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Acute Pyelonephritis: University of La Salette College of Nursing Santiago City
Acute Pyelonephritis: University of La Salette College of Nursing Santiago City
COLLEGE OF NURSING
Santiago City
A CASE STUDY
IN
ACUTE PYELONEPHRITIS
PRESENTED BY:
GROUP C
Balot, Jr,, German M.
Bugarin, Rhadharani Paula Mae N.
Buhat, Janny Lie R.
Camangeg jr., Joselito M.
Cambia, Charlene M.
Canosa, Julie Ann U.
Cansino, Rina Antonette P.
Cairel, Princess C.
Carabacan, Arleen C.
Carlos, Amazing Grace M.
Casayuran, Karen Ivy V.
Leal, Joenna Joy I.
PRESENTED TO:
Mr. Jesper Bayaua, RN
Mrs. Mary Jane Gonzales, RN
Ms. Theresa Bermusa, RN
Ms. Pristine Gonzales, RN
TABLE OF CONTENTS
I. Introduction
A. Case Description
II. Demographic Data
Nursing History
A.
Present Health History
B.
Past Medical History
C.
Family History
D. Pattern of Functioning
a. Physiological Health
b. Socio-cultural Health
c. Spiritual Health
Health Perception
Nutrition Pattern
Sleep and Rest
Activity and Exercise
Elimination Pattern
Self Perception
Cognitive and Perception Pattern
Role and Relationship Pattern
Sexuality Pattern
Coping of Stress Pattern
Value and Belief Pattern
INTRODUCTION
(ACUTE PYELONEPHRITIS)
Pyelonephritis
Definition
Pyelonephritis is an infection of the kidney and the ureters, the ducts that carry urine
away from the kidney.
Alternative Names
Urinary tract infection - complicated; Infection - kidney; Complicated urinary tract
infection; Kidney infection
Causes
Pyelonephritis most often occurs as a result of urinary tract infection, particularly when
there is occasional or persistent backflow of urine from the bladder into the ureters or an area
called the kidney pelvis. See:Vesicoureteric reflux
Pyelonephritis can be sudden (acute) or long-term (chronic).
Acute uncomplicated pyelonephritis is the sudden development of kidney inflammation.
Chronic pyelonephritis is a long-standing infection that does not go away.
Pyelonephritis occurs much less often than a bladder infection, although a history of such
an infection increases your risk. You're also at increased risk for a kidney infection if you have
any of the following conditions:
elderly.
Exams and Tests
A physical exam may show tenderness when the health care provider presses (palpates)
the area of the kidney.
Kidney biopsy
Kidney scan
Kidney ultrasound
Voiding cystourethrogram
Treatment
The goals of treatment are to:
Amoxicillin
Cephalosporin
Levofloxacin and ciprofloxacin
Keep the genital area clean. Wiping from front to back helps reduce the chance of
introducing bacteria from the rectal area to the urethra.
Urinating immediately after sexual intercourse. This may help eliminate any bacteria that
may have been introduced during sexual activity.
Drink more fluids (64 to 128 ounces per day). This encourages frequent urination and
flushes bacteria from the bladder.
Drink cranberry juice. Doing so prevents certain types of bacteria from attaching to the
wall of the bladder and may lessen your chance of infection.
DEMOGRAPHIC DATA
Name:
Address:
Age:
25 years old
Birthday:
September 5, 1985
Gender:
Female
Religion:
INC
Nationality:
Filipino
Civil Status:
Married
Occupation:
Self Employed
Date of Admission:
Painful urination, fever with chills, vomiting for 2 days and body malaise
110/80
T:
38
RR:
21
PR:
81
Acute Pyelonephritis
Nursing History
Family History
The patient has a family history of Hypertension on Mother side and asthma to
her Father side.
According to the patient she had her 1st menstruation when she was 14 years old.
She has a regular menstruation. They use natural method (withdrawal)for family planning and to
prevent possible pregnancy.
Physical Assessment
METHOD
FINDINGS
INTERPRETATIOJN
Inspection
Black in color
Normal
Scalp
FACE
*EYES
Eyebrows
Inspection
(-)dandruff
Normal
Inspection
Symmetrically
aligned
Normal
Eyelashes
Inspection
Normal
Eyelids
Inspection
Convex
Normal
Conjunctiva
Inspection
Reddish to pinkish in
color
Normal
Sclera
Inspection
White in color
Normal
Pupil
Inspection
PERRLA, 2mm
Normal
*NOSE
Inspection
(-)discharge
Normal
*EARS
Inspection
(-)secretion
Normal
*MOUTH
Lips
Inspection
Dry,
reddish in color
Gums
Inspection
Pinkish in color
Normal
Teeth
Inspection
Complete, no
dentures
Normal
Tongue
NECK
Inspection
Inspection
Pinkish,(-)lesions
Symmetrical in both
sides
Normal
Normal
Palpation
Normal
Inspection
No tenderness &
mass nodes
Not distended
Auscultation
Normal
Percussion
Normal
Palpation
(-) mass
(-) tenderness
Normal
Inspection
(-)edema,(-)lesions
Normal
Inspection
(-)edema,(-)lesions
Normal
Inspection
Normal
ABDOMEN
UPPER
EXTREMITIES
*R arm
Normal
*L arm
*Nails
LOWER
EXTREMITIES
*Nails
sec.
Inspection
(-)bipedal edema
Normal
SKIN
Inspection
Inspection
Normal
Due to fever
DOCTORS ORDER
Date
Progress note
Doctors order
Interpretation
8/23/10
BP: 110/80
Temp. 36.9 C
Admit to ROC
Secure consent
For CBC
For U/A
To check if there is
abnormalities.
Paracetamol 1 amp IV q 82
Ranitidine 1 amp IV now then q
8 for vomiting
H2 blocker antagonist to
prevent or reduce N/V
To check any fluctuations.
v/s q 4
please inform AP
refer accordingly
To update prognosis to
the pt.
To communicate any
untoward signs and
symptoms that may occur.
To prevent recurrent
vomiting.
3:00 pm
NPO temporary
H2 blocker antagonist to
prevent or reduce N/V
Ranitidine 50mg IV q 8
Antibiotic to treat
bacterial infection
IVF d5LR 1L x 8
5:45pm
To sustain metabolic
needs.
T: 38 C
BP: 90/60
May have DAT
8/24/10
H2 blocker antagonist to
prevent or reduce N/
Antibiotic to treat
bacterial infection
Continue Cefuroxime IV
Antibiotic to treat
bacterial infection
PLR 1L x 122
For comparison
Antibiotic to treat
bacterial infection
8/25/10
Home meds.
1. Zinnat 5oomg BID x 5
days
Antibiotic to treat
bacterial infection
2. Paracetmol q 42
LABORATORY RESULTS
RESULTS
RANGES
INTERPRETATION
WBC
RBC
HgB
HCT
MCV
MCH
MCHC
PLT
RDW-SD
RDW-CV
PDW
MPV
P-LCR
PCT
NEUTROCYTES
LYMPHOCYTES
MONOCYTES
EOSINOPHIL
BASOPHIL
5.00 10.00
4.00 5.00
110 180
27.0 54.0
86.0 110
26.0 38.0
310 370
150 400
37.0 54.0
11.0 16.0
9.0 17.0
9.0 13.0
13.0 43.0
0.17 0.35
1.50 7.00
1.00 3.70
0.00 0.70
0.00 0.40
0.00 0.10
d/t infection
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
08-23-08
URINALYSIS
Color
Transparency
pH
Specific
Protein
Glucose
RBC
Dark yellow
Turbid
6.5 pH
1.010 (normal = 1.010-1.025)
(+) 30 mg/dl
(-)
5 10
Pus cells
Epithelial cells
Amorphous materials
Mucus threads
Bacteria
INTERPRETATION
d/t infection
d/t infection
normal
normal
d/t damage of the kidney
normal
d/t damage of the function
of the kidney
d/t infection
normal
normal
normal
normal
yellow
INTERPRETATION
normal
08-25-08
URINALYSIS
Color
Transparency
pH
Specific
Protein
Glucose
RBC
Slightly Turbid
7.0 pH
1.015 (normal = 1.010-1.025)
(-)
(-)
0-2
Pus cells
Epithelial cells
Amorphous materials
Mucus threads
Bacteria
30 40 HPF
Moderate
Occasional
Rare
Occasional
normal
normal
normal
normal
normal
d/t damage of the function
of the kidney
d/t infection
normal
normal
normal
normal
ANATOMY AND
PHYSIOLOGY
The kidneys are essentially regulatory organs which maintain the volume and
composition of body fluid by filtration of the blood and selective reabsorption or secretion of
filtered solutes.
The kidneys are retroperitoneal organs (ie located behind the peritoneum) situated on the
posterior wall of the abdomen on each side of the vertebral column, at about the level of the
twelfth rib. The left kidney is slightly higher in the abdomen than the right, due to the presence
of the liver pushing the right kidney down.
The kidneys take their blood supply directly from the aorta via the renal arteries; blood is
returned to the inferior vena cava via the renal veins. Urine (the filtered product containing waste
materials and water) excreted from the kidneys passes down the fibromuscular ureters and
collects in the bladder. The bladder muscle (the detrusor muscle) is capable of distending to
accept urine without increasing the pressure inside; this means that large volumes can be
collected (700-1000ml) without high-pressure damage to the renal system occuring.
When urine is passed, the urethral sphincter at the base of the bladder relaxes, the detrusor
contracts, and urine is voided via the urethra.
Blood supply
The kidneys receive blood from the renal arteries, left and right, which branch directly
from the abdominal aorta. Despite their relatively small size, the kidneys receive approximately
20% of the cardiac output.
Each renal artery branches into segmental arteries, dividing further into interlobar arteries
which penetrate the renal capsule and extend through the renal columns between the renal
pyramids. The interlobar arteries then supply blood to the arcuate arteries that run through the
boundary of the cortex and the medulla. Each arcuate artery supplies several interlobular arteries
that feed into the afferent arterioles that supply the glomeruli.
The interstitum (or interstitium) is the functional space in the kidney beneath the
individual filters (glomeruli) which are rich in blood vessels. The interstitum absorbs fluid
recovered from urine. Various conditions can lead to scarring and congestion of this area, which
can cause kidney dysfunction and failure.
After filtration occurs the blood moves through a small network of venules that converge
into interlobular veins. As with the arteriole distribution the veins follow the same pattern, the
interlobular provide blood to the arcuate veins then back to the interlobar veins which come to
form the renal vein exiting the kidney for transfusion for blood.
Histology
Renal histology studies the structure of the kidney as viewed under a microscope. Various
distinct cell types occur in the kidney, including:
Kidney glomerulus parietal cell
Kidney glomerulus podocyte
Kidney proximal tubule brush border cell
Loop of Henle thin segment cell
Thick ascending limb cell
Kidney distal tubule cell
Kidney collecting duct cell
Interstitial kidney cell
Innervation
The kidney and nervous system communicate via the renal plexus, whose fibers course along the
renal arteries to reach the kidney. Input from the sympathetic nervous system triggers
vasoconstriction in the kidney, thereby reducing renal blood flow. The kidney is not thought to
receive input from the parasympathetic nervous system. Sensory input from the kidney travels to
the T10-11 levels of the spinal cord and is sensed in the corresponding dermatome. Thus, pain in
the flank region may be referred from the kidney.
Functions
The kidney participates in whole-body homeostasis, regulating acid-base balance, electrolyte
concentrations, extracellular fluid volume, and regulation of blood pressure. The kidney
accomplishes these homeostatic functions both independently and in concert with other organs,
particularly those of the endocrine system. Various endocrine hormones coordinate these
endocrine functions; these include renin, angiotensin II, aldosterone, antidiuretic hormone, and
atrial natriuretic peptide, among others.
Many of the kidney's functions are accomplished by relatively simple mechanisms of filtration,
reabsorption, and secretion, which take place in the nephron. Filtration, which takes place at the
renal corpuscle, is the process by which cells and large proteins are filtered from the blood to
make an ultrafiltrate that will eventually become urine. The kidney generates 180 liters of filtrate
a day, while reabsorbing a large percentage, allowing for only the generation of approximately 2
liters of urine. Reabsorption is the transport of molecules from this ultrafiltrate and into the
blood. Secretion is the reverse process, in which molecules are transported in the opposite
direction, from the blood into the urine.
Excretion of wastes
The kidneys excrete a variety of waste products produced by metabolism. These include the
nitrogenous wastes urea, from protein catabolism, and uric acid, from nucleic acid metabolism.
Acid-base homeostasis
Two organ systems, the kidneys and lungs, maintain acid-base homeostasis, which is the
maintenance of pH around a relatively stable value. The kidneys contribute to acid-base
homeostasis by regulating bicarbonate (HCO3-) concentration.
Osmolality regulation
Any significant rise or drop in plasma osmolality is detected by the hypothalamus, which
communicates directly with the posterior pituitary gland. An increase in osmolality causes the
gland to secrete antidiuretic hormone (ADH), resulting in water reabsorption by the kidney and
an increase in urine concentration. The two factors work together to return the plasma osmolality
to its normal levels.
ADH binds to principal cells in the collecting duct that translocate aquaporins to the membrane
allowing water to leave the normally impermeable membrane and be reabsorbed into the body by
the vasa recta, thus increasing the plasma volume of the body.
There are two systems that create a hyperosmotic medulla and thus increase the body
plasma volume: Urea recycling and the 'single effect.
Urea is usually excreted as a waste product from the kidneys. However, when plasma
blood volume is low and ADH is released the aquaporins that are opened are also permeable to
urea. This allows urea to leave the collecting duct into the medulla creating a hyperosmotic
solution that 'attracts' water. Urea can then re-enter the nephron and be excreted or recycled again
depending on whether ADH is still present or not.
The 'Single effect' describes the fact that the ascending thick limb of the loop of Henle is
not permeable to water but is permeable to NaCl. This means that a countercurrent system is
created whereby the medulla becomes increasingly concentrated setting up an osmotic gradient
for water to follow should the aquaporins of the collecting duct be opened by ADH.
Blood pressure regulation
Long-term regulation of blood pressure predominantly depends upon the kidney. This
primarily occurs through maintenance of the extracellular fluid compartment, the size of which
depends on the plasma sodium concentration. Although the kidney cannot directly sense blood
pressure, changes in the delivery of sodium and chloride to the distal part of the nephron alter the
kidney's secretion of the enzyme renin. When the extracellular fluid compartment is expanded
and blood pressure is high, the delivery of these ions is increased and renin secretion is
decreased. Similarly, when the extracellular fluid compartment is contracted and blood pressure
is low, sodium and chloride delivery is decreased and renin secretion is increased in response.
Renin is the first in a series of important chemical messengers that comprise the reninangiotensin system. Changes in renin ultimately alter the output of this system, principally the
hormones angiotensin II and aldosterone. Each hormone acts via multiple mechanisms, but both
increase the kidney's absorption of sodium chloride, thereby expanding the extracellular fluid
compartment and raising blood pressure. When renin levels are elevated, the concentrations of
angiotensin II and aldosterone increase, leading to increased sodium chloride reabsorption,
expansion of the extracellular fluid compartment, and an increase in blood pressure. Conversely,
when renin levels are low, angiotensin II and aldosterone levels decrease, contracting the
extracellular fluid compartment, and decreasing blood pressure.
Hormone secretion
The kidneys secrete a variety of hormones, including erythropoietin, calcitriol, and renin.
Erythropoietin is released in response to hypoxia (low levels of oxygen at tissue level) in the
renal circulation. It stimulates erythropoiesis (production of red blood cells) in the bone marrow.
Calcitriol, the activated form of vitamin D, promotes intestinal absorption of calcium and the
PATHOPHYSIOLOGY
OF
ACUTE PYELONEPHRITIS
Etiology:
Bacteria: escherichia coli
Modifiable:
Predisposing factors:
Non-modifiable:
>urinary retention
>age
>diabetes mellitus
>gender (female)
>pregnancy
>instrumentation of urinary tract
>recurrent UTI
IVP
microbial growth
bacteriuria
mucosal defense
nocturia
Inflammation of the bladder
Suprapubic or pelvic pain
hematuria
Vesicoureteral reflex
Flank pain
hydronephrosis