Pyelonephritis

Case Study Presented to

In Partial Fulfillment

For the Requirements in

Care for Clients with Problems in Oxygenation, Fluid and Electrolyte, Infectious, Inflammatory, and

Immunologic Response, Cellular Aberration, Acute and Chronic

Submitted By:

November 19, 2023

Table of Contents
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Introduction................................................................................................................................................3
Objectives of the Study...........................................................................................................................3
Overview of Medical Diagnosis..............................................................................................................3
Prevalence and Incidence.......................................................................................................................4
Overview of Care....................................................................................................................................4
Patient’s Database......................................................................................................................................5
Health History.........................................................................................................................................5
Review of Systems..................................................................................................................................2
Physical Assessment...............................................................................................................................3
Diagnostic Test........................................................................................................................................3
Final Medical Diagnosis..........................................................................................................................2
Developmental Tasks..............................................................................................................................2
Underlying Concepts...................................................................................................................................4
Anatomy..................................................................................................................................................4
Physiology...............................................................................................................................................4
Pathophysiology (Narrative)...................................................................................................................5
Pathophysiology (Diagram)....................................................................................................................7
Standard of Care.....................................................................................................................................9
Nursing Process.........................................................................................................................................10
Prioritized Nursing Problems List.........................................................................................................10
Problem No. 1: Back pain and dysuria..................................................................................................10
Problem No. 2: Fever and Chills............................................................................................................13
Problem No. 3: Urinary urgency with unsuccessful urination.............................................................15
Recommendations....................................................................................................................................19
Bibliography..............................................................................................................................................21
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Introduction
Objectives of the Study
This case study aims to aid in:

1. Understanding the case of Pyelonephritis and its nature

2. Identifying the pathophysiology of Pyelonephritis

3. Utilizing the nursing process in the case of Pyelonephritis

Overview of Medical Diagnosis

Pyelonephritis is a severe urinary tract infection syndrome, which consists of symptoms such as

fever, regardless of the presence or absence of tenderness and flank pain, acute prostatitis, nausea and

vomiting, dysuria, urinary frequency, and urinary-source bacteremia. This denotes inflammation of

kidneys and the renal pelvis (Johnson & Russo, 2018). This arises as a complication of an ascending

urinary tract infection (UTI), which progresses from the bladder to the kidneys and their respective

collecting systems. In most patients, the infecting organisms, such as Escherichia coli, Proteus, Klebsiella,

and Enterobacteria, will be contracted from their fecal flora. E. coli is the most common etiology of

pyelonephritis due to its unique ability to adhere to and colonize the urinary tract and kidneys.

Furthermore, inadequate emptying and urine stasis brought on by urinary tract obstruction—which may

be brought on by kidney stones—can result in acute pyelonephritis by providing conditions for the

bacteria to flourish in the body. Pyelonephritis classically presents as a triad of fever, flank pain, and

nausea or vomiting. Costovertebral and suprapubic tenderness during abdominal examination may be

present. While some may appear weak and ill, some patients appear healthy and asymptomatic,

therefore laboratory works and imaging studies should be done to confirm diagnosis (Belyayeva &

Jeong, 2022).
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Prevalence and Incidence

The incidence of Pyelonephritis is highest among women of 15-29 years of age (Herness,

Buttolph, & Hammer, 2020), with lifetime incidence of 50-60% in adult women. Women are more at risk

to Pyelonephritis due anatomical factors. A population-based study in the United States found overall

annual rates of 15-17 cases per 10,000 females and 3-4 cases per 10,000 males (Fulop, 2023). This is due

to that women have shorter urethra than men. The proximity of the urethral opening makes it easier for

the bacteria to reach the urethra and bladder, thus posing a great risk for progressing to kidneys, thus

leading to pyelonephritis (Pruthi et. Al, 2023). The prevalence of UTI increases with age, and in women

aged over 65 years of age is approximately double the rate seen among overall female population.

Etiology in this age group varies by health status with factors such as catheterization, changes in the

vaginal flora, urethral changes, urinary retention, incomplete bladder emptying, decline in immune

function due to medications and overall physical status, affecting the risk for infection and the

microorganisms most likely to be responsible, such as E. coli. Increased sexual activity is a significant risk

factor for UTIs in younger women, and recurrence within six months is common. Approximately 20% of

women over 65 years of age experience this condition, compared to 11% of the general population.

Furthermore, groups with extremes of age, such as elderly and infants, impose high risk for this

complication due to abnormalities in anatomy and hormonal changes (Medina & Pina, 2019).

Overview of Care
A 58-year-old patient was presented to the emergency department with complaints of fever,

chills, dysuria, urgency, and back pain, as verbalized and assessed. Upon physical exam, CVA tenderness

is noted, no other significant physical findings. She has a fever of 101.2F; however, she is

hemodynamically stable in ED. Patient was admitted with chief complaint of having severe back pain and
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dysuria. Upon admission, vital signs and review of systems were assessed. Laboratory works were done.

Urinalysis showed increasing levels of WBC and presence of E.coli.

Patient’s Database
Health History
Client Information and Source

Name: KJ Age: 58 years old

Date of Birth: n/a Gender: Female

Weight: 78 kg Height: 5’4”

Chief complaint: Severe backpain with

dysuria

History of Present Illness

KJ is a 58-years-old female who presents to the emergency department with complaints of

fever, chills, dysuria, urgency, and back pain. Upon physical exam CVA tenderness is noted; no

other significant findings. She has a fever of 101.2F; however, she is hemodynamically stable in

ED.

Past Medical History

Hypertension x 10 years, congestive heart failure, hyperlipidemia, type 2 diabetes mellitus

a. Hospitalizations/Surgeries

 None

d. Medications

● Home Medications

○ Lisinopril 40 mg PO daily

○ Carvedilol 6.25 mg PO BID

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○ Furosemide 20 mg PO daily

○ Atorvastatin 40 mg PO daily

○ Metformin 500 mg PO BID

e. Allergies

Penicillin (reported a rash as a child)

f. Transfusions

The patient does not have any history of transfusions.

Family History

Parents:

Father: No known disease

Mother: No known disease

Personal/Social History

Patient KJ is married, lives at home with husband, and has 2 adult children who do not

live at home.

Review of Systems
General

Mild distress, nontoxic appearing

HEENT

Atraumatic, pupils equal round and reactive to light and accommodation, moist mucosa, normal

pharynx, normal tonsils and adenoids, normal tongue.

Pulmonary

Normal chest wall expansion; no rales, no rhonchi, no wheezing.

Cardiovascular

Regular rate and rhythm, no murmurs, no gallops, normal S1 and S2.

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Genitourinary

No incontinence. Patient complains of dysuria.

Muscolo-skeletal

CVA tenderness noted, normal ROM in upper and lower extremities, no swelling, no joint

erythema; Integumentary: warm, dry, pink, with no rash, purpura, or petechia.

Neurological

No headache, focal numbness or weakness, dizziness, or seizures.

Physical Assessment
Subjective

Patient complains of back pain, dysuria, and urinary urgency. Patient reports pain scale of 9/10.

Inspection

Patient in mild distress, non-toxic appearing.

Palpation

Skin is warm to touch. Abdomen is soft and non-tender. CVA tenderness is noted.

Percussion

N/A

Auscultation

Heart at regular rate and rhythm. No murmurs and gallops. Normal S1 and S2. Normal bowel

sounds in all quadrants.

Diagnostic Test
A. Laboratory Findings

Na 140 mEq/L BUN 26 mg/dL

K 3.8 mEq/L SCr 1.0 mg/dL

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Hgb 13.2 g/dL Ph 280 x 103/mm s

Hct 36% CO2 26 mEq/L

Cl 98 mEq/L WBC 14.2 x tc}'/ mm3

Glucose 161 mgldL

B. Urinalysis

Component Value Range and Units

Color Yellow

Transparency Cloudy

Specific Gravity 1.009 1.005-1.030

pH 5.0 5.0-8.0

Protein Negative Negative, mg/dL

Glucose Negative Negative, mg/dL

Ketones Negatives Negative, mg/dL

Bilirubin Negative Negative

Blood Negative Negative

Nitrite Negative Negative

Urobilinogen 0.2 0.2-1.0 mg/dL

Leukocyte esterase Large Negative

WBC >50 None seen/HPF

RBC 0-2 None seen/HPF

Bacteria Many None seen/HPF

Epithelial cells Many None seen/HPF


C. Test for antibiotic resistance
Final Medical Diagnosis
Pyelonephritis
Developmental Tasks
Developmental Task
Generativity vs. Stagnation
The positive resolution for Erik Psychosocial Theory
Erikson’s generativity vs.
stagnation includes striving to
create and nurture things that
will outlast them, often by
parenting children or fostering
positive changes that benefit
others. Negative resolution is
9
Theory Status
Erik Erikson’s Based on the definition of Erik
Erikson’s psychosocial theory,
the patient shows success in
this stage as she expresses
satisfaction in striving to
create and nurture things that
will benefit others.
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inability to feel that they are not

making a positive impact or are
not involved in productive or
creative tasks.

Genital Stage Sigmund Freud’s Based on the definition of

The positive resolution for Psychosexual Theory Freud’s psychosexual theory,
Sigmund Freud’s genital stage the patient shows success in
includes the focus on sexual this stage as she expresses
instinct through heterosexual satisfaction and happiness
intercourse and settling down in towards her marriage with her
a loving one-to-one relationship. husband.
The negative resolution on this
stage includes frigidity,
incompetence, and unsatisfying
relationships. (McLeod, 2023)

Formal Operational Jean Piaget’s Cognitive Based on the definition of Jean

The positive resolution for Jean Development Theory Piaget’s cognitive
Piaget’s stage of formal development theory, the
operation involves the use of patient shows success in this
hypothetical reasoning that is stage as she is able to use
deductive and systematic hypothetical reasoning that is
planning. The negative deductive and systematic.
resolution includes inability to
think which involves the use of
hypothetical reasoning that is
deductive and systematic
planning. (McLeod, 2023)
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Underlying Concepts
Anatomy
The renal system consists of the kidneys, ureters, bladder, and urethra. The system's general

function is to filter about 200 liters of fluid each day from renal blood flow, allowing excess ions, toxins,

and metabolic waste products to be expelled while maintaining blood levels of vital nutrients. The

kidneys are paired retroperitoneal organs located anterolateral to the spinal cord, near the posterior

wall of the body. The lower rib cage and a layer of perirenal fat provide protection for the bean-shaped

kidneys. The renal vein and renal artery are the two main blood arteries that enter and leave the

kidneys. Located on each kidney's superior pole are the adrenal glands. The inner renal medulla and the

highly vascularized outer renal cortex make up the two layers that make up the kidney's interior.

Millions of nephrons, the functional units of the kidneys, are distributed across these two layers. Urine is

temporarily stored in the muscle bladder during urination. It is situated immediately behind the pubic

symphysis in the pelvis. Because the smooth muscle in its walls is what gives the bladder stretch, it may

hold more urine in store. Urine is transported from the bladder to the outside of the body via the

urethra, a single, thin-walled tube. It's linked to two urethral sphincters: the voluntary external skeletal

muscle urethral sphincter and the involuntary internal smooth muscle urethral sphincter (Netter, 2019;

Standring, 2016; Moore et al., 2014).

Physiology
Blood is filtered by kidneys in three stages. Blood that passes through the glomerulus's capillary

network is first filtered by the nephrons. A procedure known as glomerular filtration is used to filter out

almost all solutes—aside from proteins—into the glomerulus. Second, the renal tubules are where the

filtrate is gathered. Tubular reabsorption is the process by which most of the solutes in the PCT are

reabsorbed. The filtrate keeps exchanging water and solutes with the renal medulla and the peritubular

capillary network inside the loop of Henle. In this step, water is also reabsorbed. Then, during tubular
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secretion—basically, the reverse of tubular reabsorption—more solutes and waste products are

secreted into the kidney tubules. Filtrate from the nephrons is collected by the collecting ducts, which

then merge in the medullary papillae. The filtrate, which is now known as urine, is then transported by

the papillae into the minor calyces, which subsequently connect to the ureters via the renal pelvis.

Pathophysiology (Narrative)
Pyelonephritis can be caused by various risk factors. First is immunosuppression. The immune

system plays a huge role in recognizing and clearing infections. A compromised immune system may

struggle to detect and eliminate bacteria efficiently, allowing them to adhere and proliferate in the

urethra and may then ascend to kidneys. Secondly, instrumentation such as the use of foley catheters

put the patient at risk for Pyelonephritis as E. coli can have direct and quick access to the bladder, which

may ascend to kidneys. Moreover, renal calculi cause urine stasis due to the obstruction present that

disturbs the flow of urine through the urinary tract. This creates a suitable environment for bacterial

growth. The stagnation of urine increases the risk for urinary tract infections (UTI) that may further

progress to pyelonephritis as the infection ascends due to reflux of urine (Belyayeva & Jeong, 2022). In

addition to this, patients with Type-2 Diabetes Mellitus are at higher risk for Pyelonephritis. Antibiotic-

resistant urinary pathogens may emerge more frequently in these patients due to the high rates of

antibiotic prescriptions, particularly broad-spectrum antibiotics, for UTIs. Furthermore, increased urine

glucose concentrations could facilitate the development of pathogens. In addition to this case, diabetic

patients may experience autonomic neuropathy. When autonomic neuropathy affects the genitourinary

tract, it causes dysfunctional voiding and retention of urine. This reduces the physical elimination of

bacteria through micturition, which promotes the growth of bacteria (Nitzan et. al, 2015).

For non-modifiable factors, women are more at risk for UTIs because of a short urethra that is

close to the vulvar, perianal, and warm, moist areas where enteric bacteria are present (Nitzan et. al,
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2015). The prevalence of UTI increases with age, and in women aged over 65 years of age is

approximately double the rate seen among overall female population. Etiology in this age group varies

by health status with factors such as catheterization, changes in the vaginal flora, urethral changes,

urinary retention, incomplete bladder emptying, decline in immune function due to medications and

overall physical status, affecting the risk for infection and the microorganisms most likely to be

responsible, such as E. coli. Lastly, sexual intercourse can be a risk factor for acquiring UTI, although it is

not sexually transmitted. It can result to poor sexual practice and hygiene after sex (Medina & Pina,

2019). Moreover, thrusting during sexual intercourse can introduce bacteria into the urethra, which may

ascend to bladder and kidneys (Lindberg, 2023).

Escherichia coli is the most common bacteria to cause acute pyelonephritis due to its ability to

adhere to and colonize the urinary tract and kidneys. Once the bacteria are introduced to the system

due to the presence of risk factors, it will adhere to the mucosal lining of the urethra, initiating an

infection, therefore leading to urethritis. This will then cause urethrovesical reflux or the backing up of

urine, which is supposed to be expelled, into the bladder, therefore causing infection into the bladder,

called cystitis. Due to the inflammation, the flow of urine is disrupted, therefore causing the urine to

reflux once again into the ureter, causing ureteritis. The stagnation of urine in the ureter will cause the

urine to back up once again to the kidneys, leading to a severe upper urinary tract infection, called

Pyelonephritis. Pyelonephritis causes the activation of immune response that activates the pyrogens or

the fever-inducing hormone, and the release of prostaglandin E2. This signals the hypothalamus to

increase body’s thermostat, causing the vasoconstriction to reduce heat loss through the skin, therefore

manifested as fever and chills. The patient will also experience malaise due to the action of infection.

Moreover, since the kidneys are responsible for the production of erythropoietin, it cannot take its

course due to inflammation and infection, therefore causing decrease of RBC production, leading to
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anemia. Moreover, the most symptoms that the patient will experience are dysuria, back pain, and

urinary urgency due to irritation of the affected organs (Roberts, 1991).

Pathophysiology (Diagram)

Modifiable Risk Factors The entry of foreign organisms such as E.

Immunosuppression coli (brought by risk factors)
Instrumentation/
Catheterization
Attachment of the bacteria to the urethra
Renal calculi
Urinary Retention
Urinary obstruction Proliferation of bacteria in the urethra
Type-2 Diabetes Mellitus

Non-modifiable Risk Factors Urethritis

Sex (Female)
Age
Urethrovsical reflux
Sexual intercourse

Introduction of bacteria to the bladder

Cystitis

Uterovesical reflux

Introduction of bacteria to the ureter

Ureteritis

Infection ascends to
kidneys
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PYELONEPHRITIS

Decreased Irritation of involved

Activation of General feeling of
erythropoietin organs (urethra, ureter,
Immune Response being unwell
production bladder, & kidneys)

Decreased
Release of pyrogens
Malaise stimulation of bone
from bacteria Dysuria
marrows

Release of Decreased
prostaglandin E2 erythropoiesis Back pain

Elevation of the
Decreased RBC
body thermostat by
production Urinary urgency
the hypothalamus

Vasocontriction Anemia

Reduced heat loss

through skin

Fever and chills

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Standard of Care
Diagnostics

To diagnose pyelonephritis, laboratory testing and imaging tests must undergo.

 Urinalysis: to examine the sample to detect presence of foreign organisms,

nitrites, leukocyte esterase, bacteria, epithelial cells, and increase of WBC

present in the urine.

 Urine culture: to detect what type of bacteria is causing the infection to

determine the best course of treatment.

 Imaging tests such as Computed Tomography (CT) Scan, Magnetic Resonance

Imaging (MRI), or Ultrasound can be done to assess the condition of the kidneys

(National Institute of Diabetes and Digestive, and Kidney Disease, 2022).

Treatment

Acute pyelonephritis is primarily treated with antibiotics, analgesics, and antipyretics.

NSAIDs, or nonsteroidal anti-inflammatory drugs, are effective in treating the fever and pain that

accompany acute pyelonephritis. Based on the level of antibiotic resistance in the area, an

empirical selection of antibiotics should be made initially. The outcomes of the urine culture

should then be used to modify the antibiotic treatment. E. coli will be the cause of most simple

cases of acute pyelonephritis. E. coli, for which patients may receive a 14-day course of

treatment with TMP-SMX or oral cephalosporins. Intravenous (IV) antibiotic therapy is necessary

for complex cases of acute pyelonephritis until clinical improvements occur. Fluoroquinolones,

cefepime, meropenem, and piperacillin-tazobactam are a few examples of IV antibiotics.

Vancomycin can be used for patients with penicillin allergies. Follow-up for non-admitted

patients should occur within a day or two in order to assess symptom resolution.
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Nursing Process

Prioritized Nursing Problems List

1. Back pain and dysuria

2. Fever and chills

3. Urinary urgency with unsuccessful urination

Problem No. 1: Back pain and dysuria

Subjective Data: “My lower back hurts and I feel a burning kind of pain when I urinate. I would rate my

pain as 9/10.”

Objective Data: Grimace

Nursing Diagnosis: Acute pain related to inflammation and infection in the urinary tract as evidenced by

complaints of back pain and dysuria, and grimace, with pain scale of 9/10.

Rationale:

The patient’s chief complaint includes back pain and dysuria. This has to be addressed first because this

is what made the patient bring herself under the care of healthcare providers. Pain interferes with many

daily activities and the goal of prioritizing it is to reduce the effect of pain on patient’s function, quality

of life, and even emotional well-being (Wells, Pasero, & McCaffery, n.d.).

Goal

Short Term: After 1 hour of nursing intervention, patient will report pain relief, having a pain scale lower

than the initial assessment, specifically at least 3/10.

Long Term:

After 3 days of NI, the patient will be able to perform at least 3 preventive measures and treatment

modalities and recover with no signs of further complications.

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Planning

NOC: Alleviation of Pain

Independent

1. Assess patient’s description of pain.

Rationale: Pain associated with pyelonephritis may be described as heaviness, pressure, or

discomfort of the back, abdomen, or flank area with or without radiation to the groin. Assess for

dysuria or burning with urination (Wagner, 2023).

2. Use alternative therapies like positioning, heat, relaxation, and guided imagery to promote

comfort.

Rationale: Development of specific images helps remove the perception of pain and offers

distraction. These measures assist in relaxation of perineal muscles which can further healp

promote, appropriate effective voiding (Cumpian, 2021).

3. Increase oral intake, unless contraindicated.

Rationale: Adequate fluid intake at 2 liters per day will help with urine dilution, promote renal

blood flow, reduce bladder irritation, and flush bacteria from the urinary tract (Wagner, 2023).

4. Provide comfortable environment by dimming the lights and adjusting room temperature based

on client’s preference.

Rationale: Comfortable environment promotes relaxation and patients tend to recover quickly

and have better health outcomes. A negative and uncomfortable environment delays healing

and induces anxiety and stress, which may trigger pain (Clark, 2021).

5. Encourage to void on regular basis.

Rationale: To reduce risk for urinary retention that may worsen bladder irritation that

contributes to pain (Clark, 2021).

6. Instruct to avoid urinary irritants such as food and drinks containing caffeine and spicy foods.
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Rationale: Bladder irritants such as caffeine and spicy foods irritate the lining of the bladder and

triggers the nervous system that controls the bladder. These then results to further discomfort

that the patient might be experiencing (Bradley, Kowalski, & Kenne, 2020).

7. Promote rest.

Rationale: Fatigue worsens pain sensations and induces stress to the patient (Wagner, 2023).

Dependent

1. Administer pain medications and antibiotics, as ordered.

Rationale: Antibiotics are prescribed to treat the infection. Pain medications are given to

alleviate pain.

2. Educate patient to complete antibiotic therapy.

Rationale: To prevent antibiotic resistance and recurrence of infection

Collaborative

1. Obtain laboratory results for urinalysis and urine culture.

Rationale: To monitor progression of infection

Evaluation

Short Term Goal: Goal met. After 1 hour of nursing intervention, the patient reported pain relief, having

a pain scale of 0/10.

Long Term Goal: Goal met. After 3 days of nursing intervention, patient was able to perform at least 3

preventive measures and treatment modalities, such as wiping and cleaning the vagina front to back,

avoided bladder irritant food and drinks, and voided on regular basis instead of refusing to go to the

toilet, and recovered from severe pain with no signs of further complications.
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Problem No. 2: Fever and Chills

Subjective Data:

“I feel so extremely cold. My eyes are so hot when I blink...”

Objective Data:

Temperature of 38.4 C

Presence of WBC in urine

Nursing Diagnosis: Hyperthermia related to inflammatory and infectious process as evidenced by pt

verbalization of feeling extremely cold, temperature of 38.4C, and presence of WBC in urine as shown in

urinalysis.

Rationale: When a body generates or absorbs more heat than it can release, a malfunction in

thermoregulation results in elevated body temperature is known as hyperthermia. Temperatures this

high can range from moderate to severe; body temperatures over 40 °C (104 °F) can be fatal. This has to

be addressed because uncontrolled fever may lead to further complications such as dehydration, and

even seizures (Vera, 2023).

Goal

Short Term: After 1 hour of nursing intervention, the patient will be able to reduce body temperature to

at least 37.5 C.

Long Term:

After 3 days of nursing intervention, the patient will be able to maintain or restore defenses and

demonstrate at least 3 ways to prevent infection and early detection to allow for prompt treatment.
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Planning

NOC: Reduced body temperature

Independent

1. Closely monitor vital signs.

Rationale: Unreduced fever is a sign of progressive infection that has to be treated as soon as

possible. HR and BP increase as hyperthermia progresses (Vera, 2023).

2. Provide tepid sponge bath (TSB).

Rationale: A tepid sponge bath is a non-pharmacological measure to allow evaporative cooling.

Do not use alcohol as it can cool the skin rapidly and may cause shivering (Vera, 2023).

3. Promote hydration and adequate rest.

Rationale: Dehydration can coincide with hyperthermia. Dehydration manifests as a weak and

rapid pulse, dry mouth, poor skin turgor, thirst, decreased urine output, and elevated urine

concentration. A sufficient amount of rest permits a reduction in oxygen consumption and

metabolic demands, which lowers body temperature (Vera, 2023).

Dependent

1. Administer antipyretics, as ordered.

Rationale: Antipyretic medications reduce prostaglandin synthesis to lower body temperature.

2. Educate patient to complete antibiotic therapy.

Rationale: To prevent antibiotic resistance and recurrence of infection

Collaborative

1. Review laboratory data, such as hemoglobin, hematocrit, and electrolytes.

Rationale: Severe plasma leakage patients will have hematocrit levels that are at least 20%

higher than baseline. Hypovolemia shock can be brought on by severe plasma leakage.
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Moreover, during a fever, the body may lose more fluids through sweating and increased

respiratory rate (Chalowemwong et al, 2018).

2. Develop a dietary plan with the patient and dietician.

Rationale: Encourage high-calorie diet due to increased metabolic demands when a patient has

fever. Acid-ash diet is also necessary for patients with pyelonephritis to increase the acidity of

urine to fight off bacteria. Bacteria survive poorly in an acidic environment. Urine pH should be

maintained at around 5. Cranberry or prune juice and Vitamin C can help acidify urine and

prevent bacterial colonization.

Evaluation

Short Term Goal: Goal met. After 1 hour of nursing intervention, the patient was able to reduce body

temperature to 37.5 C.

Long Term Goal: Goal met. After 3 days of nursing intervention, the patient was able to maintain and

restore defenses as her fever was significantly reduce and was able demonstrate at least 3 ways to

prevent infection and early detection to allow for prompt treatment, such as by practicing proper

hygiene, learning how to monitor her own vital signs especially her body temperature, and having

adequate rest and hydration.

Problem No. 3: Urinary urgency with unsuccessful urination

Subjective Data:

“I experience this constant feeling of having the urge to go to the toilet and it’s painful to urinate.”

Objective Data:

Sudden onset of the need to urinate

Output of 5 mL/hour
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Nursing Diagnosis: Impaired urinary elimination related to irritated and weakened bladder muscles as

evidenced by urinary urgency, dysuria, and urine output of 5 mL per hour.

Rationale: Patients with pyelonephritis may experience this as a result of the illness symptoms and

complications, which include frequent urination, a strong, ongoing urge to urinate, and urinary

hesitancy. This has to be addressed because further stasis of urine in the body will lead to further fatal

infections and serious complications (Wagner, 2023).

Goal

Short Term: After 1 hour of nursing intervention, the patient will be able to increase urinary output to

30 mL/hour, absence of dysuria with pain scale of at least 3/10 and improved bladder control to be

reported as absence of urinary urgency.

Long Term:

After 3 days of nursing intervention, the patient will be able to demonstrate at least 3 behaviors and

techniques to improve urinary elimination and prevent urinary infection.

Planning

NOC: Effective urinary elimination and bladder control

Independent

1. Strictly monitor input and output.

Rationale: The documentation of the patient’s intake and output can help monitor changes in

urine characteristics, such as amount and concentration, which can suggest the progression of

pyelonephritis.

2. Provide patient with routine voiding measures such as by providing privacy, effective voiding

positions, and non-pharmacologic methods that may stimulate urination like the sound of
 24

running water.

Rationale: Development of specific images helps remove the perception of pain and offer

distraction. These measures assist in relaxation of perineal muscles which can further healp

promote, appropriate effective voiding (Cumpian, 2021).

3. Observe for bladder distention.

Rationale: This indicates incomplete emptying after urination or urinary retention (Wagner,

2023).

4. Facilitate a comfortable voiding position and making use of urinals or bed pans as needed.

Rationale: Discomfort can affect the patient’s elimination patterns. Offer urinary devices

frequently for the patient who cannot communicate to support urination (Wagner, 2023).

5. Avoid bladder irritants.

Rationale: Bladder irritants such as caffeine and spicy foods irritate the lining of the bladder and

triggers the nervous system that controls the bladder. These then results to further discomfort

that the patient might be experiencing (Bradley, Kowalski, & Kenne, 2020).

6. Teach pelvic floor exercises.

Rationale: This strengthens the pelvic floor muscles to promote urethral support to prevent

urine leakage and suppress urgency (Cho & Kim, 2021).

Dependent

1. Administer medications such as antispasmodic, anticholinergic, and beta-3 agonist as ordered.

Rationale: Medication can help with overactive bladder and retention if prescribed by a doctor.

Flomax relieves blockage by relaxing the bladder muscles. Ditropan is an anticholinergic that

stops the urge to urinate by inhibiting bladder contractions.

2. Install foley catheter, as ordered.

Rationale: To facilitate urine elimination to prevent urinary retention that may worsen infection
 25

Collaborative

1. Collaborate with patient with regards to the time and habit preferences for routine/timed

urination.

Rationale: This allows patients to be involved in the plan of care and express their preferences.

2. Refer to physician for further ineffective urination.

Rationale: Chronic urinary elimination problems need further monitoring and evaluation. A

urologist can perform testing and provide treatments to ease pain, incontinence, and retention.

Evaluation

Short Term Goal: Goal met. After 1 hour of nursing intervention, the patient was able to increase

urinary output to 30 mL/hour, absence of dysuria with pain scale of 0/10 and improved bladder control

reported as absence of urinary urgency.

Long Term Goal: Goal met. After 3 days of nursing intervention, the patient was able to demonstrate at

least 3 behaviors and techniques to improve urinary elimination and prevent urinary infection such as

cleaning vagina from front to back, performing pelvic floor exercises, and avoiding bladder irritants in

her diet.
 26

Recommendations
The study of Johnson and Russo (2018) investigated the case of an otherwise healthy 35-year-

old patient that presents herself with urinary urgency, dysuria, fever, malaise, nausea, and flank pain.

She recently took a fluoroquinolone for diarrhea while visiting India. Upon examination, the patient's

temperature is 38.6°C, her blood pressure is 105/50 mm Hg, and her pulse and suprapubic areas are

tender, but her abdomen is not tender. The serum creatinine concentration is 1.4 mg per deciliter (124

μmol per liter) (most recent measurement prior to presentation was 0.8 mg per deciliter [71 μmol per

liter]). The white-cell count is 16,500 per cubic millimeter. A positive urine analysis for leukocyte

esterase and citrates.

The recommendations of this study suggest that in the emergency room, fluid resuscitation

would most likely be beneficial for her. If she makes quick progress, her condition might be cleared to be

sent home with instructions to start an empirical oral therapy (such as an extended-spectrum

cephalosporin or fluoroquinolone). However, due to her recent use of antibiotics and her recent visit to

a region where endemic extensively resistant bacteria exist, prior to being released from the emergency

room, she ought to start receiving additional treatment that more reliably addresses multiresistant E.

coli (such as amikacin or ertapenem). However, before being released from the emergency room, she

should receive additional therapy that more reliably covers multiresistant E. coli because of her recent

use of antibiotics and her recent visit to a region where extensively resistant bacteria are endemic. coli

(such as amikacin or ertapenem). A more consistently effective antibiotic regimen and hospital

admission would be necessary if symptoms of sepsis emerged during her visit to the ER. Prudence

dictates that, in this case as well as others that may involve highly resistant pathogens, a combination

regimen that maximizes the chance that at least one agent will be effective against the pathogen should

be used initially, pending the availability of susceptibility data. A consultation on infectious diseases

could be beneficial. Following the discovery of susceptibility results, therapy should be suitably
 27

constricted. If an appropriate medication is on hand, the patient can receive oral treatment once her

condition is clinically stable. If the clinical course proceeds as planned, there is no need for additional

testing; however, if the condition worsens or does not improve within a day or two, repeat cultures and

imaging should be performed.

 28

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