Gordon College

College of Nursing

CASE STUDY
Acute pyelonephritis
Group A3

Leader:
Kabigting, Alvin
Members:
Laruta, Anna Grace
Layug, Dexteria Merwin
Legrama, Mykel Mae
Miguel, Marie Thea
Movilla, Ian
Musni, Joshua
Nacor, Sherry Mae
Najera, Rheva
Obida, Jescel Mae

Table of Contents
 I. Introduction
II. History Taking
a. Demographic Data
b. Review of System
c. Physical Assessment
III. Anatomy and Physiology
IV. Pathophysiology
V. Laboratory and Diagnostic Examinations
VI. Drug Study
VII. Nursing Care Plan
VIII. Discharge Plan
IX. Conclusion
X. Recommendation

Introduction

History Taking

a.Demographic Data
1. Patient’s profile
Name: Patient A
Age: 20 y/o
Sex: Female
Address: Purok #@ Calapacuan, Subic, Zambales
Civil status: Married
Religion: Roman Catholic

2. Chief Complaint: Fever

Date of Admission: August 30, 2009; 6:30 pm

3. History of present illness

 2 days PTA, pt. experienced undocumented high grade fever.

No other associated signs and symptoms. Sought consult,
hence admitted

PNCU: LHC Calapacuan

LMP: February 15, 2009
AOG: 28
EDC: Nov. 22, 2009
Menarche: 14 y/o
Coitarche: 19 y/o
Intensity: Regular
Duration: 7 days
Amount: 2 pads fully soaked
Symptoms experience: (-) dysmenorrhea
# of sexual partner: 1
STD: None

4. Past Medical History

 >No known allergy to any food and drugs
 (-)HPN, (-)DM, (-)Asthma
 Non-smoker
 Non-alcoholic beverage drinker

5. Personal history

6. Family History
 (+)HPN
 (-) CVD
 (+) Asthma
 (-) blood dyscrasia
 (-) DM
  (-) CAD
 (-) PTB
 (-) Kidney failure

7. Course in the ward

DATE/TIME COURSE IN THE WARD

August 30, The patient is a 20 year old G1 P0. Her LMP was on February
2009 15, 2009 with an AOG of 28 weeks. She was diagnosed with
6:15 pm Acute Pyelonephritis. She was admitted to OB ward under
the service of DR. Lintao/Tubban/Roxas. She was given IVF
D5Lrs 1L x 30 gtts/min., Cefuroxime 1.5 g IV ANST (750 mg
IV q8), Paracetamol 300 mg IV for temp. ≥ 39°C q4 or 500
mg/tab 1tab q4 for temp. ≥ 37.8°C. she will undergo HBSAg,
BUN, creatinine and urine C/S today.

August 31, The patient continues her IV and oral meds. She starts
2009 taking Isosuxprine/tab (10mg/tab) 1tab q8. The FH is 28 cm
with FHT of 150 bpm. She is for pelvic ultrasound today.

September 1, The patient has FH of 28 cm with FHT of 150 bpm. She will
2009 continue her IV and oral meds. In addition to her drugs, the
doctor also ordered her to take multivitamins, Ferous sulfate
1 cap OD and isosuxprene HCL 1tab q8 x 7days.

She was given last dose of Cefuroxime at 3pm and will shift
to oral meds. She’s for possible discharge tomorrow.

8. Gordon’s 11 Functional Health Pattern

Gordon’s 11 Findings
Functional Health
Pattern
Health Perception/ Prior to admission, the client sees herself normal
Health Management as any individual should be, even before and
during the onset of pregnancy. The client may not
be physically fit, but she never complained of any
abnormalities regarding her health ever.
The client goes to health center as soon as she
had suspected she was pregnant and then
 regularly for her scheduled prenatal visit. Since
she got pregnant, she had been conscious about
herself especially her health.
Upon admission, the client had been worried not
mostly about her health but the condition of her
baby. She has been experiencing on and off fever
for about 2 days and was told by the doctors that
her baby is not doing well. By that time, she have
entrusted their health to their resident doctors.
Nutritional/ Metabolic Prior to admission, the client was never been fond
of eating vegetables; otherwise, she loves eating
preserved and poultry products. The client has a
good appetite and she usually eats four meals a
day, which shows in her above normal body weight
and bodily figure.
Even before, until now that she is pregnant, she
loves eating sweets like chocolates, ice cream and
cookies. Even though advised by the community
nurse to minimize eating foods high in sugar
content, she still did not listen. Also, the patient
prefers drinking fruit juices rather than water.
Upon admission, the client still has a good appetite
but is now conscious on her diet since she is
worried that she might lose her baby if she would
not do so.
Elimination Prior to pregnancy, the patient is able to urinate
with no discomfort and has a normal bowel
movement. But during pregnancy, on her second
trimester, she experienced dysuria with slightly
turbid yellowish colored urine. She was not
alarmed back then because she only thought it
was normal for pregnant women to manifest such
condition. But the condition worsened and she is
now experiencing flank pain.
Two days before the admission, the client
experienced high on and off fever and then she
was admitted to San Marcelino District Hospital
and was diagnosed of acute pyelonephritis and
referred to JLGMH for further evaluation. She
defecates dark colored stool only once a day.
Activities and Exercise The client is a housewife and practices everyday
living just at home doing household chores. The
daily work at home served as her exercise but it
has never been enough to keep her body fit. She
eats a lot but works a little and been an
overweight just when she was still a child.
 During pregnancy, she does light activities
because she is always experiencing flank pain,
which gets worse as time goes by. She exercises
every morning for about 30 minutes by doing brisk
walking from their house to the public market and
back home.
Upon admission, she never got the chance to
exercise and do activities since she was advised
for a bed rest for the rest of her stay in the
hospital. Moreover, she didn’t like standing that
much since her lower back is really painful.
Cognitive Perceptual Prior to pregnancy the patient has normal
Pattern cognitive function and has a normal level of
consciousness and is able to converse on every
topic. The client responds appropriately to any
verbal and physical stimulus and has an intact
recent and remote memory period. She is able to
state her condition whether it is normal or
abnormal. Still there has been no deviation on her
perceptual pattern during pregnancy and upon
admission. But sometimes, she gets agitated by
her experiencing a very painful lower back pain
making her restless and irritated.
Sleep-Rest Pattern Prior to pregnancy, the patient sleeps at a range of
6-8 hours daily and is able to relax by watching TV
or listening to music. The partner lives with the
boy’s relative but the client does not get
intimidated by his relatives, rather, she enjoys
chatting with them and helping in the household
chores.
The client loves staying late at night together with
his husband watching late night TV series. Even
until she got pregnant, her sleep pattern hasn’t
been changed but still gets enough rest since she
wakes up late too.
Upon admission the patient has been restless and
irritable because of her environment and her
underlying condition. That is why the couple is
eager to go home as soon as the doctor says so
that it is safe to go.
Self-relation and Self- Prior to admission, the patient is well groomed and
perception Pattern is able to perform proper hygiene by taking a bath
daily and brushing teeth twice a day. She sees
herself as a normal person and enjoys living a life
with his beloved partner. She sees herself lovely
as it is what she thinks her husband sees in her.
 During pregnancy, she has heard of many advises
from their elders and relatives about proper
grooming during pregnancy and has doubted that
taking a bath everyday would harm their baby. So
she has not looked on her personal hygiene as of
importance.
Upon admission, she has been concerned about
her grooming and self care since she was advised
to do so and that it would do well not only for
herself, but also the baby she is carrying.
Role-Relation Pattern The patient lives in a nuclear type of family with
her husband. But they live just beside the
husband’s relatives. She is the one who’s
responsible in maintaining cleanliness and order at
home and spending the money. On the other
hand, the husband is in charge of earning for the
family, a typical kind of family. Her husband is a
good provider and performs the roles as the head
of the family as well.
Prior to pregnancy, she is able to state a good
relation to her families and friends. But on the
onset of pregnancy, she has limited her visits to
her friends since it would not do her good if she
would travel often. Rather, her friends and families
is the one who visits her at home now.
Upon admission the patient is unable to perform
her role as a housewife because of hospitalization
and her present condition.
Sexuality and The patient reports of satisfactory sexual
Reproductive Pattern relationship with her husband and is able to show
affection to one another any time of the day. The
couple is open about their intimate relation and is
loving sexual intercourse before pregnancy. The
couple boasts of an active sexual lifestyle and
shows no sign of cheating.
The client is a newlywed and she and her husband
had been eager to have a child. But still, this will
be her first pregnancy so she is the most doubtful
and afraid of all.
Upon pregnancy the patient is unable to engage in
any sexual activity as they thought it would not be
appropriate and also due to her present illness.
But still, the patient’s husband and her relatives
are able to show love by visiting the patient
frequently.
Coping-Stress Tolerance The couple did not have any problems regarding
Pattern their relationship but more on financial. The couple
saves for their upcoming addition to the family
and is thrifty in anything they do. This issue
doesn’t do much trouble with regards to the
couple.
On the onset of pregnancy, the client’s stress
tolerance have lowered since she is experiencing
bodily function changes that a normal pregnant
woman experiences. She still copes with the
frequent SOBs and easy fatigability.
Values-Belief Pattern The patient is born Catholic which she inherited
from her parent. They always go to the Church
every Sunday making it their family day. They
value their faith in God despite of what they are
facing. For them, God is important and sees the
current condition as one of the hindrances God has
given them that they should overcome.

b.Review of System
Integumentary System:
• Good skin turgor
• (-) pallor
• Normal capillary refill (<2 secs.)
• (+) rashes of both upper extremities
Endocrine System:
• (+)polyuria
• (+) urinary frequency
Respiratory System:
• (+) SOB
• (+) DOB on sitting position
• RR = 23 cpm
Cardiac System:
• (+) Palpitations
• PR = 73 bpm
• BP = 110/70 mmHg
Gastrointestinal Tract:
• (+) constipation
• Diminished bowel sounds
• (+) abdominal distress
• FHT = 140 bpm
Genitourinary Tract:
• (+) Polyuria
• (+) Dysuria
• Turbid yellow colored urine
 Musculoskeletal System:
• (+) Body malaise
Neurologic System:
• (+) Weakness
• (+) Drowsiness
• (+) Restlessness and irritability

c. Physical Assessment

ACTUAL NORMAL INTERPRETA

TION
SKIN  Light brown  Varies from The client has
complexion light to deep normal skin,
 Uniform in brown having no signs
color  Generally of dehydration
 Moist uniform and congestion.
 Good skin except in But the client
turgor(<2sec. areas has rashes on
) exposed to both hands that
the sun. can be a sign of
 (+) rashes on
 Moisture in an adverse
both hands
skin folds reaction to a
and axillae drug.
 Good skin
turgor
HAIR  black, thin,  Color varies The client has
dull hair upon the signs of poor
 (+)Hair fall race. hair and scalp
 evenly  Thick, silky, hygiene.
distributed resilient hair Presence of
 (+) dandruff, evenly dandruff and
(-) lice distributed thin and dull hair
 (-) dandruff, shows dry and
 (-) lesion, (-)
(-) lice unhealthy scalp.
scars
 (-) lesion, (-) Other than that,
scars client shows
normal signs.
SKULL  Rounded  Rounded The client shown
(normocephal (normocepha no deviation in
ic) lic & the structure of
 Symmetrical symmetrical the skull.
 Smooth skull with frontal,
contour parietal, and
occipital
  (-)nodules, (-) prominences
masses )
 Symmetrical
 Smooth skull
contour
 (-)nodules,
(-) masses
FACE  Symmetric  Symmetric
Eyes facial facial
structures movement movement Eyebrows are
a.) eyebrow  Hair evenly  Hair evenly normal and
distributed distributed intact.
 Symmetricall  Symmetricall
y aligned y aligned
 Equal  Equal
b.) eyelids movement movement Eyelids are
normal and
 Skin intact  Skin intact
symmetrical
 No  No
showing no signs
discoloration discoloration
of abnormalities.
 Lids close  Lids close
symmetrically symmetricall
 Palpebral y
c.) fissures equal  Palpebral
conjunctiva in size fissures Conjunctivas are
 (-)edema/ equal in size normal and
d.) pupil (-)tenderness  (-)edema/ intact.
 Shiny, smooth (-)tenderness Pupils are
& pink  Shiny, normal.
conjunctiva smooth &
 Black in color pink
 (+) PERRLA conjunctiva
 Varies color
depend on
race
 (+) PERRLA
EARS  Color same as  Color same The ears showed
facial skin as facial skin no signs of
 Symmetric  Symmetric abnormalities.
 Aligned with  Aligned with
the outer the outer
canthus of canthus of
eyes eyes
 Mobile, firm  Mobile, firm
 (-)tenderness  (-)tenderness
  Pinna recoils  Pinna recoils
after folded after folded
 (-)discharge  (-)discharge
 Able to hear  Able to hear
sound on sound on
both ears both ears
NOSE  Symmetric &  Symmetric & The nose is
straight straight aligned and
 (-) discharge  (-) discharge normal, and the
 Uniform in  Uniform in nares are patent
color color and functioning
 (-)  (-) well.
tenderness, tenderness,
(-) lesions (-) lesions
 Pink mucosa  Pink mucosa
 Intact nasal  Intact nasal
septum & in septum & in
midline midline
 Able to  Able to
determine determine
mild aroma mild aroma
 Patent nares  Patent nares
MOUTH
a.) lips  Uniform pink  Uniform pink Lips are moist
in color in color and intact
 Soft, moist,  Soft, moist, showing a
smooth smooth normal couture
texture texture and function.
 Symmetriy of  Symmetriy of
contour contour
 Ability to  Ability to
b.) buccal purse lips purse lips
mucosa Buccal mucosa
 Uniform pink  Uniform pink
is normal and
in color in color
intact.
 Moist,  Moist,
smooth, smooth,
glistening & glistening &
c.) teeth &
elastic elastic
gums Gums are intact
texture texture
and teeth are
 32 adult teeth  32 adult complete with
 Smooth light teeth no seen plaque
yellow, shiny  Smooth, formation.
enamel color varies
 Pink gums from white to
d.) tongue  No retraction light yellow,
of gums shiny enamel Tongue is
 central  Pink gums aligned perfectly
position  No retraction and functioning
 pink in color of gums well.
 moves freely  central
 (-) nodules position
 pink in color
 moves freely
 (-) nodules
NECK  Muscle equal  Muscle equal Neck is aligned
in size in size centrally and
 Head is  Head is normal, with no
centered centered palpable
 (-) palpable  (-) palpable masses.
lymphnodes lymphnodes
THORAX  Chest  Chest Dyspnea is
symmetric symmetric normal on
 Spine  Spine pregnant women
vertically vertically since the
aligned aligned diaphragm is
 Skin intact  Skin intact pushed upward
 Uniform  Uniform by the
temperature temperature increasing size
of the uterus.
 Chest wall  Chest wall
The back pain is
intact intact
caused by the
 (-)  (-)
client’s
tenderness, tenderness,
underlying
(-) masses (-) masses
condition. The
 Symmetric  Symmetric client is suffering
chest chest from acute
expansion expansion pyelonephritis
 (+) dyspnea  Even breath and as a result
at sitting sounds of the kidney
position tissues necrosis,
 Lower back pain is present.
pain
 Even breath
sounds
BREAST  Rounded  Rounded According to the
shape shape client, her breast
 Slightly  Slightly had enlarged
unequal in unequal in since she got
size size pregnant, this is
  Skin uniform  Skin uniform normal for the
in color in color client is getting
 Skin smooth  Skin smooth ready to lactate.
& intact & intact Other than that,
 Fullness of  Dark colored the client has
breast (firm) areola normal breasts.
 Dark colored  (-)
areola tenderness,
 (-) (-) nodules
tenderness,
(-) nodules
ABDOMEN  Light brown in  Light brown The client can
color in color now be heard of
 Round shape  Round shape the Fetal heart
 Vertical dark  (+) bowel tone and fetal
line at the sound parts can be
center palpated. The
(+)linea fetus is
negra presented on a
 (+) bowel cephalic
sound presentation.
 (+)FHT
(141bpm)
 (+)fetal parts
(upon
palpation)
UPPER  Equal in size  Equal in size The client shows
EXTREMITIES on both sides on both sides no signs of
of the body of the body abnormalities in
 (-)  (-) the upper
contractures contractures extremities. But
 Smooth  Smooth the client has
coordinated coordinated rashes on both
movement movement extremities than
 Equal  Equal can be a
strength strength reaction to a
drug taken.
 (+) rashes on  Good
both hands. capillary
 (+) edema, refill (<2 sec)
redness,
warm to
touch skin at
the IV site
((+)inflammat
 ion)
 Good
capillary
refill (<2 sec)
GENITALIA  (-) discharge (as verbalized by the client)
THIS AREA HAVE BEEN REFUSED TO BE EXAMINED
LOWER  Equal size in  Equal size in The client has
EXTREMITIES both side of both side of normal lower
the body the body extremities and
 (-) contures  (-) contures no signs of
 (+)  (-) Homan’s congestion or
occasional sign formation of
numbness  Good thrombophlebitis
 (-) Homan’s capillary refill .
sign (<2 sec)
 Good
capillary refill
(<2 sec)

Anatomy and Physiology

The principal function of the urinary system is to maintain the volume

and composition of body fluids within normal limits. One aspect of this
function is to rid the body of waste products that accumulate as a result of
cellular metabolism. Other aspects of its function include regulating the
concentrations of various electrolytes in the body fluids and maintaining
normal pH of the blood.

In addition to maintaining
fluid homeostasis in the body,
the urinary system controls red
blood cell production by
secreting the hormone
erythropoietin. The urinary
system also plays a role in maintaining normal blood pressure by secreting
the enzyme renin.

The urinary system consists of the kidneys, ureters, urinary bladder, and
urethra. The kidneys form the urine and account for the other functions
attributed to the urinary system. The ureters carry the urine away from
kidneys to the urinary bladder, which is a temporary reservoir for the urine.
The urethra is a tubular structure that carries the urine from the urinary
bladder to the outside.

CHANGES OF THE URINARY SYSTEM DURING PREGNANCY

The kidneys must work extra hard excreting the mother's own waste products plus those of
the fetus. There is an increase in urinary output and a decrease in the specific gravity. The
patient may develop urine stasis and pyelonephritis in the right kidney. This is due to
pressure on the right ureter resulting from displacement of the uterus slightly to the right by
the sigmoid colon. Frequent urination is a complaint during the first through third trimester.
As the uterus rises out of the pelvic cavity in early pregnancy, pressure on the bladder
decreases and frequency diminishes. When lightening occurs during the final weeks of
pregnancy, pressure on the bladder returns to cause frequency.

Laboratory and Diagnostic Examinations

A. SEROLOGY-IMMUNOLOGY 26 August 2009

TEST RESULT REF. VALUES-MTD/CUT- INTERPRETATION

OFF index
HBsAg Non-reactive SD/QIA (Rapid Test) The client has not
been exposed to the
hepatitis virus.
Syphilis Non-reactive SD/QIA (Rapid Test) The client has not
been exposed to the
bacteria Treponema
pallidum.

B. Microscopic Examination 30 August 2009

Examination Result Reference Interpretation

Value
 Color Yellow ----- Urine’s color may vary
with the client’s diet and
drugs taken.
Transparency Turbid Clear Turbidity shows that
there is presence of large
diameter molecules that
is not seen in normal
urine. This turbidity is
caused by the presence
of large amounts of
WBCs.
Specific Gravity 1.010 1.001 – 1.035 Client’s urine’s specific
gravity is within normal
range.
Reaction Acidic ----- Urine’s pH is usually
acidic to maintain an
environment that is not
conducive for bacterial
growth, client’s urine pH
is normal.
Protein +1 Negative Proteinuria shows that
there is damage to the
filtering capacity of the
kidneys that allows large
molecules to flow.
Ketone -------
Others -------

C. Microscopic Examination 30 August 2009

Examination Result Reference Interpretation

Value
WBC Too (0-2/hpf) WBC is greatly elevated
numerous that shows a recent
immunologic response
from an infection.
RBC 0-1 (0-1/hpf) RBC is within normal
range.
Epithelial cells Few Epithelial cells should not
be seen in a normal urine
but urine samples are
usually contaminated
 since the client doesn’t
follow the mid-stream
clean catch.
Renal epithelial ----------
cells
A Urates/ ----------
Phosphates
Bacteria Many Bacteria are present in
large amount showing
the infection was caused
by a bacterium.
Mucus threads ---------
Crystal ---------

D. Hematology 30 August 2009

Examination Result Reference Interpretation

Value
Blood type “B” Rh(+)
Hgb 106 F: 120-150 Hemoglobin count is
below the normal range
and the client is already
taking iron supplements
to correct the condition.
Hct 0.32 F:0.30-0.40 Hematocrit is within
normal range showing no
signs of dehydration or
congestion.
WBC Count 20.39 x 5.0-10.0x109/L WBC is greatly elevated
109/L showing that there is an
infection.
Neutrophils 0.88 0.30-0.70 Neutrophils are the first
line of defense and is
greatly elevated until the
immunologic response is
finished.
Lymphocytes 0.12 0.20-0.40 Lymphocytes are lower
than the normal range
showing no signs of viral
infection.
Eosinophils --------
Monocyte 320x 150-350x109/L
Platelet 109/L
Reticulocyte count ---------- 28-32 pg
MCH ---------- 82-98 fl
MCV ----------

E. Clinical Chemistry 30 August 2009

Examination Result Reference Interpretation

Value
BUN 1.55mmol/ 1.7-8.3 Client’s BUN has a slight
L lowering beyond the
normal range showing
that the kidney is still
functioning well in
cleansing the blood.
Creatinine 42 umol/L 35.4-123.8 Creatinine level is within
normal range

Discharge Plan
 For the client to be discharged, he needs to be physically, mentally and
emotionally stable. For this to be obtained, the researchers developed a
discharge method. These are the following:

Medications
• Advice patient to continue taking medications needed (noting on
medication that should not be able to discontinue abruptly) to maintain
a normal functioning of the body and maintain homeostasis. The
treatment regimen ordered by the doctors must be followed strictly
and should not be stopped to prevent the aggravation of the condition.
The full course of antibiotics should be followed. (At least 7 days.)
• Advice the patient to observe the any reaction towards the given
medications and signs that needs to call the attention of the physician.

Exercise
• Discuss to the client importance or help client develop a program of
exercise and relaxation techniques as tolerated.

Teaching
• Moreover, a teaching plan that affect client’s holistic wellness should
be done in order to maintain an environment that is conducive for
health promotion.

Home Medications
• Always instruct the client the proper dosage of the drug to be given,
frequency, and route of administration. Proper emphasis on important
parts is best to remember the teachings.
• Also instruct relatives on some drug’s precautions before
administration to prevent adverse reactions of the drug.

OPD Schedule
• Proper referral is best for the health care provider to evaluate condition
of the client, whether it is improving or not. Also, for early diagnosis of
any other underlying conditions.

Diet
• Proper execution of client’s diet is very important so informing and
instructing client about proper meals to be given to the client and
increasing oral fluid intake is important.

Conclusion
Recommendation