48 hours. In order to achieve the set
objectives, these orders were carried out; firstly, patient and family were reassured that
temperature will return to normal range. Patient’s temperature was checked and recorded every
30 minutes for 1 hour and recorded accordingly. Patient was tepid sponged with tepid water
whenever the temperature was above 37.2℃. Cold compresses were applied to the forehead
and armpit. Patient was then served with cold drinks i.e coca cola drinks. Moreover, patient
was encouraged and assisted to wear light cotton clothing. Nearby windows were opened and
the fans in the ward switched on to ensure adequate ventilation. Prescribed antipyretic
(Diclofenac 50mg) was served and its therapeutic effect monitored.
On the 22/07/2018, at 1pm, the goal set on the 20/07/2017 to ensure patient’s temperature
returned to normal was evaluated. Goal was fully met patient’s temperature reducing from 37.9
C to 36.3oC when temperature checked and patient’s body feeling warm when touched
o
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3. Patient was relieved of anxiety
At 1:20pm on the day of admission (20/07/2018), Patient and family were observed to be
anxious as she was asking questions about the prognosis of the disease condition. A nursing
diagnosis of anxiety related to unknown outcome of disease condition. An objective was set to
ensure she was relieved of anxiety within twenty four hours. The nursing interventions carried
out on patient included; Firstly, patient was reassured that, with their cooperation and
compliance to treatment regimen, the condition will be successfully treated. Also, patient was
educated on the need for hospitalization and all procedures that were performed on the patient
were explained to her to gain her cooperation. Patient and family was then encouraged to ask
questions about condition. To ensure patient and family comprehended everything said to
them, simple and straight forward answers were given to them. Other patient’s recovering from
the same condition was introduced to her. Physiological response such as palpitations,
headache, restlessness etc was observed for the degree of fear and anxiety patient was facing.
On the 21/07/2018 at 1:20pm, patient was assessed to ensure if goal set on the day of
admission to relieve patient of anxiety had being met. Goal set was fully met as Mrs. A.O
verbalised that she was no more anxious and she looked cheerful.
4. Mrs. A.O regained her normal appetite
On the 21/07/2018 at 8am, upon interaction with the patient, patient complained of loss of
appetite. Nursing diagnosis of risk for altered nutritional pattern (less than body requirement)
related to loss of appetite (anorexia) was made. An objective was set to be achieved within 48
hours to ensure patient regain her normal appetite and interest in food. Patient was reassured
that she will be able to regain her normal eating pattern and appetite with the measures been
put in place. Meals were planned with patient considering her likes and dislikes. Patient mouth
was cared for early in the morning and in the evening after super. Also, patient’s husband was
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present at mealtime to encourage patient to eat and all unpleasant articles like bedpan and
vomits bowl were removed. Meals were served attractively at regular intervals to patient.
At 8am on the 23/07/2018, the objective set on the 21/07/2018 to ensure patient regained her
normal appetite was evaluated. Goal was fully met as patient was able to consumed more than
half plate of meal served her and patient verbalised improved appetite.
5. Patient regained her normal sleep pattern
On the 21/07/2018 at 8:30am, patient also complained of interrupted sleep pattern due to the
flank pains and also increased frequency of eliminating her bladder within the night. Sleep
pattern disturbance (insomnia) related to flank pain and nocturia was the nursing diagnosis
formulated for patient. An objective was set to ensure patient regained her normal sleep pattern
within 48 hours. Patient was reassured that she will regain her normal sleeping pattern. Patient
was educated to urinate before going to bed. Patient was educated to reduce intake of fluids
containing natural diuretics such as tea at night. Patient was also educated to eat early before
going to bed. Physiology of frequent micturition at night was then explained to the patient.
Prescribed analgesics (tab Diclofenac) was served and its therapeutic effects were observed.
On the 23/07/2018 at 8am, upon assessment patient verbalised that she could sleep
uninterrupted during the night. This meant that objective set on the 21/07/2018 to ensure
patient regained her normal sleeping pattern was met fully met.
6. Patient gained adequate knowledge on the disease condition (pyelonephritis) within
2 hours.
On the 22/07/2018 at 11am, upon interaction with patient, it was realised patient had little or
no knowledge at all on the causes, prognosis, signs and symptoms and treatment plan for
pyelonephritis. Nursing diagnosis of knowledge deficit related to lack of inadequate
information on causes, signs and symptoms and prevention of disease condition. An objective
66
was set to ensure patient had adequate knowledge on the disease condition within 2 hours.
Nursing orders carried out included, Patient and family were reassured that detailed
information on pyelonephritis will be given for better understanding. Time was scheduled with
patient and relatives to educate them on pyelonephritis. Patient was then made comfortable by
lying in bed whiles relatives and the nurse sat by bedside. Patient and family knowledge on
pyelonephritis was assessed. Accurate information on the predisposing causes, signs and
symptoms, prevention, drug management and lifestyle modification were provided to correct
misconceptions. Questions were invited and tactfully answered. Finally, pamphlets on
pyelonephritis were given to patient to ensure she is able to refer from it even when she is
discharged.
On the same day, at 1pm, patient was evaluated to know if objective set to ensure patient had
adequate knowledge about disease condition. Goal was fully met as patient and family gave
correct answers to questions asked on pyelonephritis.
5.2. Amendment of Nursing Care Plan for Partially Met or Unmet Outcome Criteria
Goals were set to help resolve the six (6) health problems that were identified during patient’s
period of hospitalization. Nursing interventions were implemented for the set of goals and at
the end, the set goals were fully met due to good nursing and medical interventions hence Mrs.
A.O recovered fully without any complication. All the objectives set to help solve Mrs. A.O’s
health problems were met within the stipulated times therefore there was no amendment to be
done to the care plan originally drawn.
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5.3 Termination of Care
Termination is the end stage of the care and interaction between patient and the health care
professional (weller,2010). The process of termination of care started on the day of admission
when patient and relative was told that hospitalization was temporal and that patient will be
discharged at as soon as she was well. This was done to enable my patient and family accept
that the care will not be there forever since the goal was to make Mrs. A.O regain her health.
On the day of review, the doctor revealed that she was fully recovered and very fit. Patient
was informed that care will be terminated on the next home visit. On 04/08/2018, patient and
family were visited for the third and last time in the company of Mrs Mavis Osei, a
community health nurse who is with the public health unit of the Ghana health service at
Drobo. . Mrs. A.O had no complains and had recovered fully during this visit. The need to
adhere to the education given to them during the period of hospitalization was stressed on and
Mrs A.O was also encouraged to report to the hospital anytime they had a health related
problem. The importance of personal and environmental hygiene was again stressed. Patient
was adviced to drink adequate amount of water and fluid daily and the need to take nutritious
diet, periodic medical check-up, compliance to the drug regimen and also to renew the
National Health Insurance Scheme (NHIS) when it expired were encouraged.
They were introduced to Mrs Mavis Osei, who in turn promised to continue the care rendered
to Mrs. A.O and to visit them regularly to assess their health care needs and intervene
appropriately. Finally, they expressed their profuse gratitude for the holistic care rendered to
Mrs. A.O throughout the period, from admission to that day. They also told me I was always
welcomed to pass by anytime I was in the vicinity. I took the opportunity to thank them for
their cooperation. Care was officially terminated. We sought permission to leave and they
accompanied us to the road side where we took a car to Drobo
68
CHAPTER SIX
SUMMARY AND CONCLUSION
6.0 Introduction
According to Weller(2010), summary is a short description that gives the main facts or ideas
about something.
This is the last step of the patient/family care study which entails the student’s personal
appreciation of the therapeutic relationship with the patient as well as the use of the nursing
process.
6.1 Summary
Mrs A.O is 45 year old police professional who was admitted to the females ward on the
20/07/2018 accompanied by a colleague. Patient was diagnosed as pyelonephritis. Patient was
made comfortable in bed and nursing assessment was done to identify patient’s problem. Vital
signs were then checked and charted. The problems identified throughout period of patient’s
admission included pains on the flanks, high body temperature (37.9oc), anxiety, loss of
appetite, and sleep pattern disturbance due to nocturia and finally knowledge deficit on the
disease condition. On admission till discharge, routine nursing care such as checking and
charting of vital signs, administration of medication, laying of patient’s bed, education of
patient on disease condition, reassurance etc. were rendered on daily basis to ensure patient’s
was cared for holistically. Patient was managed on the following medications
IV Metronidazole 500mg tid for 2 days
IV Ciprofloxacin 400mg bd for 2 days
Tablet diclofenac 50mg tid for 5 days
69
IVF normal saline 2l for 24hours.
Tablet Ciprofloxacin 500mg bd for 5days
Tablet metronidazole 400mg tid for 7 days.
The following laboratory investigations were ordered, done and reviewed by the attending
medical officer
During patient’s stay at the hospital, a care plan was drawn with clear objectives, stated time
frame and appropriate nursing interventions instituted to tackle each of the problems identified.
All objectives set were fully met as patient was relieved of pains, had normal body
temperature, patient was relieved of anxiety, regained her appetite, had interrupted sleep
pattern and patient had adequate knowledge on the causes, signs, symptoms, treatment and
prevention of pyelonephritis.
Patient was prepared towards discharge from the first day of admission. Mrs A.O. recovered
within six days of admission without any complication and was scheduled for review on the
01/08/2018. In all patient was visited on three different occasions. The first home visit was
paid while patient was till on admission to assess patient’s home environment and to validate
data given to me. The second home visit was to ensure patient was adhering to treatment
regimen and to remind her of the review date. The third home visit was to terminate care and to
hand over patient to a community health nurse to ensure continuity of care. During the home
70
visits, education on patient’s condition and its management, personal and environmental
hygiene was done.
Care was terminated on the 4/08/2018.
6.2 Conclusion
Both medical and nursing care rendered to Mrs. A.O. and her family was possible through the
positive attitude, understanding and co-operation from the client and family. I enjoyed nursing
Mrs. A.O , and I am glad for putting into practice most of my acquired knowledge and skills in
helping Mrs. A.O regain her health eventually. The care rendered to Mrs. A.O has made me
gain more knowledge on the condition (Pyelonephritis) with regards to the cause, clinical
features, drug management, nursing management and prevention. It has equipped me with skill
on how to render total individual care. It has also helped me improve on my interpersonal
relationship with other members of the health team, the patient and family. I would therefore
use this opportunity to recommend that, every student in his/her final year should take this
studies seriously as it would not only broaden their knowledge but will also improve their
practical experience and skills in the profession. Also, it is my recommendation that all
students should be given the opportunity to embark on the patient/family care study in order to
render individualized comprehensive care to patients/families.
71
APPENDIX
Table 7: Vital Signs check for Mrs A.O from Admission to discharge
Date Time Temperature Pulse Respiration Blood

(oC) (bpm) (cpm) pressure
20/07/2018 12pm 37.9 84 21 110/60

10pm 37.2 80 22 110/75
21/07/2018 6:00 am 36.7 76 18 110/60

2:00 pm 36.1 86 22 120/80
10:00 pm 36.3 77 19 120/75
22/07/2018 6:00 am 36.5 80 20 110/80

120/70
1:00 pm 36.3 86 20
10:00 pm 36.3 74 18 110/70
23/07/2018 6:00 am 35.7 64 17 120/70

2:00 pm 35.8 73 16 115/80
10:00 pm 36.6 67 18 115/70
24/07/2018 6:00 am 36.1 79 18 120/70

2:00pm 36.7 87 24 110/80
10:00pm 35.8 82 24 110/60
25/07/2018 6:00am 36.3 72 16 110/70
1/08/2018 8:00am 36.7 76 20 130/70
72
References
Hinkle, J.L., & Cheever, K.H. (2010). Brunner and Saddarth's Textbook of Medical –
Surgical Nursing.( 12 th edition ). London: Wolter's Kluwer Health/ Lippincott
Joint Formulary Committee(2015) , British National Formula (75th edition), London;
BMJ Group and pharmaceuticals press, London
Marilyn E., Mary F.M., & Alice C.M., (2012), Nursing care plans guidelines for
individualizing Patient care across the life span, 8th edition, F.A Davis
Company. Philadelphia
Ministry of health /Ghana health service.(2010).standard treatment guidelines 10th edition,
Accra, Ghana.
Waugh, A. and Grant, A. (2010).Ross and Wilson Anatomy and Physiology in Health and
illness. 11th Edition Elsevier limited
Weller, F.B. (2009).Bailliere’s Nurses’ Dictionary for Nurses and Health Workers.
(25thed.) New York: Bailliere Tindal Elsevier.
Others
Patient’s folder number: STM/1209-09 St. Mary’s Hospital, Drobo
73

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CHAPTER ONE

ASSESSMENT OF PATIENT AND FAMILY

According to Weller (2010), assessment is the gathering of information about a patient’s

psychological, physiological, sociological, and spiritual status by a nurse. Nursing assessment

is the first step in the nursing process.

examination, laboratory investigation and x-ray report.

the possible ways of nursing the patient back to an independent life.

1.1 Patient’s Particulars

are written down and kept as record.

of education is tertiary education, when she enrolled in Polytechnic education in Sunyani.

Her next of kin is her junior sister, Miss Y.O.

1.2 Patient’s Family Medical History

family’s medical treatment is orthodox.

1.3 Patient’s/Family Socio-economic History

the elderly. As a security personnel, she believes in discipline.

1.4 Patient’s Developmental History

According to Weller (2010), development refers to the biological, physiological and

individual progress from dependency till increasing autonomy.

mentally and emotionally.

Patient does not have wrinkled skin or grey hair.

1. Trust versus mistrust (birth to 1year)

2. Autonomy versus shame and doubt (2 to 3years)

3. Initiative versus guilt (3 to 5years)

4. Industry versus inferiority (6 to 11years)

5. Identity versus role confusion (12 to 18years)

6. Intimacy versus isolation (19 to 40years)

7. Generativity versus stagnation (40 to 65years)

8. Integrity versus despair (65 to death)

1.5 Patient’s lifestyles / hobbies

1.6 Patient’s Past Medical/Surgical/Obstetric History

never experienced any allergies.

Pulse -95 bpm.

Blood pressure -110/80mmHg.

for nursing and medical management of pyelonephritis.

1.8 Admission of Patient

discharge book and daily ward state.

Vital signs was checked and recorded as follows

Blood Pressure - 110/60mmHg

Laboratory investigations requested on admission were

Blood for Full blood count

Blood for malaria parasite

Urine for Routine examination

Venereal Disease Research Laboratory (VDRL) for syphilis.

investigations to be carried out.

Patient was placed on the following medications;

Intravenous Ciprofloxacin 400mg twice daily for 2 days

Intravenous Metronidazole 500mg three daily for 2 days

Infusion Normal Saline 2Litres within 24hours

intravenous medications commenced.

1.9 Patient’s Concept Of Illness

discharge home soon.

Review Of The Anatomy Of The Kidneys

Diagram of the kidney (Macroscopic)

Hinkle & Cheever (2014)

because of the considerable space occupied by the liver.

is covered by a fibrous capsule which provides a firm smooth covering.

Longitudinal Section Of The Kidneys

divided longitudinally are:

Blood Vessels Of The Kidney

renal vein, and finally to the inferior vena cava.

Functions Of The Kidneys

(i) Excretion of protein metabolic wastes

(ii) Excretion of toxins and certain drugs