De Sagun, Leila Camille A.

BSN3Y1-1B
312-LEC-CU5

PYELONEPHRITIS
A patient consulted in the emergency department with complaints of high fever, chills, dysuria, and back pain.
Laboratory results are as follows:
WBC –13,000 cells/mcL
Neutrophils –10,000 per mm3
Lymphocytes –3,500 per mm3
Serum Sodium –136 mEq/L
Serum Potassium –3.7 mEq/L
Urinalysis:
Color: Hazy yellow
Bacteria: Too many to count
Pus cells: >100 cells/hpf
RBC: >100 cells/hpf
Specific gravity: 1.280

The doctor ordered co-trimoxazole (Bactrim) 800/160mg tablet TID for 14 days and phenazopyridine
(Pyridium) 200 mg tablet TID for 3 days.Given the above case, answer the following questions:

1. WHAT LABORATORY VALUES POINT TOWARDS THE DIAGNOSIS OF PYELONEPHRITIS?

 The laboratory values point towards the diagnosis of Pyelonephritis is increased neutrophil secondary
to increased WBC count and hematuria presence in the urine.

2. WHAT IS THE MOST COMMON CAUSATIVE AGENT OF URINARY TRACT INFECTIONS?

 The most common causative agent of urinary tract infections is Escherichia coli it is the most common
pathogen in acute pyelonephritis, and in the past decade, there has been an increasing rate of E. coli
resistance to extended-spectrum beta-lactam antibiotics. Though it is less common to older adults, the
prevalence rate of catching the infection is 82% for women, and 73% for men.

3. GIVE AT LEAST TWO (2) HEALTH TEACHING POINTS THAT WILL HELP THE
PREVENTION OF RECURRENCE OF UTI?

 Drink plenty of liquids, especially water. Drinking water helps dilute your urine and ensures that you'll
urinate more frequently — allowing bacteria to be flushed from your urinary tract before an infection
can begin.

 Wipe from front to back. Doing so after urinating and after a bowel movement helps prevent bacteria
in the anal region from spreading to the vagina and urethra.

4. CREATE A DRUG STUDY FOR THE MEDICATION: CO-TRIMOXAZOLE SPECIFYING THE

FOLLOWING:

a. Drug classification: Sulfonamides

b. MOA: Sulfamethoxazole interferes with bacterial folic acid synthesis and growth via inhibition of
dihydrofolic acid formation from para-aminobenzoic acid; trimethoprim inhibits dihydrofolic acid reduction to
tetrahydrofolate resulting in sequential inhibition of enzymes of the folic acid pathway.

c. Indication: Use to treat urinary bladder or urinary tract infections (water infections)
De Sagun, Leila Camille A.
BSN3Y1-1B
312-LEC-CU5
d. Contraindications: patients with a known hypersensitivity to trimethoprim or sulfonamides and in patients
with documented megaloblastic anemia due to folate deficiency.

e. Adverse reactions:

CNS: headache, mental depression, aseptic meningitis, apathy, seizures, hallucinations, ataxia, nervousness,
fatigue, vertigo, insomnia.

CV: thrombophlebitis.

EENT: tinnitus.

GI: nausea, vomiting, diarrhea, abdominal pain, anorexia, stomatitis, pancreatitis, pseudomembranous colitis.

GU: toxic nephrosis with oliguria and anuria, crystalluria, hematuria, interstitial nephritis.

Hematologic: agranulocytosis, aplastic anemia, megaloblastic anemia, thrombocytopenia, leukopenia,

hemolytic anemia, pancytopenia.

Hepatic: jaundice, hepatic necrosis.

Musculoskeletal: arthralgia, myalgia, muscle weakness.

Respiratory: pulmonary infiltrates.

Skin: erythema multiforme (Stevens-Johnson syndrome), generalized skin eruptions, epidermal necrolysis,
exfoliative dermatitis, photosensitivity, urticaria, pruritus.

Other: hypersensitivity reactions (serum sickness, drug fever, anaphylaxis), rhabdomyolysis.

f. Nursing considerations:

- Maintain adequate fluid intake to prevent crystalluria

- Monitor CBC, renal function test, liver function test, urinalysis

5. Create a drug study for the medication: PHENAZOPYRIDINE specifying the following:

a. Drug classification: Urinary Tract Analgesic

b. MOA: Mechanism unknown. Has a local anesthetic effect on urinary tract mucosa.

c. Indication: This medication is used to relieve symptoms caused by irritation of the urinary tract such as
pain, burning, and the feeling of needing to urinate urgently or frequently.

d. Contraindications: Contraindicated in patients with Hypersensitivity. Glomerulonephritis, Severe hepatitis,

uremia, or renal failure, Renal insufficiency, G6PD deficiency

e. Side Effects:

CNS: headache.

GI: nausea, GI disturbances.

Hematologic: hemolytic anemia, methemoglobinemia.

Skin: rash, pruritus.

De Sagun, Leila Camille A.
BSN3Y1-1B
312-LEC-CU5
Other: anaphylactoid reactions.

f. Nursing considerations:

- Lab tests: Obtain periodic blood work and kidney function tests in patients on prolonged therapy or with
impaired kidney function.

- Be aware that drug will impart an orange to red color to urine and may stain fabric.

- Discontinue drug report to physician immediately the appearance of yellowish tinge to skin or sclerae may
indicate drug accumulation due to renal impairment.

- Discontinue drug when pain and discomfort are relieved (usually 3–15 d). Keep physician informed.

B. GLOMERULONEPHRITIS
A patient with cleft lip and bronchial asthma was brought to the emergency department with chief complaint of
low-grade fever, puffiness of the face and eyes in the morning, +2 edema on both feet, and tea-colored urine.
Urinalysis revealed numerous RBC and certain degree of proteinuria and Antistreptolysin-O titer reaches
more than 300 todd units. The doctor came up with the diagnosis of Acute Glomerulonephritis (AGN).

Answer the following questions:

1. WHAT HISTORY-TAKING QUESTION SHOULD BE ASKED BY THE NURSE TO
STRENGTHEN THE DIAGNOSIS OF AGN?

 The history-taking question that be asked by the nurse to strengthen the diagnosis of AGN is if the
patient had post pharyngeal strep infection for 1-2 weeks or post dermal strep infection for 2-4 weeks
prior to AGN.

2. EXPLAIN THE PATHOPHYSIOLOGICAL TRACING ON THE DEVELOPMENT OF AGN.

 The pathophysiological tracing on the developmental of AGN is there’s an infection of Streptococcus

that the immune system complexes, producing antigen-antibody product that is being deposited in
glomeruli causing increased production of epithelial cells lining the glomerulus. Then the leukocytes
infiltrate the glomerulus therefore there’s thickening or inflaming of the glomerular infiltration
membrane. There’s a proliferation of mesangial and endothelial cells that’s why there’s blockage of
renal capillaries indicating decreased glomerular infiltration rate that leads to glomerular basement
damage and leakage of blood elements resulting to hematuria, proteinuria, oliguria and red blood cells
casts indicating edema and hypertension that could lead chronic where heart and kidney failure is
possible when left untreated.

3. THE DOCTOR ORDERED HYDROCORTISONE TIV, CREATE A DRUG STUDY SPECIFYING

THE FOLLOWING:

a. Drug classification: glucocorticoid, mineralocorticoid

b. Mechanism of action: The short term effects of corticosteroids are decreased vasodilation and permeability
of capillaries, as well as decreased leukocyte migration to sites of inflammation. Corticosteroids binding to the
glucocorticoid receptor mediates changes in gene expression that lead to multiple downstream effects over
hours to days.
De Sagun, Leila Camille A.
BSN3Y1-1B
312-LEC-CU5
c. Indication (*for the case of the patient mentioned above): Hydrocortisone (or cortisone) is usually the
drug of choice for replacement therapy in patients with adrenal insufficiency.

d. Contraindication: Contraindicated in patients allergic to any component of the formulation, in those with
systemic fungal infections

e. Side effects:

CNS: euphoria, insomnia, psychotic behavior, pseudotumor cerebri, vertigo, headache, paresthesia,

seizures.

CV: heart failure, hypertension, edema, arrhythmias, thrombophlebitis, thromboembolism.

EENT: cataracts, glaucoma.

GI: peptic ulceration, GI irritation, increased appetite, pancreatitis, nausea, vomiting.

Metabolic: hypokalemia, hyperglycemia, altered thyroid function test results.

Musculoskeletal: muscle weakness, osteoporosis

Skin: delayed wound healing, acne, various skin eruptions, easy bruising, hirsutism.

Other: susceptibility to infections, cushingoid state (moonface, buffalo hump, central obesity), carbohydrate
intolerance, acute adrenal insufficiency with increased stress (infection, surgery, trauma) or abrupt withdrawal
(after long-term therapy).

f. Nursing Considerations:

- Establish baseline and continuing data on BP, weight, fluid and electrolyte balance, and blood
glucose.

- Lab tests: Periodic serum electrolytes blood glucose, Hct and Hgb, platelet count, and WBC with
differential.

- Monitor for adverse effects.

C.RENAL CALCULI
An elderly patient with osteoporosis consulted in an Out-patient Department with complaints of severe lower
back pain. She is taking 1000 mg of calcium carbonate once a day and reports of poor hydration due to her
mobility problems. Ultrasound of the Kidneys, ureters, and bladder reveal several calculi in both kidneys and
is counselled to be a candidate for nephrolithotomy.

Answer the following questions:

1. WHAT PERTINENT DATA IN THE PATIENT’S HISTORY MAY HAVE CONTRIBUTED WITH
THE DEVELOPMENT OF RENAL CALCULI, DEFEND YOUR ANSWER?

 An elderly patient is taking 1000 mg of Calcium carbonate to supplement calcium loss as evidenced
by osteoporosis but it’s not metabolized well due to her poor fluid intake and aging process affecting
any part of her urinary tract. Often, stones form when the urine becomes concentrated, allowing
minerals to crystallize and stick together.
 De Sagun, Leila Camille A.
BSN3Y1-1B
312-LEC-CU5

2. IDENTIFY THREE (3) PRIORITY NURSING DIAGNOSES IN RELATION TO THE PATIENT’S

CONDITION AND CREATE A HYPOTHETICAL NURSING CARE PLANS FOR EACH NURSING
DIAGNOSIS.

ASSESSMEN NURSING PLANNING INTERVENTION RATIONALE EVALUATIO

T DIAGNOSI N
S

Subjective: Impaired After a week of  Establish rapport. - Therapeutic After a week of

Complained comfort nursing communicatio nursing
severe low back related to intervention, n intervention, the
pain. calculi the client will  Provide measures client reported
deposits in report to relieve pain - It is preferable pain
Objective: the kidney experience no before it becomes to provide an management
signs/symptom severe. analgesic methods relieve
Facial grimace s of infection. before the pain to a
onset of pain satisfactory
Pain scale of or before it level.
7/10 becomes
severe when a
BP: 130/80 larger dose
PR: 110 bpm may be
RR: 20 cpm required.

 Encourage more - Works by

nonpharmacologica increasing the
l pain relief release of
methods endorphins,
(relaxation boosting the
exercises, therapeutic
breathing effects of pain
exercises, music relief
therapy, body medications.
massage, heat and
cold applications). - To gain
enough sleep.
 Provide quiet
room.
- Water can
simply help
our bodies
 Encourage reduce pain.
sufficient fluid Also for
intake. metabolization
of calcium
levels.
 De Sagun, Leila Camille A.
BSN3Y1-1B
312-LEC-CU5

ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS

Subjective: Impaired After a week Record I&O and - Provides After a week of
Reported poor Urinary of nursing characteristics of information nursing
hydration Elimination intervention, urine. about kidney intervention,
related to patient will function and patient
Objective: Mechanical be presence of demonstrated no
obstruction as experiencing complications signs of
evidenced by no signs of (infection and obstruction.
hematuria obstruction. hemorrhage).

Determine - Calculi may

patient’s normal cause nerve
voiding pattern and excitability,
note variations. which causes
sensations of
urgent need
to void.
Usually
frequency
and urgency
increase as
calculus
nears
ureterovesical
Encourage the junction.
patient to walk if
possible. To facilitate
spontaneous passage.
Promote sufficient
intake of fluids.
Increased hydration
flushes bacteria,
blood, and debris and
may facilitate stone
passage.

ASSESSMEN NURSING PLANNIN INTERVENTIO RATIONALE EVALUATIO

T DIAGNOSI G N N
S
 De Sagun, Leila Camille A.
BSN3Y1-1B
312-LEC-CU5
Subjective: Activity After a  Establish - Therapeutic After a week of
Complained Intolerance week of rapport communicatio nursing
severe low related to nursing n. intervention,
back pain. aging intervention  Assess patient
, patient physical demonstrated
Objective: will restore health - Identify if the normovolemic
(+) history of the ability level and health state.
osteoporosis to perform potential condition is
regular injuries severe or
activities in and/or minor and
a healthy illnesses. short-term or
manner long-term.
without
experiencin  Assess - To gain
g any signs and enough
or evaluate energy and
symptoms nutritiona nutrients to
of activity l health the body.
intolerance. habits to
identify - Physical
dietary activity
needs and can also have
food a positive
related effect on the
concerns. patients
psychological
 Encourag status
e
physical
activities. - Ensure
optimal
 Allow performance.
and
encourag
e proper
rest
periods in
between
individua
l
exercises.

3. IDENTIFY AT LEAST TWO (2) HEALTH TEACHING POINTS ON THE PREVENTION OF

RECURRENCE OF RENAL CALCULI FOR THE PATIENT.

 Encourage patient to drink enough to excrete 3,000 to 4,000 mL of urine every 24 hours.

 Recommend that patient have urine cultures every 1 to 2 months the first year and
periodically thereafter.
De Sagun, Leila Camille A.
BSN3Y1-1B
312-LEC-CU5

D. RENAL FAILURE
A patient with uncontrolled Type 2 Diabetes consulted in the emergency department due to shortness of
breath, bipedal edema, palpitation, and decreased urinary output during the past 2 days. The following
laboratory test values are presented:
Serum Creatinine –2.5 mg/dL
BUN level –30 mg/dL
Serum potassium –5.9 mEq/L
HBA1C –8%
A diagnosis of Acute Renal Failure secondary to DM Nephropathy was made by the doctor. Sodium
polyesterene sulfonate (Kayexalate) was ordered to normalize potassium level. Oral hypoglycemic agents
 De Sagun, Leila Camille A.
BSN3Y1-1B
312-LEC-CU5
were revised, and insulin therapy was started to manage the blood sugar level. Urine output is closely
monitored for possible hemodialysis.

Answer the following questions:

1. EXPLAIN THE RELATIONSHIP OF DIABETES MELLITUS ON THE DEVELOPMENT OF
ACUTE RENAL FAILURE USING A FLOW CHART

Peripheral insulin resistance

Type II DM

Hyperglycemia

Oxidative Stress Inflammation Hypertension

Thickened Glomerular Basement Membrane

Mesangial Expansion

Glomerulosclerosis

Disruption of podocytes

Diabetic Nephropathy (Albuminuria + Glomerulopathy)

ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS

Subjective: Risk for decreased After 30  Monitor BP Fluid volume After 30 mins of
“nahihirapan cardiac output mins of and HR. excess, combined nursing
ako huminga” related to Fluid nursing with hypertension intervention, the
overload kidney intervention, (common in renal patient
Objective: dysfunction/failur the patient failure) and maintained
DOB e will maintain effects of uremia, cardiac output
cardiac increases cardiac
output workload and can
lead to cardiac
De Sagun, Leila Camille A.
BSN3Y1-1B
312-LEC-CU5
failure.

 Auscultate  Development of
heart sounds. S3/S4 is indicative
of failure.
Pericardial
friction rub may
be only
manifestation of
uremic
pericarditis,
requiring prompt
intervention and
possibly acute
dialysis.

 Assess color
of skin,  Pallor may reflect
mucous vasoconstriction
membranes, or anemia.
and nail beds. Cyanosis is a late
Note capillary sign and is related
refill time. to pulmonary
congestion and/or
cardiac failure

 Note
occurrence of  Use of drugs (like
slow pulse, antacids)
hypotension, containing
flushing, magnesium can
nausea and result in
vomiting, and hypermagnesemia
depressed , potentiating the
level of neuromuscular
consciousness dysfunction and
. risk of a
respiratory or
cardiac arrest. Use
aluminum-
hydroxide-based
antacid.
 De Sagun, Leila Camille A.
BSN3Y1-1B
312-LEC-CU5
2. IDENTIFY THREE (3) NURSING DIAGNOSES PERTINENT TO THE PATIENT’S
CONDITION AND CREATE HYPOTHETICAL NURSING CARE PLANS (NCPS) FOR EACH
NURSING DIAGNOSIS.

ASSESSMEN NURSING PLANNING INTERVENTION RATIONALE EVALUATION

T DIAGNOSIS

Subjective: Excess Fluid After 8 hours  Record intake - Decrease in After 8 hours of
“nagmamanas Volume of nursing and output output (to nursing
ako” related to intervention, (I&O) less than 400 intervention, the
Compromised the patient ml per 24 patient
Objective: regulatory will hours) may demonstrated
Bipedal edema mechanism as demonstrate indicate absence of
evidenced by absence of acute failure, edema.
bipedal edema. especially in
edema high-risk
patients.

 Weigh daily at - Daily body

same time of weight is
day, on same best monitor
scale, with of fluid
same status. A
equipment weight gain
and clothing. of more than
0.5 kg/day
suggests
fluid
retention.
 Assess skin,
face, - Edema
dependent occurs
areas for primarily in
edema. dependent
Evaluate tissues of the
degree of body,
edema (on (hands, feet,
scale of +1– lumbosacral
+4). area). Patient
can gain up
to 10 lb (4.5
kg) of fluid
before
pitting
edema is
detected.
 Assess level
of - May reflect
consciousness fluid shifts,
. Investigate accumulation
of toxins,
 De Sagun, Leila Camille A.
BSN3Y1-1B
312-LEC-CU5
changes in acidosis,
mentation, electrolyte
presence of imbalances,
restlessness. or
developing
hypoxia.

ASSESSMEN NURSING PLANNING INTERVENTION RATIONALE EVALUATIO

T DIAGNOSIS N

Subjective: Risk for After 8 hours  Promote good - Reduces After 8 hours
“nahihirapan infection related of nursing hand washing risk of cross of nursing
din ako to Changes in intervention, by patient contaminati intervention,
umihi” dietary the patient and staff. on the patient
intake/malnutriti will demonstrated
Objective: on demonstrate no
no  Avoid - Limits signs/symptom
Oliguria signs/sympto invasive introduction s of infection.
ms of procedures, of bacteria
infection. instrumentati into body.
on, and Early
manipulation detection of
of indwelling developing
catheters infection
whenever may
possible. Use prevent
aseptic sepsis.
technique - Limits
when caring introduction
and of bacteria
manipulating into body.
IV and
invasive
lines. Change
site dressings
per protocol.
Note edema,
purulent
drainage.
- Reduces
bacterial
 Provide colonizatio
routine n and risk
catheter care of
De Sagun, Leila Camille A.
BSN3Y1-1B
312-LEC-CU5
and promote ascending
meticulous UTI.
perineal care.
Keep urinary
drainage
system closed
and remove
indwelling
catheter as
soon as - Fever
possible. (higher than
100.4°F)
 Monitor vital with
signs. increased
pulse and
respirations
is typical of
increased
metabolic
rate
resulting
from
inflammato
ry process,
although
sepsis can
occur
without a
febrile
response.

3. CREATE A DRUG STUDY FOR THE MEDICATION: SODIUM POLYESTERENE

SULFONATE SPECIFYING THE FOLLOWING:

a. Drug classification: cation-exchange resin

b. Mechanism of action: : Sulfonic cation-exchange resin that removes potassium from body by
exchanging sodium ion for potassium, particularly in large intestine; potassium-containing resin is then
excreted. Small amounts of other cations such as calcium and magnesium may be lost during treatment.

c. Indication (*for the case of the patient mentioned above): used to treat high levels of potassium in
the blood, also called hyperkalemia.

d. Contraindication: Contraindicated in patients hypersensitive to drug and in patients with

hypokalemia. Use cautiously in patients with marked edema or severe heart failure or hypertension.
De Sagun, Leila Camille A.
BSN3Y1-1B
312-LEC-CU5

e. Side effects:
GI: constipation, anorexia, gastric irritation, nausea, vomiting
Metabolic: hypokalemia.

f. Nursing Considerations
- Use cautiously in patients with marked edema or severe heart failure or hypertension.
- Use P.R. route when patient is vomiting, has P.O. restrictions, or has upper GI tract problems.
- Monitor serum potassium at least once daily. Watch for other signs of hypokalemia.
- Monitor patient for symptoms of other electrolyte deficiencies (magnesium, calcium) because
drug is nonselective. Monitor serum calcium determination in patients receiving sodium
polystyrene therapy for longer than 3 days. Supplementary calcium may be needed.